Low-volume Group Research Articles

Association between case volume of ambulance stations and clinical outcomes of out-of-hospital cardiac arrest: A nationwide multilevel analysis

ObjectivesThe case volume effects of ambulance stations on the survival of out-of-hospital cardiac arrest (OHCA) patients are uncertain. This study was conducted to evaluate the association between the case volume of ambulance stations and clinical outcomes in OHCAs by the number of emergency medical services (EMS) providers at the scene. MethodsAdult cardiac EMS-treated OHCAs between 2015 and 2018 were enrolled. The main exposure was the annual OHCA case volumes of 204 ambulance stations in Korea, which were categorized into three groups; low-volume (<100), moderate-volume (100–159) and high-volume (≥160). The primary and secondary outcomes were good neurological recovery and survival to discharge. Multilevel multivariable logistic regression analysis was conducted to calculate adjusted odds ratios (AORs). Interaction analysis between the number of EMS providers at the scene and the exposure variable was performed. ResultsA total of 92,534 patients were enrolled. OHCAs in the low-volume group tended to be arrest in a public place or a non-metropolitan area, less prehospital administration of an advanced airway and intravenous management. Significant differences were found the main analysis: AORs (95% CIs) compared to the low-volume group were 1.15 (1.03–1.29) and 1.14 (1.03–1.27) in the high-volume and moderate-volume groups for good neurological recovery and 1.19 (1.07–1.33) and 1.14 (1.04–1.25) in the high-volume and moderate-volume groups for survival to discharge. Significant interaction effects between the number of EMS providers at the scene and case volume on clinical outcomes were found. ConclusionOHCA case volumes of ambulance stations are associated with clinical outcomes after cardiac arrest.

Effect of surgeon volume on long-term quality of life outcomes following tension-free vaginal tape surgery.

The role of the general obstetrician/gynaecologist completing routine urogynaecology procedures is controversial, and some research has suggested that these patients should be referred to high-volume subspecialists. In response to recent public and regulatory scrutiny of vaginal mesh procedures, credentialling guidelines have been released in Australia requiring surgeons to demonstrate a minimum caseload prior to performing tension-free vaginal tape (TVT) surgery for incontinence. Hence, a retrospective cohort study was conducted to evaluate the long-term quality of life outcomes of TVT procedures for high- and low-volume surgeons. One hundred seventy patients who had undergone TVT surgery between 1 May 2011 and 1 May 2016 in the Sunshine Coast health district were invited to complete the UDI-6 (Urinary Distress Inventory) and IIQ-7 (Incontinence Impact Questionnaire) surveys. Perioperative information was accessed from available health records. Mean UDI-6 and IIQ-7 scores were compared for high- and low-volume groups, and the groups were assessed for confounding factors. Of the 170 patients eligible, 83 completed the surveys (47.2%). No differences in UDI-6 or IIQ-7 scores were found between high- and low-volume surgeons (p > 0.05). High-volume surgeons completed more concomitant procedures amongst survey respondents (p < 0.05), though this was not reproduced when considering all 170 patients eligible for the study. There were no significant differences in age, ASA (American Society of Anaesthesiologists) score or complication rate amongst survey respondents. Amongst the patients surveyed, high- and low-volume surgeons had similar long-term quality of life outcomes for TVT surgery, without any significant difference in complication rate.

Impact of Individual Surgeon Volume on Outcomes Following LVAD Implantation

<h3>Purpose</h3> Surgeon volume affects outcomes of complex operations. However, it is not clear if individual surgeon volume in a large volume program affects left ventricular assist device (LVAD) outcomes. <h3>Methods</h3> We reviewed primary LVAD implants at our center between 2013 and 2020. Cases were dichotomized into a high-volume group (surgeons averaging more than 10 LVAD cases per year), and a low-volume group (10 or less cases per year). Propensity score matching was performed. Survival and incidence of major adverse events were compared; predictors of survival were identified with multivariable analysis. <h3>Results</h3> There were 315 patients who met inclusion criteria- 45 implants in the low-volume group, 270 in the high-volume group. In the propensity matched cohort, there was no difference in survival to hospital discharge between the low (91.9%) and high (91.7%) volume groups (p=1). Survival at 1-year was also similar between the groups (85.4% vs 88.6%, p=0.732). There was no difference in the incidence of major adverse events between the groups. Predictors of mortality in the first year included: age (Hazards Ratio [HR] 1.061, p<0.001), prior sternotomy (HR 1.991, p=0.014), elevated INR (HR 4.748, p<0.001), higher AST (HR 1.001, p=0.001), higher bilirubin (HR 1.081, p=0.014), and pre-operative mechanical ventilation (HR 2.662, p=0.005). Individual surgeon volume was not an independent predictor of discharge or one-year survival. <h3>Conclusion</h3> There was no difference in survival or adverse events between high and low volume surgeons suggesting that, in an experienced center, low-volume VAD surgeons can achieve similar outcomes to their high-volume colleagues.

