Longer Mean Length Of Hospital Research Articles

Impact of Iron Supplementation on Hospital Length of Stay for Pneumonia or Skin and Skin Structure Infections: A Retrospective Cohort Study.

Objectives: Pathogenic organisms utilize iron to survive and replicate and have evolved many processes to extract iron from human hosts. The goal of this study was to elucidate the impact of iron supplementation given in the setting of acute infection. Methods: This was a retrospective cohort study of Veterans Affairs patients who received intravenous antibiotics for pneumonia or skin and skin structure infections. Five-thousand subjects were included in each of the 2 cohorts: iron-receiving and non-iron-receiving. Data was analyzed using Fischer's Exact test if categorical and independent t-tests if continuous. Primary and secondary objectives analyzed with Cox proportional hazard regression and outcome rates estimated utilizing Kaplan-Meier method. Results: Five-thousand patients were included in each cohort. The iron cohort was significantly older (Mean-years: Iron = 71.6, No-iron = 68.9; mean-difference = 2.7, P < .0001) with reduced renal function (Mean-eGFR[mL/min/1.73 m²]: Iron = 67.2, No-iron = 77.4; mean-difference = 10.2, P < .0001). For the primary outcome, the iron cohort had a significantly longer mean length of hospital stay (10.4 days) compared to the no-iron cohort (8.7 days) (mean difference 1.7 days, P < .0001). Secondary outcome analysis showed the iron cohort received intravenous antibiotics for longer (Iron = 8.2 days, No-iron = 7.1 days; mean-difference = 1.1 days, P < .0001) with a higher proportion of 30-day readmissions (Iron = 15.6%, No-iron = 12.8%; proportion difference = 2.8%, P < .0001). No significant difference was found between cohort proportions for 30-day mortality (Iron = 12.7%, No-iron = 11.3%, proportion difference = 1.4%, P = .052). Conclusions: Baseline characteristic differences between cohorts is representative of patients who would be expected to require iron replacement therapy. Given the magnitude of primary and secondary-outcomes, further studies controlling for these factors would be warranted.

Impact of the COVID-19 pandemic and restrictive measures on acute appendicitis: Do not let your guard down.

The COVID-19 pandemic has altered the usual dynamics of consultation and presentation for acute appendicitis (AA). The aim of this study was to evaluate the impact of the pandemic and restrictive measures on the cases of AA. A retrospective study of patients diagnosed with AA between December 2019 and July 2020 was conducted. Patients were classified into two groups; one that underwent treatment in the 16 weeks before the implementation of lockdown in Argentina (Group 1) and another that underwent treatment in the 16 weeks after (Group 2). Demographic, clinical and surgical variables were evaluated. Overall, 91 patients underwent surgery, 61 and 30 patients in each group, showing a 51% drop in the incidence. The second group delayed seeking medical care longer (mean 46 h vs. 27 h, P < 0.05), had a higher rate of perforated appendicitis (30% vs. 11%, P < 0.05) and a higher rate of complicated appendicitis (56.6% vs. 18%, P < 0.01). These results were associated with a longer operative time (43.7 ± 15.5 min vs. 36.1 ± 11.1 min, P < 0.05) and a longer mean length of hospital stay (1.9 days vs. 1.4 days, P < 0.01); however, no increase in the quantity and severity of post-operative complications was observed. COVID-19 pandemic and restrictive social measures led to fewer consultations for abdominal pain, resulting in a lower number of AA diagnosed. In addition, a longer delay in seeking medical care was observed, leading to more advanced disease, longer operative time and length of hospital stay.

Therapeutic plasma exchange practices in immune thrombocytopenia related hospitalizations: Results from a nationally representative sample.

Per the American Society for Apheresis, therapeutic plasma exchange (TPE) is a Category III indication in the management of immune thrombocytopenia (ITP). This nationally representative study evaluates TPE utilization in hospitalized adults with a primary admission diagnosis of ITP. Hospitalizations with ITP as the primary admitting diagnosis were analyzed from the 2010 to 2014 National Inpatient Sample, the largest all-payer inpatient database in the United States. Univariate and multivariable logistic regressions were used to determine clinical outcomes in ITP patients undergoing TPE. Sampling weights were applied to generate nationally representative estimates. From 2010 to 2014, there were a total of 56,149 admissions with a primary admitting diagnosis of ITP, of which 0.66% admissions (n=372) also coded TPE. Most subjects undergoing TPE were the highest disease severity class: major (34.6%) and extreme severity (31.0%), by all-patients refined diagnoses-related groups severity of illness subclass. After multivariable analysis, underlying severity of illness remained the most significant predictor of TPE (P < .001). ITP admissions with TPE had a high rate of comorbidities (50%) and significantly longer mean length of hospital stay than those without (P < .001). TPE was reported in ~0.6% of hospitalizations with ITP as the primary diagnosis in this nationally representative sample from 2010 to 2014. TPE was performed in patients with the highest severity of underlying illness, and higher rates of comorbidities.

