Difference In Pneumonia Rates Research Articles

Association of chronic or acute systolic and diastolic heart failure with incidence rates of pneumonia, sepsis, and septic shock in patients with lung cancer.

e24005 Background: Systolic heart failure (SHF) and diastolic heart failure (DHF) can lead to volume overload and cause pulmonary venous congestion and pulmonary edema. While an association between lung cancer (LC) and increased infection rates is well established, we investigated whether chronic SHF or DHF, as well as acute SHF or DHF in concomitance with LC, influenced the incidence of pneumonia (PNA), sepsis, and septic shock. Methods: A retrospective study was conducted by obtaining patients with LC by applying specific ICD 10 codes (C34.0 - C34.9 including all sub-codes) from the National Inpatient Sample 2019-2020. Among this cohort, patients with acute and chronic SHF or DHF were further identified by applying specific ICD 10 codes ((I50.1 - I50.4 including all sub-codes). Pneumonia, sepsis, and septic shock outcomes were compared between LC patients with each of these types of heart failures versus those without using multivariate regression analysis (MVRA), adjusting for demographic factors, hospital-specific characteristics, common comorbidities and alcohol, smoking, or substance use. Results: 802,230 patients were identified with LC. 48.7% were female. 77.9% were Caucasian, 12.8% were African American, 4.6% were Hispanic, and 3.5% belonged to other ethnicities. Patients with LC and chronic SHF (n = 25880) had no significant difference in rates of PNA [Adjusted (Ad) odds ratio (OR): 0.9, p = 0.13] and sepsis (Ad OR: 0.9, p = 0.59) but had higher rates of septic shock (Ad OR: 1.4, p < 0.001) compared to those LC patients without any heart failure (HF). Patients with LC who had acute SHF (n = 22295) showed higher rates of PNA (Ad OR: 1.4, p < 0.001), sepsis (Ad OR: 1.5, p < 0.001), as well as septic shock (Ad OR: 1.6, p < 0.001) versus those without any HF. Patients with LC and concurrent chronic DHF (n = 31580) had similar rates of PNA (Ad OR: 1, p = 0.64), sepsis (Ad OR: 1.1, p = 0.62) and septic shock (Ad OR: 1, p = 0.77) compared to LC patients without any HF. However, acute DHF (n = 24080) led to a higher incidence of PNA (Ad OR: 1,4, p < 0.001) and sepsis (Ad OR: 1.2, p = 0.05) in patients with LC, but no difference in the incidence of septic shock (Ad OR: 0.8, p = 0.072). Conclusions: Chronic SHF led to an increased incidence of septic shock, whereas acute SHF was associated with accentuated rates of PNA, sepsis, and septic shock in patients with LC. Chronic DHF did not predict an increased risk of infections; however, acute DHF was associated with enhanced rates of PNA and sepsis. Future investigations may focus on the effect of SHF or DHF on outcomes beyond hospitalization in patients with LC and the subtypes of LC and infection risk. Based on this signal-finding analysis, it may be postulated that early inter-disciplinary collaboration between oncology and cardiology may be crucial in managing patients with heart failure and LC and potentially lead to better patient outcomes.

375. RURAL PATIENTS HAVE A PROLONGED INPATIENT RECOVERY PROCESS AFTER ESOPHAGECTOMY COMPARED TO NON-RURAL PATIENTS AT A HIGH-VOLUME ESOPHAGEAL PROGRAM

