Longer Hospital Length Of Stay Research Articles

Validity of the I‑FEED classification in assessing postoperative gastrointestinal impairment in patients undergoing elective lumbar spinal surgery with general anesthesia: a prospective observational study

BackgroundThe I-FEED classification, scored 0–8, was reported to accurately describe the clinical manifestations of gastrointestinal impairment after colorectal surgery. Therefore, it is interesting to determine whether the I-FEED scoring system is also applicable to patients undergoing lumbar spine surgery.MethodsAdult patients undergoing elective lumbar spine surgery were enrolled, and the I-FEED score was measured for 4 days after surgery. The I-FEED scoring system incorporates five elements: intake (score: 0, 1, 3), feeling nauseated (score: 0, 1, 3), emesis (score: 0, 1, 3), results of physical exam (score: 0, 1, 3), and duration of symptoms (score: 0, 1, 2). Daily I-FEED scores were summed, and the highest overall score is used to categorize patients into one of three categories: normal (0–2 points), postoperative gastrointestinal intolerance (POGI; 3–5 points), and postoperative gastrointestinal dysfunction (POGD; 6 + points). The construct validity hypothesis testing determines whether the I-FEED category is consistent with objective clinical findings relevant to gastrointestinal impairment, namely, the longer length of hospital stay (LOS), higher inhospital medical cost, more postoperative gastrointestinal medical treatment, and more postoperative non-gastrointestinal complications.ResultsA total of 156 patients were enrolled, and 25.0% of patients were categorized as normal, 49.4% POGI, and 25.6% POGD. Patients with higher I-FEED scores agreed with the four validity hypotheses. Patients with POGD had a significantly longer length of hospital stay (1 day longer median stay; p = 0.049) and more inhospital medical costs (approximately 500 Taiwanese dollars; p = 0.037), and more patients with POGD required rectal laxatives (10.3% vs. 32.5% vs. 32.5%; p = 0.026). In addition, more patients with POGD had non-gastrointestinal complications (5.1% vs. 11.7% vs. 30.0%; p = 0.034).ConclusionThis study contributes preliminary validity evidence for the I-FEED score as a measure for postoperative gastrointestinal impairment after elective lumbar spine surgery.

Body Mass Index, Sex, and Age Are Predictors of Discharge to a Post-acute Care Facility Following Total Ankle Arthroplasty.

The utilization of total ankle arthroplasty (TAA) continues to increase. Discharge to a post-acute care (PAC) facility can increase patient morbidity and postoperative costs. The purpose of this study is to investigate the effects of age and body mass index (BMI) on discharge to a PAC facility and hospital length of stay (LOS) following TAA. A retrospective review of patients who underwent TAA from the National Surgical Quality Improvement Program (NSQIP) database was performed. Using overweight patients as the reference BMI group, sex- and age-adjusted log-binomial regression models were utilized to estimate risk ratios of BMI categories for being discharged to a PAC facility. A linear regression was utilized to estimate the effect of BMI category on hospital LOS. Obese patients had 1.36 times the risk of overweight patients (P = .040), and morbidly obese patients had 2 times risk of overweight patients (P = .001) of being discharged to a PAC facility after TAA. Men had 0.48 times the risk of women (P < .001). Compared with patients aged 18 to 44 years, patients aged ≥65 years had 4.13 times the risk (P = .012) of being discharged to a PAC facility after TAA. Relative to overweight patients, on average there was no difference in hospital LOS for underweight patients, but healthy weight patients stayed an additional 0.30 days (P=.003), obese patients stayed an additional 0.18 days (P = .011), and morbidly obese patients stayed an additional 0.33 days (P = .009). Men stayed 0.29 fewer hospital days than women (P < .001) on average. Women and patients who are obese or morbidly obese have a longer hospital LOS and an increased chance of being discharged to a PAC facility. Increasing age is also associated with an increased risk of being discharged to a PAC. These may be important factors when developing and discussing the postoperative plan with patients prior to TAA. Level III.

Peri-operative outcomes following radical prostatectomy in the setting of advanced prostate cancer.

To compare the peri-operative outcomes of radical prostatectomy (RP) for locally advanced, node-positive, and metastatic prostate cancer (PCa), as determined through pathological staging, using the American College of Surgeons National Surgical Quality Improvement Project. We identified RP procedures performed between 2019 and 2021. Patients were stratified by pathological staging to compare the effect of locally advanced disease (T3-4), node positivity (N+) and metastasis (M+) vs localised PCa (T1-2 N0 M0). Baseline demographics and 30-day outcomes, including operating time, length of hospital stay (LOS), 30-day mortality, readmissions, reoperations, major complications, minor complications and surgery-specific complications, were compared between groups. Pathological staging data were available for 9276 RPs. Baseline demographics were comparable. There was a slightly higher rate of minor complications in the locally advanced cohort, but no significant difference in major complications, 30-day mortality, readmissions, or rectal injuries. Node positivity was associated with longer operating time, LOS, and some slightly increased rates of 30-day complications. RP in patients with metastatic disease appeared to be similarly safe to RP in patients with M0 disease, although it was associated with a longer LOS and slightly increased rates of certain complications. For patients with pathologically determined locally advanced, node-positive, and metastatic PCa, RP appears to be safe, and is not associated with significantly higher rates of 30-day mortality or major complications compared to RP for localised PCa. This study adds to the growing body of literature investigating the role of RP for advanced PCa; further studies are needed to better characterise the risks and benefits of surgery in such patients.