Human bocavirus and human metapneumovirus in children with lower respiratory tract infections: Effects on clinical, microbiological features and disease severity .

We aimed to compare the clinical findings of human bocavirus (HBoV) and human metapneumovirus (HMPV) infections, and to analyze the effects of coinfections on clinical features and disease severity in children with HBoV and HMPV infections. Data were collected from 125 children with lower respiratory tract infections due to HBoV or HMPV, detected from nasal swap by real-time polymerase chain reaction (PCR) during the period from January, 2013 to December, 2017. In total, there were 101 HBoV (group 1) and 23 HMPV (group 2) infections in our data. The patients were further divided into four subgroups according to the coinfection status: HoBV only (subgroup 1, n = 41), HMPV only (subgroup 2, n = 19), HBoV and coinfection with other respiratory viruses (subgroup 3, n = 60), and HMPV and coinfection with other respiratory viruses (subgroup 4, n = 4). The majority (88.8%) of the patients were aged 5 years or younger. Coinfections with other respiratory viruses were significantly more common in group 1 (P = 0.001). Among patients who had nosocomial pneumonia, patients with HBoV infections had significantly longer mean length of hospital stay (LOS) than those with HMPV infections (P = 0.032). The hospitalization and antibiotic requirements were significantly higher in subgroup 1 than subgroup 3 (P = 0.005, 0.039, resp.) According to the logistic regression analyses, the LOS increased by 21.7 times with HBoV infections (P = 0.006). Human bocavirus and HMPV infections are serious pathogens mostly seen in children and usually requiring hospitalization regardless of co-infection status. The HBoV infections caused longer LOS than the HMPV infections in patients with nosocomial infections.

Admission to the Regular Ward is Safe Following Uncomplicated Craniosynostosis Surgery: A Retrospective Study

Background: At our craniofacial center patients are routinely admitted to a regular ward, or floor, rather an intensive care unit (ICU) after uncomplicated craniosynostosis surgery. In this study, we review the safety of our postoperative placement policy, examining the rate of transfer from floor to ICU. Methods: The charts of patients who underwent craniosynostosis surgery from 2009 through 2017 at a single children’s hospital were reviewed. Postoperative hospital courses were characterized as preoperatively-planned ICU admission, perioperatively-planned ICU admission, or primary floor admission. The primary outcome was transfer from floor to ICU. Secondary outcomes included duration of hospitalization. Results: Chart review yielded 420 patients. Three hundred sixty-eight (88%) were admitted directly to the floor and 52 (12.0%) directly to an ICU. Of patients admitted to the floor, 2 (0.5%) were transferred to an ICU. Twenty-four patients with syndromic and 20 patients with multisutural craniosynostosis were admitted to the floor. Only 1 patient from each group (the same patient; 4.2% and 5.0%, respectively), was transferred to an ICU. Thirty-two ICU admissions were preoperatively planned and 20 were perioperatively planned. Reasons for preoperatively planned ICU admission included significant comorbidities and type of surgery. Reasons for perioperatively planned ICU admissions included significant intraoperative adverse events, excessive blood loss, and failure of clearance from the post-anesthesia care unit (PACU). Patients admitted to the ICU had a statistically significant longer mean length of hospitalization (4.8 days vs 2.7 days) than did patients admitted to the floor. Conclusions: Most postoperative craniosynostosis surgery patients—including patients with syndromic and/or multisutural synostosis—are managed safely on the floor at our center. Some patients still need postoperative ICU admission, but are easily identified preoperatively, intraoperatively, or in the PACU. Our findings should be applicable to other large craniofacial centers.

Minimally invasive treatment of laryngoceles: a systematic review and pooled analysis.