Abstract Background Geographic access to care plays a large role in health disparities in esophageal cancer care, with rural individuals often travelling further to access complex healthcare services. We sought to characterize peri-operative outcomes in patients undergoing esophagectomy for loco-regional cancer at a single academic tertiary care center based on geographic home location. We hypothesize that rural patients will have worse peri-operative outcomes after esophagectomy, despite receiving care at the same high-volume hospital. Methods Prospectively collected data from patients with loco-regional esophageal cancer who underwent esophagectomy at a single academic medical center between 2003 to 2022 were analyzed based on county. The counties were aggregated into previously existing state-level ‘metropolitan’ versus ‘rural’ designations per the Rural Health Information Hub guidelines. Distance traveled by the patients were calculated using driving distance between the patient’s reported zip code and hospital address. Demographics, pre-operative treatment, surgical complications, post-operative outcomes, length of stay (LOS), and mortality of the two groups were analyzed using chi-squared, paired t-tests, and single-factor ANOVA. Results The cohort consisted of 1545 patients with 76.0% from metropolitan counties and 24.0% from rural counties. Patients were more likely to be male in both groups (p = 0.004), with no significant differences in pre-operative characteristics. Both groups had similar rates of pre-operative chemotherapy (p = 0.11) and pre-operative radiation (p = 0.58). Rural patients traveled greater distances for healthcare services compared to metropolitan patients (rural: 192.4 ± 101.2 miles; metropolitan: 63.4 ± 36.7 miles; p < 0.001). Post-operatively rural patients had higher rates of pneumonia (p = 0.04) and more initial ICU visits (p < 0.001). Rural patients had longer ICU LOS (p < 0.001), but no difference in total hospital LOS (p = 0.28) or 30-day mortality (p = 0.35). Conclusion Rural patients tended to have a more complex inpatient recovery process after esophagectomy despite receiving surgery at the same high-volume institution and no differences in pre-operative characteristics (BMI, smoking history, and co-morbidities). It is unclear as to the reason for differences in pneumonia rates and ICU stays. Future studies should focus on the impact of rural location on disparities for individuals undergoing esophagectomy.

446. VOCAL FOLD AUGMENTATION REDUCES PNEUMONIA INCIDENCE IN PATIENTS WITH IATROGENIC RECURRENT LARYNGEAL NERVE PALSY AFTER ESOPHAGECTOMY

Abstract Background Recurrent laryngeal nerve (RLN) palsy is a significant complication associated with esophagectomy, resulting in a high incidence of pneumonia and a poor quality of life. Vocal fold augmentation (VFA) can help alleviate the associated symptoms of dysphonia. We aimed to investigate the impact of VFA on pneumonia incidence in patients suffering from RLN palsy after esophagectomy. Methods This is a retrospective cohort study. Patients who underwent esophagectomy at our center from 2003 to 2022, and experienced right, left or bilateral RLN palsy postoperatively were selected from a prospectively managed database. VFA consisted of medialisation thyroplasty, injection laryngoplasty, arytenoid adduction or a combination of these procedures. Pneumonia was defined as lung changes on chest x-ray, along with clinical evidence of infection within six months after esophagectomy. Pearson’s chi-squared test was used to assess the difference in pneumonia rates. Univariate and multivariate logistic regression analyses were used to identify associations between variables and the outcome of pneumonia. Results A total of 107 esophagectomy patients with RLN palsy were included. The overall palsy rate was 14.5%. 41 patients (38.3%) underwent VFA. Of the patients who underwent VFA, 13 (31.7%) underwent medialization thyroplasty, 26 (63.4%) underwent injection laryngoplasty, 1 (2.4%) underwent injection laryngoplasty and medialization thyroplasty, and 1 (2.4%) underwent injection laryngoplasty and arytenoid adduction. Pneumonia rate (14.6%) for patients who underwent VFA was significantly lower than that of patients without VFA (47.0%, P < 0.001). On univariate and multivariate analyses, patients who underwent VFA were less likely to suffer from pneumonia compared to those without VFA (OR = 0.194, P = 0.001). Conclusion Vocal fold augmentation reduces pneumonia incidence in patients with recurrent laryngeal nerve palsy after esophagectomy.