Refining the predictive value of preoperative apparent diffusion coefficient (ADC) by whole-tumor analysis for facial nerve outcomes in vestibular schwannomas.

Apparent diffusion coefficient (ADC) in MRI has been shown to correlate with postoperative House-Brackmann (HB) scores in patients with vestibular schwannoma despite limited methodology. To rectify limitations of single region of interest (ROI) sampling, we hypothesize that whole-tumor ADC histogram analysis will refine the predictive value of this preoperative biomarker related to postoperative facial nerve function. Of 155 patients who underwent resection of vestibular schwannoma (2014-2020), 125 patients were included with requisite clinical and radiographic data. After volumetric analysis and whole-tumor ADC histogram, regression tree analysis identified ADC cutoff for significant differences in HB grade. Outcomes were extent of resection, facial nerve function, hospital length of stay (LOS), and complications. Regression tree analysis defined three quantitative ADC groups (× 10-6 mm2/s) as high (> 2248.77; HB 1.7), mid (1468.44-2248.77; HB 3.1), and low (< 1468.44; HB 2.3) range (p 0.04). The mid-range ADC group had significantly worse postoperative HB scores and longer hospital LOS. Large tumor volume was independently predictive of lower rates of gross total resection (p <0.0001), higher postoperative HB score (p 0.002), higher rate of complications (p 0.04), and longer LOS (p 0.003). Whole-tumor histogram yielded a robust regression tree analysis that defined three ADC groups with significantly different facial nerve outcomes. This likely reflects tumor heterogeneity better than solid-tumor ROI sampling. Whole-tumor ADC warrants further study as a useful radiographic biomarker in patients with vestibular schwannoma who are considering surgical resection.

Evaluation of disease severity and prediction of severe cases in children hospitalized with influenza A (H1N1) infection during the post-COVID-19 era: a multicenter retrospective study

BackgroundThe rebound of influenza A (H1N1) infection in post-COVID-19 era recently attracted enormous attention due the rapidly increased number of pediatric hospitalizations and the changed characteristics compared to classical H1N1 infection in pre-COVID-19 era. This study aimed to evaluate the clinical characteristics and severity of children hospitalized with H1N1 infection during post-COVID-19 period, and to construct a novel prediction model for severe H1N1 infection.MethodsA total of 757 pediatric H1N1 inpatients from nine tertiary public hospitals in Yunnan and Shanghai, China, were retrospectively included, of which 431 patients diagnosed between February 2023 and July 2023 were divided into post-COVID-19 group, while the remaining 326 patients diagnosed between November 2018 and April 2019 were divided into pre-COVID-19 group. A 1:1 propensity-score matching (PSM) was adopted to balance demographic differences between pre- and post-COVID-19 groups, and then compared the severity across these two groups based on clinical and laboratory indicators. Additionally, a subgroup analysis in the original post-COVID-19 group (without PSM) was performed to investigate the independent risk factors for severe H1N1 infection in post-COIVD-19 era. Specifically, Least Absolute Shrinkage and Selection Operator (LASSO) regression was applied to select candidate predictors, and logistic regression was used to further identify independent risk factors, thus establishing a prediction model. Receiver operating characteristic (ROC) curve and calibration curve were utilized to assess discriminative capability and accuracy of the model, while decision curve analysis (DCA) was used to determine the clinical usefulness of the model.ResultsAfter PSM, the post-COVID-19 group showed longer fever duration, higher fever peak, more frequent cough and seizures, as well as higher levels of C-reactive protein (CRP), interleukin 6 (IL-6), IL-10, creatine kinase-MB (CK-MB) and fibrinogen, higher mechanical ventilation rate, longer length of hospital stay (LOS), as well as higher proportion of severe H1N1 infection (all P < 0.05), compared to the pre-COVID-19 group. Moreover, age, BMI, fever duration, leucocyte count, lymphocyte proportion, proportion of CD3+ T cells, tumor necrosis factor α (TNF-α), and IL-10 were confirmed to be independently associated with severe H1N1 infection in post-COVID-19 era. A prediction model integrating these above eight variables was established, and this model had good discrimination, accuracy, and clinical practicability.ConclusionsPediatric H1N1 infection during post-COVID-19 era showed a higher overall disease severity than the classical H1N1 infection in pre-COVID-19 period. Meanwhile, cough and seizures were more prominent in children with H1N1 infection during post-COVID-19 era. Clinicians should be aware of these changes in such patients in clinical work. Furthermore, a simple and practical prediction model was constructed and internally validated here, which showed a good performance for predicting severe H1N1 infection in post-COVID-19 era.Graphical