Laryngoceles are best treated with surgery. The goal of this study is to compare patient outcomes and complications in patients undergoing removal of laryngoceles with either transoral endoscopic/microlaryngoscopic or robotic approaches. A systematic review of the published literature was conducted using Pubmed, Web of Science, and the Cochrane Clinical Trials databases. A pooled analysis of individual data was used to compare outcomes between robotic and endoscopic approaches. A total of 30 studies were included. Nine studies with 95 patients were included in the final analysis. Eighty-one (85.26%) were treated with microlaryngoscopic surgery and 14 (14.74%) were treated with robotic-assisted surgery. The rates of tracheostomy (RR = 1.44, 95% CI = 0.389-5.332), complications (RR = 0.329, 95% CI = 0.047-2.294) and recurrence (RR = 0.354, 95% CI = 0.021-5.897) were not statistically different between groups. Within the endoscopic subgroup, 66 laryngoceles (78.57%) were completely excised, while 18 (21.43%) laryngoceles were treated with marsupialization. Marsupialization was associated with an increased risk of recurrence (RR = 4.889, 95% CI = 1.202-19.891). In the robotic subgroup, there was an increased risk of nasogastric tube use (RR = 103.867, 95% CI = 6.379-1619.214) and a longer mean length of hospital stay (p = 0.0001). Transoral treatment of laryngoceles has complication and recurrence rates of 18.95% and 7.37%, respectively. Robotic approaches are associated with higher rates of NGT use and increased hospital stay, however much of this is due to one robotic surgeon's preference for routine NGT placement and higher rates of combined laryngocele removal via robotic approach. Complete excision of combined laryngoceles is possible with transoral approaches. Marsupialization, reported in traditional endoscopic approaches, is associated with a significantly higher rate of recurrence (22.22% vs. 4.76%).

HIPEC after neoadjuvant chemotherapy and interval debulking is associated with development of platinum-refractory or -resistant disease

ObjectiveTo describe our single-institution oncologic outcomes of patients who received neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC). MethodsWe compared clinicopathologic information and outcomes for all patients with advanced stage, high-grade serous ovarian cancer who received NACT and IDS with (N = 20) or without (N = 48) HIPEC at our institution from 2010 to 2019 ResultsMean age (62 years with HIPEC and 60 years without HIPEC) and proportion of stage 4 disease (40% for both) did not differ between cohorts. HIPEC patients had higher rates of complete cytoreduction (95% vs 50%), longer mean duration of surgery (530 vs. 216 min), more grade 3 or 4 postoperative complications (65% vs. 4%), and longer mean length of hospital stay (8 vs. 5 days). HIPEC patients had significantly higher risk for platinum-refractory progression or platinum-resistance recurrence (50% vs 23%; RR = 2.18; 95% CI 1.11, 4.30, p = 0.024). Median progression free survival (11.5 vs. 12 months) and all-cause mortality (19.1 vs. 30.5 months) in the HIPEC and non-HIPEC cohorts, respectively, did not differ ConclusionsHIPEC was associated with increased risk for platinum refractory or resistant disease. Higher surgical complexity may contribute to higher complication rates without improving oncologic outcomes in our patients. Further investigations and long-term follow-up are needed to assess the utility of HIPEC in primary treatment of advanced stage ovarian cancer

Hospitalizations for Community-Acquired and Non-Ventilator-Associated Hospital-Acquired Pneumonia in Spain: Influence of the Presence of Bronchiectasis. A Retrospective Database Study

To examine and compare in-hospital mortality (IHM) of community-acquired pneumonia (CAP) and non-ventilator hospital-acquired pneumonia (NV-HAP) among patients with or without bronchiectasis (BQ) using propensity score matching. A retrospective observational epidemiological study using the Spanish Hospital Discharge Records, 2016–17. We identified 257,455 admissions with CAP (3.97% with BQ) and 17,069 with NV-HAP (2.07% with BQ). Patients with CAP and BQ had less comorbidity, lower IHM, and a longer mean length of hospital stay (p < 0.001) than non-BQ patients. They had a higher number of isolated microorganisms, including Pseudomonas aeruginosa. In patients with BQ and NV-HAP, no differences were observed with respect to comorbidity, in-hospital mortality (IHM), or mean length of stay. P. aeruginosa was more frequent (p = 0.028). IHM for CAP and NV-HAP with BQ was 7.89% and 20.06%, respectively. The factors associated with IHM in CAP with BQ were age, comorbidity, pressure ulcers, surgery, dialysis, and invasive ventilation, whereas in NV-HAP with BQ, the determinants were age, metastatic cancer, need for dialysis, and invasive ventilation. Patients with CAP and BQ have less comorbidity, lower IHM and a longer mean length of hospital stay than non-BQ patients. However, they had a higher number of isolated microorganisms, including Pseudomonas aeruginosa. In patients with BQ and NV-HAP, no differences were observed with respect to comorbidity, in-hospital mortality, or mean length of stay, but they had a greater frequency of infection by P. aeruginosa than non-BQ patients. Predictors of IHM for both types of pneumonia among BQ patients included dialysis and invasive ventilation.