Prevalence of Pneumonia Among Patients Who Died with COVID-19 Infection in Ancestral Versus Omicron Variant Eras

The Omicron variant of COVID-19 is less severe than the ancestral strain, leading to the potential for deaths in patients infected with the virus but who die of other causes. This study evaluated the difference in rates of pneumonia among patients who died with SARS-CoV-2 infection in the ancestral vs Omicron eras. We identified patients who died within 30days of a positive SARS-CoV-2 test, from March 2020 through December 2022; variants were assigned based on the prevalent variant in the US at that time. We also obtained a control group from patients who died within 30days of a negative SARS-CoV-2 test in January 2022. The first CT after the test was reviewed in a blinded fashion and assigned a category from the RSNA Consensus Reporting Guidelines. The primary outcome was the difference in rates of positive (typical or indeterminate) COVID-19 findings in the ancestral vs Omicron eras. A total of 598 patients died during the ancestral era and 400 during the Omicron era, and 347 decedents comprised the control group. The rate of positive COVID-19 findings was 67/81 (83%) in the ancestral era and 43/81 (53%) in the Omicron era (P<.001), an absolute difference of 30% (95% CI 16%-43%). The rate of positive findings in the control group was 23/76 (30%). During the Omicron era, 30% fewer SARS-CoV-2-associated deaths were associated with COVID-19 pneumonia and were caused either by nonpulmonary effects of the infection or were unrelated to the infection.

In-hospital outcomes of intercostal nerve cryoablation and surgical stabilization of rib fractures.

Severe pain and pulmonary complications commonly follow rib fractures, both of which may be improved by surgical stabilization of rib fractures (SSRFs). However, significant postoperative pain still persists which may negatively impact in-hospital outcomes. Combining intercostal nerve cryoablation (INCA) with SSRF may improve those outcomes by further decreasing postoperative pain, opioid consumption, and pulmonary complications. The hypothesis is that INCA plus SSRF reduces opioids consumption compared with SSRF alone. The retrospective analysis included trauma patients 18 years or older who underwent SSRF, with or without INCA, in a Level I trauma center between 2015 and 2021. Patients received INCA at the surgeons' discretion based on familiarity with the procedure and absence of contraindications. Patients without INCA were the historical control group. Reported data include demographics, mechanism and severity of injury, number of ribs stabilized, cryoablated nerves, intubation rates and duration of mechanical ventilation. The primary outcome was total morphine milligrams equivalent consumption. Secondary outcomes were intensive care unit length of stay, hospital length of stay, incidence of pneumonia, and tracheostomy rates, and discharge disposition. Long-term outcomes were examined up to 6 months for adverse events. Sixty-eight patients were included, with 44 receiving INCA. There were no differences in rates of pneumonia ( p = 0.106) or duration of mechanical ventilation ( p = 0.687), and hospital length of stay was similar between groups ( p = 0.059). However, the INCA group demonstrated lower total morphine milligrams equivalent ( p = 0.002), shorter intensive care unit length of stay ( p = 0.021), higher likelihood of home discharge ( p = 0.044), and lower rate of intubation ( p = 0.002) and tracheostomy ( p = 0.032). Combining INCA with SSRF may further improve in-hospital outcomes for patients with traumatic rib fractures. Therapeutic/Care Management; Level III.

P130 Timing of nasogastric tube insertion and risk of postoperative pneumonia: international, prospective cohort study

IntroductionThis study aims to assess whether Prophylactic NGT insertion was associated with reduced rates of pneumonia, in comparison to Reactive NGT after colorectal surgery.MethodsPre-planned secondary analysis of a multicentre, prospective cohort study. Patients undergoing elective colorectal surgery between January and April 2018 were included. Those receiving NGT were divided into three groups, based on the timing of the placement: Routine (at the time of surgery); Prophylactic (after surgery, before vomiting); and Reactive (after surgery, after vomiting).Pneumonia within 30 postoperative days was considered as primary outcome measure and it was compared between the three groups using multivariable regression analysis.Results4,715 patients were included in the analysis. 1,536 (32.6%) received an NGT corresponding to 926 (60.3%) Routine, 461 (30%) Reactive and 149 (9.7%) Prophylactic. 200 patients (4.2%) developed pneumonia (No NGT: 2.7%; Routine NGT: 5.2%; Reactive NGT: 10.6%; Prophylactic NGT: 11.4%). After adjustment for confounding factors, no significant difference in pneumonia rates was detected between the Prophylactic and Reactive NGT groups (OR: 1.03, 95% CI: 0.56 – 1.87, p = 0.932).ConclusionIn patients who required NGT insertion after surgery, prophylactic insertion was not associated with fewer cases of pneumonia within 30 days of surgery in comparison to reactive insertion.