Comparative study between ventriculosubgaleal shunt and external ventricular drain for management of post infective hydrocephalus among pediatrics

PurposePost infective hydrocephalus (PIH) is a type of hydrocephalus which occurs after an infection of the brain or cerebrospinal fluid (CSF). Treatment of PIH requires temporary measures such as external ventricular drain (EVD) and ventriculosubgaleal shunt (VSGS) until CSF becomes clear and ready to implement VP shunt.Limited research has been done to explore the tradeoff between these approaches particularly in pediatric PIH patients.Our study compares the complications, mortality rates, and the cost of used resources of both procedures.MethodsA prospective study was conducted for 18 months in which we compared between VSGS and EVD for management of PIH involving 42 randomized cases with 21 patients in group A operated by VSGS and 21 patients in group B operated by EVD.ResultsOur results show a statistically significant difference between both groups in the duration of implementation of VSGS/EVD until resolution of infection occurs. Additionally, a higher rate of pediatric intensive care unit (PICU) admission and a longer length of hospital stay (LOS) were recorded among the EVD group. No statistically significant difference between the number of complications that happened in both despite variations in their forms. Moreover, both groups showed nearly similar mortality rates.ConclusionThere is no significant difference in the rate of complications between VSGS and EVD for PIH. Based on that, VSGS emerges as a favorable and cost-effective option for the management of PIH which leads to less economic burden on patients and the country’s health resources, especially in developing countries.

Eosinophilic bronchiectasis increases length and cost of hospitalization: a retrospective analysis in a hospital of southern China from 2012 to 2020

BackgroundThe concept of eosinophilic bronchiectasis has received clinical attention recently, but the association between blood eosinophil count (BEC) and hospital characteristics has rarely been reported yet. We aim to investigate the clinical impact of BEC on patients with acute bronchiectasis exacerbation.MethodsA total of 1332 adult patients diagnosed with acute exacerbation of bronchiectasis from January 2012 to December 2020 were included in this retrospective study. A propensity-matched analysis was performed by matching age, sex and comorbidities in patients with high eosinophil count (≥ 300 cell/µL) and low eosinophil count (< 300 cell/µL). Clinical characteristics, length of hospital stay (LOS), hospitalization cost and inflammatory markers were compared between the two groups.ResultsEosinophilic bronchiectasis occurred in approximately 11.7% of all patients. 156 propensity score–matched pairs were identified with and without high eosinophil count. Eosinophilic bronchiectasis presented with a longer LOS [9.0 (6.0–12.5) vs. 5.0 (4.0–6.0) days, p < 0.0001] and more hospitalization cost [15,011(9,753–27,404) vs. 9,109(6,402–12,287) RMB, p < 0.0001] compared to those in non-eosinophilic bronchiectasis. The median white blood cell (WBC), lymphocyte, platelet (PLT) and C-reactive protein (CRP) levels in eosinophilic bronchiectasis were significantly increased. Multivariate logistic regression analysis confirmed that the high levels of eosinophil count (OR = 13.95, p < 0.0001), worse FEV1% predicted (OR = 7.80, p = 0.0003) and PLT (OR = 1.01, p = 0.035) were independent prognostic factors for length of hospital (LOS) greater than 7 days.ConclusionEosinophilic bronchiectasis patients had longer length of hospital stay and more hospitalization cost compared to those in non-eosinophilic bronchiectasis group, which might be associated with the stronger inflammatory reaction.

Efficacy and safety of local ablative therapy for patients with NSCLC and coexisting interstitial lung disease.

The effective therapeutic approach is still an unmet need for patients diagnosed with both lung cancer and interstitial lung disease (ILD). This is primarily due to the possible risk of ILD exacerbation caused by surgery or radiotherapy. The current study aimed to investigate the efficacy and safety of local ablative therapy (LAT) for this specific population. Consecutive patients with non-small cell lung cancer (NSCLC) and ILD who received LAT between January 2018 and August 2022 were enrolled, and propensity score matching (PSM) was utilized to match the non-ILD group. The primary endpoint was recurrence-free survival (RFS), and secondary endpoints included overall survival (OS), adverse events (AEs) and hospital length of stay (HLOS). The PSM algorithm yielded matched pairs in the ILD group (n = 25) and non-ILD group (n = 72) at a ratio of 1:3. There were no statistically significant differences in RFS (median 16.4 vs. 18 months; HR = 1.452, p = 0.259) and OS (median: not reached vs. 47.9 months; HR = 1.096, p = 0.884) between the two groups. Meanwhile, no acute exacerbation of ILD was observed in the ILD group. However, the incidence of pneumothorax, especially pneumothorax requiring chest tube drainage, was significantly higher (36.0% vs. 11.2%, p = 0.005) among patients with NSCLC and co-existing ILD, which resulted in longer HLOS (p = 0.045). Although ILD was associated with a higher incidence of pneumothorax, the efficacy of LAT for NSCLC patients with ILD was comparable to those without ILD, suggesting that LAT might be a reliable and effective treatment option for this population, particularly in the early stage.