Robotic Cholecystectomy Is a Safe Educational Alternative to Laparoscopic Cholecystectomy During General Surgical Training: A Pilot Study

The role of robotic surgery in general surgery (GS) continues to expand. Several programs have integrated robotic-based simulators and models into surgical education; however, residents' robotic experience in the operating room is currently limited. We sought to assess the safety and feasibility of robotic cholecystectomy (RC) when independently performed by GS chief residents. From June 2016 to October 2018, RC and laparoscopic cholecystectomies (LC) performed independently by chief residents on a resident staff surgical service were prospectively included. Patient demographics, intraoperative variables, and postoperative complications were analyzed and compared between both cohorts. A total of 20 RC and 70 LC were included. Patient characteristics, indications for surgery, and comorbidities were similar in both groups. RC was more likely to be performed electively (95% vs. 17.1%, p < 0.001). No difference in operative time, estimated blood loss, intraoperative bile duct injury, or conversion to open was observed. Patients undergoing LC had an overall longer mean length of hospital stay (2.7 days ± 2.1 vs. 0.8 days ± 0.4, p < 0.001); however, length of hospital stay was similar between RC and LC performed electively (p = 0.946). No difference in postoperative complications and 30-day readmission was observed. RC can be safely and independently performed by GS residents with similar outcomes as LC. Efforts should be directed toward creating a platform to bridge competent simulator skills into safe performance in the operating suite. The integration of robotic training into the core GS curriculum should be encouraged.

Effect of Anemia in Postoperative Outcomes of Autologous Breast Reconstruction Surgery.

BACKGROUNDThe true effects of anemia on postoperative surgical outcomes in autologous breast reconstruction surgery are unknown. We intended to evaluate the effect of chronic anemia on surgical outcomes in autologous breast reconstruction surgeries using a large national database.METHODSUsing the Nationwide Inpatient Sample database, we examined the clinical data of patients who underwent immediate or delayed autologous breast reconstruction surgery from 2012 to 2014. Univariate and multivariate regression analyses were performed to independently evaluate the effect of chronic anemia on postoperative outcomes.RESULTSTotally, 55,839 patients underwent autologous breast reconstruction surgery (immediate: 40% vs. delayed: 60%) during this period. Overall, 6.0% of patients had chronic anemia at the time of surgery. Compared with patients without chronic anemia, patients with chronic anemia had a significantly higher complication rate (19.8% vs. 9.4%) and a longer mean length of hospital stay (5.4 vs. 3.7 days). Postoperative complications were significantly higher in patients with chronic anemia compared with patients without chronic anemia except for venous thromboembolism (VTE) and fat necrosis. Multivariate regression analyses demonstrated that chronic anemia was independently associated with an increased overall complication rate (adjusted odds ratio: 2.20). Also, multivariate regression analyses showed that chronic anemia was an independent risk factor of all the evaluated postoperative complications except VTE, stroke and fat necrosis.CONCLUSIONThis study demonstrated that chronic anemia was a significant predictor factor of morbidity in autologous breast reconstruction including flap failure. Correction of anemia prior to breast reconstruction may help reduce poor surgical outcomes related to chronic anemia.

Safety and Efficacy of Nonanesthesiologist-Administrated Propofol during Endoscopic Submucosal Dissection of Gastric Epithelial Tumors.