Timing of nasogastric tube insertion and the risk of postoperative pneumonia: an international, prospective cohort study.

Aspiration is a common cause of pneumonia in patients with postoperative ileus. Insertion of a nasogastric tube (NGT) is often performed, but this can be distressing. The aim of this study was to determine whether the timing of NGT insertion after surgery (before versus after vomiting) was associated with reduced rates of pneumonia in patients undergoing elective colorectal surgery. This was a preplanned secondary analysis of a multicentre, prospective cohort study. Patients undergoing elective colorectal surgery between January 2018 and April 2018 were eligible. Those receiving a NGT were divided into three groups, based on the timing of the insertion: routine NGT (inserted at the time of surgery), prophylactic NGT (inserted after surgery but before vomiting) and reactive NGT (inserted after surgery and after vomiting). The primary outcome was the development of pneumonia within 30days of surgery, which was compared between the prophylactic and reactive NGT groups using multivariable regression analysis. A total of 4715 patients were included in the analysis and 1536 (32.6%) received a NGT. These were classified as routine in 926 (60.3%), reactive in 461 (30.0%) and prophylactic in 149 (9.7%). Two hundred patients (4.2%) developed pneumonia (no NGT 2.7%; routine NGT 5.2%; reactive NGT 10.6%; prophylactic NGT 11.4%). After adjustment for confounding factors, no significant difference in pneumonia rates was detected between the prophylactic and reactive NGT groups (odds ratio 1.03, 95% CI 0.56-1.87, P=0.932). In patients who required the insertion of a NGT after surgery, prophylactic insertion was not associated with fewer cases of pneumonia within 30days of surgery compared with reactive insertion.

Prophylactic use of acid suppressants in adult acutely ill hospitalised patients: A systematic review with meta-analysis and trial sequential analysis.

Acutely ill patients are at risk of stress-related gastrointestinal (GI) bleeding and prophylactic acid suppressants are frequently used. In this systematic review, we assessed the effects of stress ulcer prophylaxis (SUP) with proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) versus placebo or no prophylaxis in acutely ill hospitalised patients. We conducted the review according to the PRISMA statement, the Cochrane Handbook and GRADE, using conventional meta-analysis and trial sequential analysis (TSA). The primary outcomes were all-cause mortality, clinically important GI bleeding and serious adverse events (SAEs). The primary analyses included overall low risk of bias trials. We included 65 comparisons from 62 trials (n=9713); 43 comparisons were from intensive care units. Only three trials (n=3596) had overall low risk of bias. We did not find an effect on all-cause mortality (RR 1.03, 95% CI 0.94 to 1.14; TSA-adjusted CI 0.90 to 1.18; high certainty). The rate of clinically important GI bleeding was lower with SUP (RR 0.62, 95% CI 0.43 to 0.89; TSA-adjusted CI 0.14 to 2.81; moderate certainty). We did not find a difference in pneumonia rates (moderate certainty). Effects on SAEs, Clostridium difficile enteritis, myocardial ischaemia and health-related quality of life (HRQoL) were inconclusive due to sparse data. Analyses of all trials regardless of risk of bias were consistent with the primary analyses. We did not observe a difference in all-cause mortality or pneumonia with SUP. The incidence of clinically important GI bleeding was reduced with SUP, whereas any effects on SAEs, myocardial ischaemia, Clostridium difficile enteritis and HRQoL were inconclusive. PROSPERO registration number CRD42017055676; published study protocol: Marker, et al 2017 in Systematic Reviews.