Socio-demographic and comorbid risk factors for poor prognosis in patients hospitalized with community-acquired bacterial pneumonia in southeastern US

BackgroundHow socio-demographic characteristics and comorbidities affect bacterial community-acquired pneumonia (CAP) prognosis during/after hospitalization is important in disease management. ObjectivesTo identify predictors of medical intensive care unit (MICU) admission, length of hospital stay (LOS), in-hospital mortality, and bacterial CAP readmission in patients hospitalized with bacterial CAP. MethodsICD-9/10 codes were used to query electronic medical records to identify a cohort of patients hospitalized for bacterial CAP at a tertiary hospital in Southeastern US between 01/01/2013–12/31/2019. Adjusted accelerated failure time and modified Poisson regression models were used to examine predictors of MICU admission, LOS, in-hospital mortality, and 1-year readmission. ResultsThere were 1956 adults hospitalized with bacterial CAP. Median (interquartile range) LOS was 11 days (6–23), and there were 26 % (513) MICU admission, 14 % (266) in-hospital mortality, and 6 % (117) 1-year readmission with recurrent CAP. MICU admission was associated with heart failure (RR 1.38; 95 % CI 1.17–1.62) and obesity (RR 1.26; 95 % CI 1.04–1.52). Longer LOS was associated with heart failure (adjusted time ratio[TR] 1.27;95 %CI 1.12–1.43), stroke (TR 1.90;95 %CI 1.54,2.35), type 2 diabetes (TR 1.20;95 %CI 1.07–1.36), obesity (TR 1.50;95 %CI 1.31–1.72), Black race (TR 1.17;95 %CI 1.04–1.31), and males (TR 1.24;95 %CI 1.10–1.39). In-hospital mortality was associated with stroke (RR 1.45;95 %CI 1.03–2.04) and age ≥65 years (RR 1.34;95 %CI 1.06–1.68). 1-year readmission was associated with COPD (RR 1.55;95 %CI 1.05–2.27) and underweight BMI (RR 1.74;95 %CI 1.04–2.90). ConclusionsComorbidities and socio-demographic characteristics have varying impacts on bacterial CAP in-hospital prognosis and readmission. More studies are warranted to confirm these findings to develop comprehensive care plans and inform public health interventions.

Liposomal bupivacaine intercostal block placed under direct vision reduces morphine use in thoracic surgery.

Thoracic epidural analgesia (TEA) and liposomal bupivacaine (LB) are two methods used for postoperative pain control after thoracic surgery. Some studies have compared LB to standard bupivacaine. However, data comparing the outcomes of LB to TEA after minimally invasive lung resection is limited. Therefore, the objective of our study was to compare postoperative pain, opioid usage, and outcomes between patients who received TEA vs. LB. We conducted a retrospective chart review of patients who underwent minimally invasive lung resections over an 8-month period. Intraoperatively, patients received either LB under direct vision or a TEA. Pain scores were obtained in the post-anesthesia care unit (PACU) and at 12, 24, and 48 hours postoperatively. Morphine milligram equivalents (MMEs) were calculated at 24 and 48 hours postoperatively. Postoperative outcomes were then compared between groups. In total, 391 patients underwent minimally invasive lung resection: 236 (60%) wedge resections, 51 (13%) segmentectomies, and 104 (27%) lobectomies. Of these, 326 (83%) received LB intraoperatively. Fewer patients in the LB group experienced postoperative complications (18% vs. 34%, P=0.004). LB patients also had lower median pain scores at 24 (P=0.03) and 48 hours (P=0.001) postoperatively. There was no difference in MMEs at 24 hours (P=0.49). However, at 48 hours, patients who received LB required less narcotics (P=0.02). Median hospital length of stay (LOS) was significantly shorter in patients who received LB (2 vs. 4 days, P<0.001). On multivariable analysis, increasing age, postoperative complications, and use of TEA were independently associated with a longer hospital LOS. Compared to TEA, LB intercostal block placed under direct vision reduced morphine use 48 hours after thoracic surgery. It was also associated with fewer postoperative complications and shorter median hospital LOS. LB is a good alternative to TEA for pain management after minimally invasive lung resection.