Objective There is no consensus regarding administration of propofol for performing endoscopic submucosal dissection (ESD) in patients with comorbidities. The aim of this study was to evaluate the safety and efficacy of propofol-induced sedation administered by nonanesthesiologists during ESD of gastric cancer in patients with comorbidities classified according to the American Society of Anesthesiologists (ASA) physical status. Methods Five hundred and twenty-two patients who underwent ESD for gastric epithelial tumors under sedation by nonanesthesiologist-administrated propofol between April 2011 and October 2017 at Dokkyo Medical University Hospital were enrolled in this study. The patients were divided into 3 groups according to the ASA physical status classification. Hypotension, desaturation, and bradycardia were evaluated as the adverse events associated with propofol. The safety of sedation by nonanesthesiologist-administrated propofol was measured as the primary outcome. Results The patients were classified according to the ASA physical status classification: 182 with no comorbidity (ASA 1), 273 with mild comorbidity (ASA 2), and 67 with severe comorbidity (ASA 3). The median age of the patients with ASA physical status of 2/3 was higher than the median age of those with ASA physical status of 1. There was no significant difference in tumor characteristics, total amount of propofol used, or ESD procedure time, among the 3 groups. Adverse events related to propofol in the 522 patients were as follows: hypotension (systolic blood pressure < 90 mmHg) in 113 patients (21.6%), respiratory depression (SpO2 < 90%) in 265 patients (50.8%), and bradycardia (pulse rate < 50 bpm) in 39 patients (7.47%). There was no significant difference in the incidences of adverse events among the 3 groups during induction, maintenance, or recovery. No severe adverse event was reported. ASA 3 patients had a significantly longer mean length of hospital stay (8 days for ASA 1, 9 days for ASA 2, and 9 days for ASA 3, P = 0.003). However, the difference did not appear to be clinically significant. Conclusions Sedation by nonanesthesiologist-administrated propofol during ESD is safe and effective, even for at-risk patients according to the ASA physical status classification.

Platelet transfusion practices in immune thrombocytopenia related hospitalizations.

The role of platelet transfusions in management of Immune Thrombocytopenia (ITP) remains controversial. Current guidelines recommend that platelet transfusions in ITP be reserved for catastrophic hemorrhage or invasive surgical procedures. This study assesses the nationwide platelet transfusion practices in hospitalized children and adults with ITP. We studied hospitalizations with ITP as the primary admitting diagnosis from 2010-2014 in National Inpatient Sample (NIS), the largest all-payer inpatient database. Univariate and multivariable logistic regression analyses were used to determine factors predicting platelet transfusions. Sampling weights were applied to generate nationally representative estimates. Propensity score matching was used to perform sensitivity analyses. From 2010 to 2014, there were 78,376 admissions with ITP as the primary admission diagnosis (mean ± SD age: 45 ± 27 years; females 56%, children [age < 18 years] 22%) and 282,285 with ITP as one of all the admission diagnoses. Overall, 27% admissions with ITP as primary (children 4%) and 15% admissions with ITP as one of all the diagnoses documented at least one platelet transfusion. On multivariable adjustment the following factors were associated with worsening disease severity and a higher odds of platelet transfusion, adult age (adjOR = 9.03, 95% CI = 7.40-11.02), male gender (adjOR = 1.21, 95% CI = 1.11-1.31), bleeding occurrence (intracranial/gastrointestinal/genitourinary/epistaxis) (adjOR = 1.78, 95% CI = 1.61-1.96), admission to rural non-teaching hospital (adjOR = 1.85, 95% CI = 1.52-2.22), and small bed-size hospital (adjOR = 1.23, 95% CI = 1.05-1.45). Of admissions reporting platelet transfusions, only 26% reported a bleeding complication, and 11% had a major operating-room surgery/procedure. Overall, 65% of transfused patients had neither bleeding nor a major operative procedure during the hospitalization. Admissions with platelet transfusions had a significantly longer mean length of hospitalization 2.2 days (95% CI = 1.96-2.41, p < 0.001), and accrued higher mean total hospital charges; $31,150 USD (95% CI = 27,644-34,656, p < 0.001). However, platelet transfusions were not associated with in-hospital mortality (adjOR = 1.02, 95% CI = 0.73-1.45, p = 0.892). Platelets are administered to a small fraction of the hospitalized ITP patients. In a majority of these cases however, platelet usage does not appear to be concordant with the current guidelines or associated with improvement in clinical outcomes.

Effect of premature rupture of membranes on maternal infections and outcome of preterm infants