Pain Managment of Multiple Rib Fractures on the Basis of Early Reduction and Fixation in Patients without Intensive Care Unit.

Objective: Blunt thoracic traumas are often complicated with rib fractures. The decision-making process of the treatment approaches not clear for clinicians. So, we aim to investigate the effect of surgical intervention on pain managment of patients as treatment indication.&#x0D; Methods: Cases with 3 or more rib fractures were evaluated in our study. 84 patients underwent open reduction from 2014 to 2018 and 127 patients were treated conservatively from 2014 to 2018 included in the study. Surgery was performed for all cases in first 24-36 hours and no patient needed intensive care. The results of hospitalization time, pneumonia, rates, thoracic deformity rates on 6.month thorax computerized tomography, intercostal blockage requirement, postoperative 6.month quality of life questionnaire for pain and clinical outputs of two groups were retrospectively analyzed.&#x0D; Results: The average hospitalization was found that it was significantly different in favor of the surgical group (z = 6.674; p &lt;0.001). Thoracic deformity rates, intercostal blockage requirement was found to be different between the surgery and non-surgery groups (χ2=7.149;p&lt;0.001), (χ2=22.462;p&lt;0.001). Pain and quality of life scores had also significant difference in favor of the surgical group, respectively (z = 9.270; p &lt;0.001) and (z = 8.796; p &lt;0.001). Additionally there was statistical difference in pneumonia rates (p= 0.020). We did not reach a statistically significant result between the early and late groups in pain 1 and pain 2 results (p1: 0.727, p2: 0.069).&#x0D; Conclusions: There is no consensus on rib fractures. The results of our study suggest that open rib reduction and fixation can be better treatment option than conservative approach in terms of pneumonia rates, hospitalization time, thoracic deformity rates and pain management.

A Nurse-Driven Oral Care Protocol to Reduce Hospital-Acquired Pneumonia.

A standardized, evidence-based oral care protocol was implemented depending on the level of care required by each ventilated, at-risk, or short-term care patient. The QI project included the introduction of a new suction toothbrush kit for at-risk patients and, for short-term patients, a new short-term oral care kit that featured a more ergonomically appropriate toothbrush, a baking soda toothpaste, and an alcohol-free antiseptic mouthwash; the project also supported the continued use of the then current suction toothbrush kit for patients receiving mechanical ventilation. We examined medical records retrospectively and used International Classification of Diseases (ICD) 9 and ICD 10 codes for pneumonia not present on admission to determine the incidence of HAP, including nonventilator hospital-acquired pneumonia (NV-HAP) and ventilator-associated pneumonia (VAP), in two seven-month periods: the baseline and intervention periods. Both periods were in the same seven calendar months of two different years to control for seasonal differences in pneumonia rates. Documentation of oral care interventions were compared with oral care supply use reports to measure protocol adherence in the intervention group. There were 202 patients in the baseline group and 215 in the intervention group. A χ(2) analysis of NV-HAP incidence showed a statistically significant decrease in occurrences of NV-HAP from 52 in the baseline group to 26 in the intervention group (χ(2) = 12.8, df = 1, P < 0.001). The number of patient deaths from NV-HAP also differed significantly between groups, with 20 in the baseline group and four in the intervention group (χ(2) = 4.33, df = 1, P = 0.037). NV-HAP incidence per 1,000 discharges was calculated at 2.84 in the baseline group and 1.41 in the intervention group. Among patients on a ventilator, there were 56 ventilatorassociated events (VAEs) with 12 cases of VAP in the baseline group and 49 VAEs and three cases of VAP in the intervention group. Infection rates in the baseline group were calculated as 12.53 VAEs per 1,000 ventilator days and 2.87 cases of VAP per 1,000 ventilator days. The intervention group yielded a VAE rate of 14.29 per 1,000 ventilator days and a VAP rate of 1.26 per 1,000 ventilator days. Overall, nurses' adherence to the new oral care protocol ranged from 36% to 100% per month, with an average adherence to protocol of 76% as evidenced by oral care documentation and supply use. Nurses improved pneumonia outcomes by providing oral health interventions to all adult patients admitted to the hospital, which reduced overall hospital costs, length of stay, and patient mortality.