Effect of successful bariatric surgery on maternal cardiovascular outcomes

Abstract Background Obesity is a common comorbidity and is prevalent in at least 20% of pregnant women. Its prevalence is increasing at an alarming rate and is associated with worse pregnancy outcomes. With increasing obesity, more females are considering bariatric surgery (BS) as a form of weight-loss. Purpose The purpose of the study is to evaluate the effect of successful bariatric surgery (sBS) on maternal cardiovascular outcomes. Methods Pregnant females were sampled from the National Inpatient Sample Database (2016-2018). Demographics and comorbidities were collected using ICD-10 and DRG codes. Pregnant patients were stratified into three groups – morbidly obese, overweight/obese, and sBS. Individuals with a history of BS and not currently morbidly obese or overweight/obese were included in the sBS group. The primary outcome was a composite and was defined as major adverse cardiovascular events (MACE; Table 1). Secondary outcomes included pre-eclampsia (preE), gestational diabetes (GDM), and length of hospital stay (LOS). Patients with concurrent history of BS and overweight/obese/morbidly obese were excluded. To address confounding factors, sBS patients were matched 1:1 with morbidly obese and overweight/obese patients by 15 variables (Table 1). Binary logistic regression analyses were performed to assess for association between sBS and cardiac outcomes. Results Out of 207,511 patients included, 5,517 were sBS, 132,483 were overweight/obese, and 69,511 were morbidly obese. Compared to the sBS group (0.1%), MACE was higher in morbidly obese (0.7%) and overweight/obese patients (0.3%). Additionally, morbidly obese patients had higher acute heart failure, peripartum cardiomyopathy, acute pulmonary edema, preE, GDM, and longer LOS than sBS patients. Overweight/obese had more preE and GDM than the sBS cohort (Table 1). After 1:1 matching, MACE was more prevalent in morbidly obese patients (OR:6.69 [1.99-22.52]; p=0.002) and overweight/obese patients (OR:6.5 [1.5-28.9; p=0.01) when compared to sBS group. Both morbidly obese and overweight/obese groups were associated with increased preE (OR:3.0 and 2.1 respectively), GDM (OR:3.2 and 2.3 respectively), LOS (Coefficient:3.4 and 3.3 respectively; Figure 1). Conclusion Despite longstanding effects of obesity, sBS patients had better cardiovascular outcomes, even after matching for pre-existing cardiac conditions. A reduction in weight leads to decreased circulatory volume and improved cardiac output, resulting in lower risk of acute pulmonary edema, peripartum cardiomyopathy, and acute heart failure. The decrease in systemic inflammation and endothelial dysfunction likely led to a reduction in preE. Although pregnancy after bariatric surgery requires multidisciplinary management due to specific nutritional needs, the significant reduction in MACE highlights the importance of considering it as an option if conventional weight loss measures fail.Table 1Figure 1

Local Antibiotic Therapy for Open Long Bone Fractures: Appropriate Prophylaxis or Unnecessary Exposure for the Orthopedic Trauma Patient?

Prophylactic local antibiotic therapy (LAbT) to prevent infection in open long bone fracture (OLBF) patients has been in use for many decades despite lack of definitive evidence confirming a beneficial effect. We aimed to evaluate the effect of LAbT on outcomes of OLBF patients on a nationwide scale. In this retrospective analysis of 2017-2018 American College of Surgeons-Trauma Quality Improvement Program database, all adult (≥18 years) patients with isolated OLBF (non-extremity-Abbreviated Injury Scale < 3) were included. We excluded early deaths (<24 h) and those who had burns or non-extremity surgery. Outcomes were infectious complications (superficial surgical site infection, deep superficial surgical site infection, osteomyelitis, or sepsis), unplanned return to operating room, and hospital and intensive care unit length of stay (LOS). Patients were stratified into two groups: those who received LAbT and those who did not receive LAbT (No-LAbT). Propensity score matching (1:3) and chi-square tests were performed. A total of 61,337 isolated OLBF patients were identified, among whom 2,304 patients were matched (LAbT: 576; No-LAbT: 1,728). Both groups were similar in terms of baseline characteristics. Mean age was 43 ± 17 years, 75% were male, 14% had penetrating injuries, and the median extremity-Abbreviated Injury Scale was 1 (1-2). Most common fracture locations were tibia (66%), fibula (49%), femur (24%), and ulna (11%). About 52% of patients underwent external fixation, 79% underwent internal fixation, and 86% underwent surgical debridement. The median time to LAbT was 17 (5-72) h, and the median time to debridement was 7 (3-15) h (85% within 24 h). The LAbT group had similar rates of infectious complications (3.5% vs. 2.5%, P = 0.24) and unplanned return to the operating room (2.3% vs. 2.0%, P = 0.74) compared to the No-LAbT group. Patients who received LAbT had longer hospital LOS (16 [10-29] vs. 14 [9-24] days, P < 0.001) but similar intensive care unit LOS (4 [3-9] vs. 4 [2-7] days, P = 0.19). Our findings indicate that prophylactic LAbT for OLBF may not be beneficial over well-established standards of care such as early surgical debridement and systemic antibiotics. Prospective studies evaluating the efficacy, risks, costs, and indications of adjuvant LAbT for OLBF are warranted.