To investigate the effect of premature rupture of membranes (PROM) on maternal infections and outcome of preterm infants. A total of 441 preterm infants and 387 mothers were enrolled as subjects. According to the presence or absence of PROM, the mothers were divided into non-PROM group with 104 mothers, PROM duration <72 hours group with 90 mothers, and PROM duration ≥72 hours group with 193 mothers. The three groups were compared in terms of clinical features of mothers and infants and complications. Compared with the control group and the PROM duration <72 hours group, the PROM duration ≥72 hours group had significantly higher maternal age, incidence rate of umbilical vasculitis, and rate of antibiotic use; the PROM duration ≥72 hours group had a significantly higher incidence rate of moderate-to-severe chorioamnionitis than the control group (P<0.05), while there was no significant difference between the PROM duration ≥72 hours group and the PROM duration <72 hours group (P>0.05). Compared with the control group and the PROM duration <72 hours group, the PROM duration ≥72 hours group had significantly higher incidence rates of pneumonia and intracranial hemorrhage in preterm infants; the PROM duration ≥72 hours group had a significantly higher incidence rate of congenital infection and a significantly longer mean length of hospital stay compared with the control group (P<0.05), while there were no significant differences between the PROM duration ≥72 hours group and the PROM duration <72 hours group (P>0.05). The multivariate analysis showed that PROM duration ≥72 hours was an independent risk factors for pneumonia (OR=2.200, 95%CI: 1.386-3.492) and intracranial hemorrhage (OR=2.331, 95%CI: 1.420-3.827) in preterm infants. PROM duration ≥72 hours significantly increases the risk of placental infection in mothers and it is an independent risk factor for pneumonia and intracranial hemorrhage in preterm infants.

Burden of Obesity on Pediatric Inpatients with Acute Asthma Exacerbation in the United States

Obesity and asthma are common health problems in the United States. The objective of this study was to evaluate the clinical and economic burdens of obesity on hospitalized children with acute asthma exacerbation in2012. Hospital discharge records of patients aged 2 to 18 years with a diagnosis of asthma were obtained from the 2012 Kids' Inpatient Database, wherein the data were compiled by the Agency for Healthcare Research and Quality. The discharge records were weighted to estimate the number of hospitalizations because of asthma exacerbations in the United States. To classify whether the patient was obese or not, we used the International Classification of Diseases, Ninth Revision, Clinical Modification code 278.0x. We compared the odds of using noninvasive or invasive mechanical ventilation, mean total charges for inpatient service, and length of hospital stay between obese and nonobese patients. A total of 74,338 patient discharges were extracted. Of these, 3,494 discharges were excluded because of chronic medical conditions. Using discharge weight variables, we estimated a total of 100,157 hospitalizations with asthma exacerbations among children aged between 2 and 18 years in 2012. Obesity was significantly associated with higher odds of using mechanical ventilation (odds ratio 1.59, 95% CI 1.28-1.99), higher mean total hospital charges (adjusted difference: $1588, 95% CI $802-$2529), and longer mean length of hospital stay (0.24 days, 95% CI 0.17-0.32 days) compared with nonobesity. These findings suggest that obesity is a significant risk factor of severe asthma exacerbation that requiresmechanical ventilation, and obesity is an economicallycomplicating factor.

Various clinical conditions can mimic Crimean-Congo hemorrhagic fever in pediatric patients in endemic regions.

Crimean-Congo hemorrhagic fever (CCHF) is a tick-borne disease with high mortality. Many disorders can mimic CCHF. It is important to recognize the condition and to perform differential diagnosis in endemic countries. Twenty-one children aged 18 years or less with a preliminary diagnosis of CCHF were retrospectively evaluated. Real-time PCR and a confirmatory indirect immunofluorescence assay for negative results were performed. The diagnoses determined that 9 patients had (42.9%) CCHF; 7 patients had (33.3%) viral upper respiratory tract infections (URTI); 2 patients had (9.5%) brucellosis; 1 patients had (4.7%) periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome episode; 1 patient had (4.7%) cerebral palsy, diabetes insipidus, acute gastroenteritis, and hypernatremic dehydration; and 1 patient had (4.7%) cellulitis after a tick bite. The mean age of patients with CCHF was greater than that of the other patients (116.1±53.6 vs. 94.1±52.1 months, p=0.02). Seventeen (81%) of the children included had a history of tick bites, 2 (9.5%) had a history of contact with a patient with CCHF, and 2 (9.5%) had no exposure, but were living in an endemic region. Three patients had an underlying disorder: cerebral palsy and diabetes insipidus, epilepsy, or PFAPA. All of the children experienced fever. Other frequent symptoms were malaise, diarrhea, vomiting, and abdominal pain, but none of these differed statistically between the patient groups. CCHF patients had a longer mean duration of symptoms (10.56±1.42 vs. 6.75±3.62 days, p=0.008) and a longer mean length of hospitalization (8.00±2.08 vs. 3.58±1.56 days, p<0.001) than the other patients. At laboratory examination, patients with CCHF had statistically significant lower leukocyte and platelet counts, more prolonged coagulation parameters, and greater AST, ALT, LDH, and CK levels than the other patients. No mortality or complications occurred in the study. Both infectious causes, such as URTI, cellulitis, and brucellosis, and non-infectious causes may resemble CCHF. Although they are not pathognomonic, some indicators, including a longer symptom duration and hospitalization, cytopenia, elevated liver enzymes, creatine kinase and prolonged coagulation parameters, were found to be in favor of CCHF.