Implementing Cough Reflex Testing in a Clinical Pathway for Acute Stroke: A Pragmatic Randomised Controlled Trial.

Silent aspiration is common after stroke and can lead to subsequent pneumonia. While standard bedside dysphagia assessments are ineffective at predicting silent aspiration, cough reflex testing (CRT) has shown promise for identifying patients at risk of silent aspiration. We investigated the impact of CRT on patient and service outcomes when embedded into a clinical pathway. 488 acute stoke patients were randomly allocated to receive either CRT or standard care (i.e. bedside assessment). Primary outcomes included confirmed pneumonia within 3months post stroke and length of acute inpatient stay. Secondary outcomes related to the feasibility of implementing a CRT pathway and clinician and patient satisfaction. There was a non-significant reduction in pneumonia rates by 2.2% points in the CRT group (OR 0.32, 95% CI 0.06-1.62). There was a non-significant difference of 0.7days (95% CI - 0.29 to 1.71days) in length of stay between the standard care group and the CRT group. The CRT took on average 3min longer to complete (p < 0.01) and resulted in a significant 6.7% increase in videofluoroscopic referrals (p = 0.02); however, these results are clinically insignificant. High patient and clinician satisfaction with CRT was found, with clinicians reporting additional knowledge and confidence in decision making for dysphagia management. Post hoc subgroup analyses according to stroke types were conducted and revealed no significant differences in pneumonia rates after adjustment for multiple comparisons. In conclusion, it was possible to implement a CRT pathway with minimal increases in clinician resources. While clinicians perceived CRT as beneficial in clinical decision making, the efficacy of CRT for reducing pneumonia rates in acute stroke remains to be established.Clinical Trial Registration-URL: http://www.anzctr.org.au . Unique identifier: ACTRN12616000724471.

Incentive Spirometry After Lung Resection: A Randomized Controlled Trial

Incentive spirometry (IS) is thought to reduce the incidence of postoperative pulmonary complications (PPC) after lung resection. We sought to determine whether the addition of IS to routine physiotherapy following lung resection results in a lower rate of PPC, as compared with physiotherapy alone. A single-blind prospective randomized controlled trial was conducted in adults undergoing lung resection. Individuals with previous lung surgery or home oxygen were excluded. Participants randomized tothe control arm (PHY) received routine physiotherapy alone (deep breathing, ambulation and shoulder exercises). Those randomized to the intervention arm (PHY/IS) received IS in addition to routine physiotherapy. The trial was powered to detect a 10% difference in the rate of PPC (β= 80%). Student's t test and chi-square were utilized for continuous and categorical variables, respectively, with a significance level of p= 0.05. A total of 387 participants (n= 195 PHY/IS; n= 192 PHY) were randomized between 2014 and 2017. Baseline characteristics were comparable for both arms.The majority of patients underwent a pulmonary lobectomy (PHY/IS= 59.5%, PHY= 61.0%; p= 0.84), with no difference in the rates of minimally invasive and open procedures. There were no differences in the incidence of PPC at 30 days postoperatively (PHY/IS= 12.3%, PHY= 13.0%; p= 0.88). There were no differences in rates of pneumonia (PHY/IS= 4.6%, PHY= 7.8%; p= 0.21), mechanical ventilation (PHY/IS= 2.1%, PHY= 1.0%; p= 0.41), home oxygen (PHY/IS= 13.8%, PHY= 14.6%; p= 0.89), hospital length of stay (PHY/IS= 4 days, PHY= 4 days; p= 0.34), or rate of readmission to hospital (PHY/IS= 10.3%, PHY= 9.9%; p= 1.00). The addition of IS to routine postoperative physiotherapy does not reduce the incidence of PPC after lung resection.