Abstract 13383: Extracorporeal Membrane Oxygenation for COVID-19-associated Acute Respiratory Distress Syndrome: A Nationwide Analysis

Introduction: While extracorporeal membrane oxygenation (ECMO) has been used for patients with COVID-19-associated acute respiratory distress syndrome (ARDS), its benefit in the nationwide setting is unknown. Aim: To evaluate the association between the use of ECMO and outcomes of COVID-19-associated ARDS in the nationwide setting. Methods: Using the United States National Inpatient Sample in 2020, we identified adults hospitalized and mechanically ventilated for COVID-19 with ARDS and divided them into three groups according to the use of ECMO (i.e., no-ECMO, venovenous [VV]-ECMO, and venoarterial [VA]-ECMO). The primary outcome was in-hospital mortality, and the secondary outcomes were the length of hospital stay (LOS) and the total costs during hospitalization. We applied a multivariable logistic regression model for the primary outcome, adjusting for baseline characteristics and underlying comorbidities. Results: Of the total of 72,415 included patients, 68,795, 3,280, and 340 patients received no-, VV-, and VA-ECMO, respectively (Table) . The crude mortality was the highest in the no-ECMO group (59.8%; 41,110/68,795), followed by VA-ECMO (47.1%; 160/340), and VV-ECMO groups (44.8%; 1,470/3,280). LOS was the longest in VV-ECMO group, followed by VA-ECMO, and no-ECMO groups. Similarly, the total costs during hospitalization were the highest in VV-ECMO group, followed by VA-ECMO, and no-ECMO groups. After adjusting for the covariates, VV- or VA-ECMO was not associated with lower mortality compared to no-ECMO (adjusted odds ratio [95% confidence interval]: 0.98 [0.82-1.18] and 1.12 [0.62-2.04], respectively). Conclusions: In the nationwide setting, ECMO was not associated with improved mortality in patients with COVID-19-associated ARDS but was associated with longer LOS and higher costs. Future studies exploring the characteristics of suitable candidates for ECMO are warranted.

A Retrospective Study Evaluating the Association of Qualitative and Quantitative Aspects of Vaso-Occlusive Crises (VOC) with Length of Hospital Stay in Children with Sickle Cell Disease Hospitalized for a VOC

Background: Children with sickle cell disease (SCD) are at risk for developing a vaso-occlusive pain crisis (VOC) due to sickled red blood cells causing turbulent blood flow and obstruction within the vasculature, leading to local tissue infarcts and subsequently pain. A VOC can often be managed with analgesics and supportive care either at home or in the emergency room. However, sometimes the pain is not adequately controlled in those settings, so children require hospitalization for further management of their VOC. There exists a high degree of variability in length of hospital stay (LOS) among children who are admitted for VOCs. The purpose of this study is to determine which factors are associated with decreased or increased length of hospital stay (LOS). By identifying these factors, it will allow for a more targeted approach to VOC management with the goal of improving overall pain and reducing LOS. Methods: This 3 year (2019 - 2022) retrospective cohort study includes 88 patients (5 years to 27 years of age) with sickle cell disease (HbSS, HbSB0, HbSB+, HbSC) who were hospitalized for VOC management. Several variables were analyzed to determine if they correlated with LOS. These variables included SCD genotype, age, sex, pain scores, average hemoglobin and reticulocyte levels during hospitalization, pain medication dosage and frequency, blood transfusions and complications during hospitalization. The statistical analysis of these variables was conducted across all VOCs of all patients. Results: There were 289 hospital admissions for VOCs with a mean of 3.55 hospital admissions per patient among the 88 patients with SCD during study duration. LOS for these VOC hospital admissions ranged from 1 day to 10 days with an overall mean of 3.81 days per hospital admission. LOS was independently highest in females (mean LOS = 4.123 days, F (1, 287) = 6.415, p = .012) and patients who developed acute chest syndrome (mean LOS = 6.333 days, F (9, 277) = 4.771, p &amp;lt; .001). LOS positively correlated with pain scores (r 2 = .272, p = .002), number of blood transfusions (r 2 = .229, p &amp;lt; .001) and total units of blood transfused during admission (r 2 = .230, p &amp;lt; .001) and negatively correlated with morphine frequency (r 2 = -.125, p = .042) and average hemoglobin during admission (r 2 = -.142, p = .016). SCD genotype, age, reticulocyte levels and medication dosage were not found to have a statistically significant association with LOS. Conclusion: Our study showed that factors such as higher average pain scores, number of blood transfusions, total units of blood transfused, females and acute chest syndrome were associated with longer LOS. Other factors such as more frequent morphine administration and higher average hemoglobin levels were associated with shorter LOS. While this study provides initial insight into some of the factors that are associated with LOS in children with SCD admitted for a VOC, further studies are warranted to determine if these factors can be used to risk stratify patients in terms of severity of VOC and thereby better optimize and individualize their pain management.

Pneumomediastinum: Experience with 87 Patients.