Abstract 16245: The Impact of Delirium After Trans-catheter Aortic Valve Replacement

Introduction: Delirium is associated with increased healthcare utilization, morbidity, and mortality. We assessed the impact of delirium on outcomes after trans-catheter aortic valve replacement (TAVR). Methods: We reviewed 294 consecutive cases of TAVR at a tertiary care academic medical center from June, 2008 to February, 2015. Delirium was identified by prospective confusion assessment method screening and retrospective chart review. The primary outcome was overall survival. Secondary outcomes included length of hospital stay, discharge destination, hospital re-admission within 30 days, and 30 day mortality. Results: Delirium was identified in 61 patients after TAVR (21%). Non-femoral access for TAVR was more common in delirious than non-delirious patients (41% vs 28%, P=0.04). There was no difference in the post-operative stroke rate between delirious and non-delirious patients (8% vs 6%, P=0.45). Post-TAVR respiratory failure was more common in delirious patients (21% vs 3%, P&lt;0.001). Of 13 delirious patients who developed respiratory failure, delirium preceded respiratory failure in 8 (62%). Median follow-up was 8.2 months. Delirious patients had decreased overall survival compared to non-delirious patients (figure, log-rank P&lt;0.01). After adjusting for Society of Thoracic Surgeons risk score and TAVR access type, delirium remained an independent predictor of overall survival (hazard ratio 1.97, 95% confidence interval 1.18 to 3.23, P&lt;0.01). Delirium was associated with longer mean length of hospital stay (13.3 +/- 9.5 days vs 6.7 +/- 3.8 days, P&lt;0.001) and higher rates of discharge to a rehabilitation facility (61% vs 27%, P&lt;0.001). There was no difference in 30 day hospital re-admission rates or 30 day mortality between groups. Conclusions: Delirium, a common syndrome after TAVR, is associated with decreased survival and increased healthcare utilization. Early detection of delirium after TAVR may help identify a high risk subset of patients.

Impact of Parkinson's disease on the acute care treatment and medium-term functional outcome in geriatric hip fracture patients.

Patients with Parkinson's disease (PD) have a heightened risk of sustaining hip fractures due to disturbed balance and gait insecurity. This study aims to determine the impact of PD on the perioperative course and medium-term functional outcome of patients with hip fractures. A total of 402 hip fracture patients, aged ≥60 years, were prospectively enrolled. On admission, the American Society of Anesthesiologists score, Mini-Mental Status Examination, and Barthel Index (BI), among other scales, were documented. The Hoehn and Yahr scale was used to assess the severity of PD. The functional outcome was assessed by performance on the BI, Tinetti test (TT), and Timed Up and Go test (TUG) at discharge and at the 6-month follow-up. Additionally, the length of hospitalization, perioperative complications, and discharge management were documented. A multivariate regression analysis was performed to control for influencing factors. A total of 19 patients (4.7%) had a concomitant diagnosis of PD. The functional outcome (BI, TT, and TUG) was comparable between groups (all p > 0.05). Grade II (52.6 vs. 26.1%; OR = 4.304, p = 0.008) and IV complications (15.8 vs. 4.4%; OR = 7.785, p = 0.012) occurred significantly more often among PD patients. While the diagnosis of PD was associated with a significantly longer mean length of hospital stay (β = 0.119, p = 0.024), the transfer from acute hospital care showed no significant difference (p = 0.246). Patients with an additional diagnosis of PD had inferior results in BI at the 6-month follow-up (p = 0.038). PD on hospital admission is not an independent risk factor for in-hospital mortality or an inferior functional outcome at hospital discharge. However, patients with PD are at risk for specific complications and longer hospitalization at the time of transfer from acute care so as for reduced abilities in activities of daily living in the medium term.