A nationwide evaluation of robotic ventral hernia surgery

BackgroundThe purpose of this study was to examine outcomes of robotic ventral hernia repair(RVHR) versus laparoscopic ventral hernia repair(LVHR). MethodsThe Nationwide Inpatient Sample was queried from October 2008 to December 2013 for ventral hernia repairs. Demographics, morbidity, mortality, and charges were compared between RVHR and LVHR. ResultsFrom 2008-2013, 149,622 ventral hernia surgeries were identified; 117,028 open, 32,243 laparoscopic, and 351 robotic. Open repairs were excluded. RVHR rose annually with 2013 containing 47.9% of all RVHRs. RVHR patients were more likely to be older and have more chronic conditions. There was no difference between length of stay. Pneumonia rates were higher with RVHR; however, after controlling for confounding variables, there was no difference in pneumonia rates. Mortality and other major complications were similar. Total charges were increased for RVHR in univariate and multivariate analysis. RVHR was more common in teaching hospitals and wealthier zip codes. ConclusionRVHR demonstrates comparable safety to the laparoscopic technique, with increased charges and increased volume in urban teaching hospitals and patients from areas of higher median income.

Etiology and long-term functional swallow outcomes in pediatric unilateral vocal fold immobility

ObjectiveUnilateral vocal fold immobility (UVFI) results in deficits in phonatory, respiratory, and swallow function of the pediatric patient. Little is known about long-term functional swallow outcomes. MethodsMedical records of children diagnosed with UVFI between 2005 and 2014 at a tertiary children's hospital were retrospectively reviewed. Etiology, laryngoscopy findings, and swallow status at diagnosis and follow-up were recorded. Swallow outcomes were compared by etiology using Fisher's exact test. McNemar's test was used to identify correlations between return of mobility and swallow recovery. Rates of pneumonia were compared with initial swallow evaluation results using a two-tailed t-test. ResultsEighty-eight patients with UVFI were identified and 73 patients (47% female, mean age 14.4 months, standard deviation (SD) 26.7 months) had complete medical records. Mean follow up time was 52.7 months (SD 36.8 months). Etiologies included cardiothoracic surgery (68.5%), idiopathic (12.3%), prolonged intubation (11.0%), central nervous system (CNS) abnormality (5.5%), and non-cardiac iatrogenic injury to the recurrent laryngeal nerve (2.7%). Forty-seven patients underwent a follow up laryngoscopy, and recovery of vocal fold (VF) mobility was documented in 42.6% (20/47). At diagnosis, 31.5% fed orally, compared with 79.5% at follow-up. Direct correlation between recovery of VF mobility and swallow recovery was not demonstrated. Cardiac etiologies demonstrated higher rates of swallow recovery than CNS abnormalities (p = 0.0393). Twenty-five children aspirated on initial modified barium swallow (MBS) and 10 children developed pneumonias at some point during the follow up period. There was no significant difference in rates of pneumonia in patients with and without aspiration on MBS. ConclusionRecovery of swallow in children with UVFI does not directly parallel return of VF mobility. Long-term swallow outcome is favorable in this population. Initial MBS does not indicate ultimate swallow outcome.

Incidence and impact of postoperative atrial fibrillation after minimally invasive esophagectomy.