The aim of the present series was first to present our experience in the management of 37 patients with spontaneous pneumomediastinum (SPM), and further to indicate the necessity of identifying true SPM cases as they are currently inadequately defined. This is a single-center, retrospective study, conducted in a university hospital. Consecutive adult patients with pneumomediastinum (PM) between January 2009 and March 2020 were involved in the series. The data about age, gender, symptoms, signs, treatment, length of hospital stay (LOS), and in-hospital mortality were evaluated. In total, 87 cases with pneumomediastinum (37 with spontaneous and 50 with secondary PM) were analyzed. Patients in both groups were of similar ages (P=0.4). Sufferers with secondary PM were more likely to have: an associated pneumothorax (19% vs 58%, P<0.05), a chest tube placed (18.9% vs 58%, P<0.05), an associated pleural effusion (0% vs 18%, P<0.05). They presented with a longer LOS (3.9 vs 5.3 days, P<0.05), and were more likely to die (0% vs 10%, P<0.05). Additionally they showed a higher prevalence of radiologic subcutaneous emphysema (49% vs 74%, P<0.05). Spontaneous pneumomediastinum is an onset of clinical importance with a low mortality rate, short LOS and good longterm prognosis. It often presents with chest pain, dyspnea and/or subcutaneous emphysema. However, secondary causes of mediastinal air must be ruled out, due to their potential devastating outcome if not diagnosed promptly. A consensus aimed at an update of the classification guidelines is more than indispensable.

Enhanced recovery programme after colorectal surgery in high-income and low-middle income countries: a systematic review and meta-analysis.

Enhanced recovery after surgery (ERAS) protocols strive to optimise outcomes following elective surgery; however, there is a dearth of evidence to support its equitable application and efficacy internationally. The authors performed a systematic review and meta-analysis of studies on the uptake and impact of ERAS with the aim of highlighting differences in implementation and outcomes across high-income countries (HICs) and low-middle income countries (LMICs). The primary outcome was characterisation of global ERAS uptake. Secondary outcomes included length of hospital stay (LOS), 30-day readmission, 30-day mortality and postoperative complications. Three hundred thirty-seven studies with considerable heterogeneity were included in the analysis (291 from HICs, and 46 from LMICs) with a total of 110190 patients. The weighted median number of implemented elements were similar between HICs and LMICs ( P =0·94), but there was a trend towards greater uptake of less affordable elements across all aspects of the ERAS pathway in HICs. The mean LOS was significantly shorter in patient cohorts in HICs (5·85 days versus 7·17 days in LMICs, P <0·001). The 30-day readmission rate was higher in HICs (8·5 vs. 4·25% in LMICs, P <0·001, but no overall world-wide effect when ERAS compared to controls (OR 1·00, 95% CI: 0·88-1·13). There were no reported differences in complications ( P =0·229) or 30-day mortality ( P =0·949). Considerable variation in the structure, the implementation and outcomes of ERAS exists between HICs and LMICs, where affordable elements are implemented, contributing towards longer LOS in LMICs. Global efforts are required to ensure equitable access, effective ERAS implementation and a higher standard of perioperative care world-wide.

Linear and non‑linear indices of vagal nerve in relation to sex and inflammation in patients with Covid‑19.

Hyperinflammation is one of the most important pathophysiological risk factors for poor prognosis in patients with coronavirus disease-2019 (Covid-19). Low vagal neuro-immune modulation can lead into this kind of immune dysregulation. The association between vagal activity, sex and inflammatory markers were investigated in patients with Covid-19. A total of 19 patients with Covid-19 were included in the present study. Vagus nerve activity was indexed by heart rate variability (HRV) derived from electrocardiogram at hospital admission. Linear HRV parameters included the root mean square of successive RR interval differences (RMSSD) and high-frequency HRV (HF-HRV), while non-linear parameters included 2 UV%. Immune/inflammatory parameters included C-reactive protein (CRP), interleukin-6 (IL-6), neutrophil/lymphocyte ratio (NLR), systemic inflammatory index (SII), and procalcitonin (PCT). It has been revealed that both linear HRV indices HF-HRV and RMSSD, are significantly negatively correlated with CRP and IL-6, independent of age. The non-linear index of 2 UV% is significantly negatively correlated with NLR and SII, which reflect subtle changes in the response of immunocompetent cells. Patients that received high-flow nasal oxygen therapy had significantly higher IL-6 and CRP levels and lower levels of HF-HRV and RMSSD. These patients also had a significantly longer length of stay in hospital (LOS) than patients receiving low-flow oxygen therapy. Men had higher plasma PCT levels and longer LOS in hospital than women, and PCT statistically explained (mediated) the association between sex and LOS. The present study showed different correlations of linear and non-linear vagal indexes of HRV and inflammatory markers in patients with Covid-19. Significant sex differences in certain inflammatory markers were also observed, which may very well verify previous findings of poor prognosis in men with Covid-19. HRV reflects a continuous interaction between the sympathetic and parasympathetic autonomic nervous systems, which are affected by mental or physical stress, and certain disease states. The increased sympathetic and decreased parasympathetic vagal tone contribute to a higher risk of diseases associated with inflammation, cardiovascular disease, cancer, pulmonary diseases and other pathologies, including infectious diseases such as Covid-19. The present study showed that higher RMSSD (a marker of vagal activity) in Covid-19 patients is associated with lower levels of inflammatory biomarkers, a lower need for treatment and is negatively correlated with intensive care unit admission, leading to a shorter hospital stay. These findings support the idea that activation of vagus nerve may help certain Covid-19 patients by reducing the cytokine storm and excessive inflammation.