Outcomes after ileoanal pouch surgery in frail and older adults

BackgroundEvidence from single-center studies suggests that ileal pouch-anal anastomosis (IPAA) can be safely performed in selected older patients with ulcerative colitis. The impact of age and frailty on surgical outcomes and hospital length of stay after IPAA has not been examined. MethodsWe identified all patients with ulcerative colitis who underwent total proctocolectomy or completion proctectomy with IPAA in the National Surgery Quality Improvement Program database from 2005–2012. We examined the associations of age and frailty trait count with length of hospital stay and surgical complications using multivariate regression. ResultsIPAA was performed in 2493 patients with ulcerative colitis. Thirty-day mortality was 0.2% (n = 6). The majority of patients had no serious postoperative complications (age ≤50 y: 79.5%, age 51–60 y: 80.4%, and age >60 y: 79.1%). After multivariate risk adjustment, patients aged >60 y had a similar mean number of complications as patients aged ≤50 y (0.31 versus 0.35, P = 0.47) and a 0.8-d longer mean length of hospital stay (7.4 versus 8.2 d, P = 0.035). Compared to patients with zero frailty traits, a frailty trait count ≥1 was associated with a similar mean number of complications (0.31 versus 0.34, P = 0.36) and length of hospital stay (7.4 versus 7.7 d, P = 0.25). ConclusionsIn this analysis of patients undergoing IPAA at National Surgery Quality Improvement Program hospitals, surgical complications were not substantially increased in older patients or those with frailty traits. Older age was associated with a small increase in hospital length of stay. These findings suggest that IPAA is safe in selected older adults with ulcerative colitis.

Microbiological characteristics of acute osteoarticular infections in children.

This study aimed to describe the microbiological characteristics of acute septic arthritis (SA) and osteomyelitis (OM) in children. Cases of children (0-15 years) with SA/OM were identified through a retrospective search of hospital discharge codes over a six-year period. In addition, a systematic literature search and meta-analysis of studies reporting culture results of children with SA/OM was performed. In our retrospective chart review, we identified 65 cases of OM and 46 cases of SA. The most frequently cultured organisms in both conditions were Gram-positive cocci, primarily Staphylococcus aureus. On admission, most patients had a normal white blood cell count (WCC) but elevated C-reactive protein (CRP) and/or erythrocyte sedimentation rate (ESR). Bacteraemia was associated with a longer mean length of hospitalization for both infections. Considering our results and the meta-analysis, we found low rates of culture-positivity in cases of clinically confirmed infection. In SA, articular fluid was culture-positive in 42.49% [95% confidence interval (CI) 28.39-57.23]. In OM, intra-operative samples were culture-positive in 52.65% (95% CI 30.54-74.22). Bacteraemia was detected in 23.91% (95% CI 8.40-44.24) of children with SA and 21.48% (95% CI 10.89-34.47) with OM. Despite appropriate sampling, a positive microbiological diagnosis is often lacking in paediatric acute osteoarticular infection using standard culture-based methods. This highlights the need for validation and use of more sensitive diagnostic methods, such as PCR.

Retrospective case–control analysis of patients with staphylococcal infections receiving daptomycin or glycopeptide therapy

Glycopeptides have been considered the antimicrobials of choice for serious meticillin-resistant Staphylococcus aureus (MRSA) and meticillin-resistant coagulase-negative staphylococci (MR-CoNS) infections for several years. Daptomycin is a new option for the treatment of these infections, including those exhibiting reduced susceptibility to glycopeptides. The aim of this study was to compare glycopeptides and daptomycin for the treatment of infections caused by MRSA or MR-CoNS. Data for 106 patients with bloodstream infections (bacteraemia or infective endocarditis) or skin and soft-tissue infections (SSTIs) were retrospectively reviewed, of which 43 were treated with daptomycin (DAP group) and 63 were treated with vancomycin or teicoplanin (GLYCO group). Patients included in the two comparison groups were homogeneous in terms of age, risk factors and clinical severity. Aetiology was mainly represented by MRSA in both groups, followed by various species of MR-CoNS. Daptomycin was used more frequently in patients with central venous catheter-associated bacteraemia or pacemaker-associated infection. Patients with SSTIs included in the GLYCO group had a longer mean duration of antibiotic therapy (18.2 days vs. 14.6 days; P = 0.009) and a longer mean length of hospital stay (28.2 days vs. 19.6 days; P = 0.01) compared with those included in the DAP group. A longer mean duration of antibiotic therapy was also observed in patients with bloodstream infections receiving glycopeptide therapy (25.6 days vs. 18 days; P = 0.004). In conclusion, the good clinical efficacy of daptomycin is associated with a more rapid resolution of the clinical syndrome and a reduced length of hospitalisation. This latter aspect may have important pharmacoeconomic implications, promoting the use of daptomycin in the clinical setting.