Atrial fibrillation (AF) following open esophagectomy has been associated with increased rates of pulmonary and anastomotic complications, and mortality. This study seeks to evaluate effects of AF after minimally invasive esophagectomy (MIE). A retrospective review of patients consecutively treated with MIE for esophageal carcinoma, dysplasia. and benign disease from November 2006 to November 2011 was performed. One hundred twenty-one patients underwent MIE. Median age was 65 years (range 26-88) with 85% being male. Thirty-eight (31.4%) patients developed AF postoperatively. Of these 38 patients, 7 (18.4%) had known AF preoperatively. Patients with postoperative AF were significantly older than those without postoperative AF (68.7 vs. 62.8 years, P = 0.008) and more likely to be male (94.7% vs. 80.7%, P = 0.04). Neoadjuvant chemoradiation showed a trend toward increased risk of AF (73.7% vs 56.6%, P = 0.07). Sixty-day mortality was 2 of 38 (5.3%) in patients with AF and 4 of 83 (6.0%) in the no AF cohort (P = 1.00). The group with AF had increased length of hospitalization (13.4 days vs. 10.6 days P = 0.02). No significant differences in rates of pneumonia (31.6% vs. 21.7% P = 0.24), stricture (13.2% vs. 26.5% P = 0.10), or leak requiring return to operating room (13.2% vs. 8.4% P = 0.51) were noted between groups. We did not find an increased rate of AF in our MIE cohort compared with prior reported rates in open esophagectomy populations. AF did result in an increased length of stay but was not a predictor of other short-term morbidities including anastomotic leak, pulmonary complications, stenosis, or 60-day mortality.

Fundoplication and gastrostomy versus percutaneous gastrojejunostomy for gastroesophageal reflux in children with neurologic impairment: A systematic review and meta-analysis

BackgroundChildren with neurologic impairment often fail medical management of gastroesophageal reflux and proceed to fundoplication and gastrostomy (FG) or percutaneous gastrojejunostomy (GJ). Current guidelines do not recommend one treatment over the other, and there is ongoing uncertainty regarding clinical management. MethodsWe conducted a structured search of Medline, Embase, trial registries, and the gray literature. We included studies that compared outcomes for FG and GJ in children with neurologic impairment. ResultsWe identified 556 children from three retrospective studies who underwent FG (n=431) or GJ (n=125). There were no differences in rates of pneumonia (17% vs 19%, p=0.74) or mortality (13% vs 14%, p=0.76). Few deaths were due to procedural complications (1%) or reflux (2%). There was a trend towards more major complications with FG (29%) compared to GJ (12%) (risk ratio=1.70, 0.85–3.41, p=0.14). Minor complications were more common with GJ (70%) than FG (45%), but this difference was also not statistically significant (risk ratio=0.38, 0.05–3.07, p=0.36). No studies reported quality of life using validated measures. ConclusionsThe quality of the evidence for outcomes of FG versus GJ is very low. Large comparative studies are needed to determine which approach is associated with the best quality-of-life outcomes.

Evaluation of oropharyngeal dysphagia: which diagnostic tool is superior?

As flexible endoscopic examinations of swallowing become more widely used to evaluate patients with oropharyngeal dysphagia, it is important to be aware of research regarding the efficacy of this procedure as compared with the videofluoroscopy procedure. A recent evidence-based review of the field threw some long-held findings into question and has stimulated a surge of new research studying the sensitivity of the two instrumental examinations, health outcomes of patients who receive each procedure, and a look at different patient outcomes. Since 1999, one quasi-randomized clinical trial has directly compared outcomes of patients given a fluoroscopy versus a fiberoptic endoscopic evaluation of swallowing (FEES) examination. This study showed no significant difference in pneumonia rates between the two groups of patients. A multitude of studies have shown a high level of agreement between the two instrumental examinations, and the use of the term gold standard as applied to fluoroscopy is no longer appropriate. The attempt to standardize each examination has been slow, and inter-judge reliability of results has come under fire. Several new scales for quality of life and functional status are now ready to be applied to research that can measure outcomes other than pneumonia. Research to date has suggested that both instrumental examinations are valuable. It is likely that both will continue to be used and will be seen as complementary rather than competitors.

Social and management factors involved in respiratory disease of calves

Various husbandry methods are discussed including calf management personnel, herd size and feeding method used. It was not possible to detect differences in pneumonia rates in different housing and penning systems per se either experimentally or by survey. The importance of adequate ventilation and air quality have been established. The concentration of aerial bacteria in a calf house can be related to the age of the calves and to their behaviour. Whilst stocking density, group size, changes within the group, weaning and transport have been related to pneumonic incidence, these effects may be explained by various concentration of pathogens and perhaps impaired immune response.