Clinical Characteristics and Outcomes of Patients Hospitalized with Epidermolysis Bullosa: A Retrospective Population-Based Observational Study in Spain (2016-2021).

(1) Background: Epidermolysis bullosa (EB) comprises a group of rare skin diseases. We assessed diagnostic procedures, comorbidity profiles, length of hospital stay (LOHS), costs, and in-hospital mortality (IHM) associated with EB. (2) Methods: A retrospective, population-based observational study was performed using the Spanish National Hospital Discharge Database. Hospitalized patients with EB in Spain were identified for the period 2016 to 2021. (3) Results: A total of 677 hospitalizations were identified among 342 patients with a diagnosis of EB. Fifty percent of patients had at least one readmission during the 6-year follow-up. Notably, rehospitalizations were more common among patients aged 2-17 years. The most prevalent comorbidity was digestive disorders, which were associated with the frequency of esophageal dilatation procedures and percutaneous endoscopic gastrostomy. The longest LOHS was recorded for the 0- to 1-year age group. IHM increased with age, and the difference was statistically significant. The prevalence of malignant neoplasm was 36.88%, with cutaneous squamous cell carcinoma being the most frequent. The overall cost per hospitalized patient was estimated to be EUR 10,895.22 (SD EUR 13,394.81), with significant variations between age groups. (4) Conclusions: Readmissions are very frequent among people with EB. We observed a higher LOHS in the 0- to 1-year age group, while the highest rates of IHM were observed in patients older than 50 years. There was a substantial prevalence of comorbidities, namely, digestive disorders, infectious diseases, and especially cancer.

Hematocrit and lactate trends help predict outcomes in trauma independent of CT and other clinical parameters.

Hematocrit and lactate have an established role in trauma as indicators of bleeding and cell death, respectively. The wide availability of CT imaging and clinical data poses the question of how these can be used in combination to predict outcomes. To assess the utility of hematocrit or lactate trends in predicting intensive care unit (ICU) admission and hospital length of stay (LOS) in patients with torso trauma combined with clinical parameters and injury findings on CT. This was a single-center retrospective study of adults with torso trauma in one year. Trends were defined as a unit change per hour. CT findings and clinical parameters were explanatory variables. Outcomes were ICU admission and hospital LOS. Multivariate logistic and negative binomial regression models were used to calculate the odds ratio (OR) and incident rate ratio (IRR). Among 840 patients, 561 (72% males, age 39 ± 18) were included, and 168 patients (30%) were admitted to the ICU. Decreasing hematocrit trend [OR 2.54 (1.41-4.58), p = 0.002] and increasing lactate trend [OR 3.85 (1.35-11.01), p = 0.012] were associated with increased odds of ICU admission. LOS median was 2 (IQR: 1-5) days. Decreasing hematocrit trend [IRR 1.37 (1.13-1.66), p = 0.002] and increasing lactate trend [2.02 (1.43-2.85), p < 0.001] were associated with longer hospital LOS. Hematocrit and lactate trends may be helpful in predicting ICU admission and LOS in torso trauma independent of organ injuries on CT, age, or admission clinical parameters.

Evolving microbial patterns of acute mastoiditis in pediatric patients undergoing mastoidectomy.

To investigate the microbial patterns and clinical outcomes of pediatric patients undergoing mastoidectomy for acute coalescent mastoiditis and to identify factors associated with poor outcomes and/or prolonged treatment. Monocentric retrospective cohort study. Tertiary referral pediatric hospital in Indiana. By cross-referencing database data from the Pediatric Health Information System (PHIS) querying for all inpatient stays (patients younger than eighteen) with a diagnostic code of mastoiditis between January 1st, 2010 and August 31, 2019, and the electronic health record (Cerner) for Riley Hospital for Children, 46 patients with mastoidectomy were included. A two-tailed T-test was used to evaluate continuous parametric data. Statistical significance was determined as P<0.05. For continuous variables, data was analyzed using continuous logistic regression. A criteria of p>0.1 was used for inclusion in the multivariate regression. Inclusion criteria was met by 46 patients. From 2010 to 2019, S. pyogenes and S. pneumoniae were the most common bacteria, each isolated in 11 of 42 bacterial isolates (26.2%). There was no growth in 35.4% (17/48) of intra-operative wound cultures. On univariate analysis, patients with negative cultures had longer length of hospital stay (LOS) (7.7 days [6.5] vs. 4.3 [2.8]; p=0.018) as well as higher rates of PICC (peripherally inserted central catheter) placement (53.3% vs. 19.4%; p=0.021). There was a statistically significant difference in terms of gender (p=0.021), with 15 males and 16 females in the positive culture cohort and 13 males and 2 females in the negative culture cohort. On multivariate analysis, which included gender, PICC placement, both intracranial and extracranial complications, duration of antibiotics, and LOS, female gender was the only significant predictor of positive culture status (p=0.039). S. pyogenes and S. pneumoniae were the predominant etiologic agents in acute coalescent mastoiditis between 2010 and 2019, and negative wound cultures were associated with worse clinical outcomes.