Association Between Anesthesiologist Volume and Short-term Outcomes in Complex Gastrointestinal Cancer Surgery

Intraoperative anesthesiology care is crucial to high-quality surgical care. The clinical expertise and experience of anesthesiologists may decrease the risk of adverse outcomes. To examine the association between anesthesiologist volume and short-term postoperative outcomes for complex gastrointestinal (GI) cancer surgery. This population-based cohort study used administrative health care data sets from various data sources in Ontario, Canada. Adult patients who underwent esophagectomy, pancreatectomy, or hepatectomy for GI cancer from January 1, 2007, to December 31, 2018, were eligible. Patients with an invalid identification number, a duplicate surgery record, and missing primary anesthesiologist information were excluded. Primary anesthesiologist volume was defined as the annual number of procedures of interest (esophagectomy, pancreatectomy, and hepatectomy) supported by that anesthesiologist in the 2 years before the index surgery. Volume was dichotomized into low-volume and high-volume categories, with 75th percentile or 6 or more procedures per year selected as the cutoff point. The primary outcome was a composite of 90-day major morbidity (with a Clavien-Dindo classification grade 3-5) and readmission. Secondary outcomes were individual components of the primary outcome. The association between exposure and outcomes was examined using multivariable logistic regression models, accounting for potential confounders. Of the 8096 patients included, 5369 were men (66.3%) and the median (interquartile range [IQR]) age was 65 (57-72) years. Operations were supported by 842 anesthesiologists and performed by 186 surgeons, and the median (IQR) anesthesiologist volume was 3 (1.5-6) procedures per year. A total of 2166 patients (26.7%) received care from high-volume anesthesiologists. Primary outcome occurred in 36.3% of patients in the high-volume group and 45.7% of patients in the low-volume group. After adjustment, care by high-volume anesthesiologists was independently associated with lower odds of the primary outcome (adjusted odds ratio [aOR], 0.85; 95% CI, 0.76-0.94), major morbidity (aOR, 0.83; 95% CI, 0.75-0.91), unplanned intensive care unit admission (aOR, 0.84; 95% CI, 0.76-0.94), but not readmission (aOR, 0.87; 95% CI, 0.73-1.05) or mortality (aOR, 1.05; 95% CI, 0.84-1.31). E-values analysis indicated that an unmeasured variable would unlikely substantively change the observed risk estimates. This study found that, among adults who underwent complex gastrointestinal cancer surgery, those who received care from high-volume anesthesiologists had a lower risk of adverse postoperative outcomes compared with those who received care from low-volume anesthesiologists. These findings support organizing perioperative care to increase anesthesiologist volume to optimize patient outcomes.

Association between hospital surgical volume and complications after total hip arthroplasty in femoral neck fracture: A propensity score-matched cohort study

BackgroundFor displaced femoral neck fractures (FNF), total hip arthroplasty (THA) or hemiarthroplasty (HA) is preferred rather than fracture fixation. THA for patients with FNF requires skilled operators since patient with FNF likely to have osteoporosis and a higher risk of complications. Several reports suggest that higher hospital surgical volume was associated with a lower risk of complications after THA for osteoarthritis. However, little is known concerning this association with THA for FNF. Herein, we investigated the association between THA and complication and the recovery of physical function after THA to optimize the quality of FNF. MethodsA nationwide retrospective cohort study of elderly undergoing THA between April 1, 2011, to March 31, 2018 was performed. The association between hospital surgical volume and complication after THA for FNF was visually described with the restricted cubic spline regression analysis. Then the risk of complications was quantified with propensity score matching analysis based on the cutoff point identified by the restricted cubic spline curve. Primary outcome was secondary revision surgery, and the secondary outcomes included surgical and systemic complications, and the recovery of physical function at hospital discharge. ResultsBy visualization of the spline curve, we identified 20 cases per year as cutoff point of low hospital surgical volume. Following 1,396 patients’ propensity score-match analysis (mean age 75.2 [SD] 8.8, female 80.4%), the risk of secondary revision surgery was significantly higher among the low hospital surgical volume group (absolute risk difference (RD), 2.44%; p = 0.011). Also, the incidence of blood transfusion was higher in the low hospital surgical volume group (RD, 4.01%; p = 0.049). However, there was no significant difference in the recovery of the transferring and walking ability at discharge between high and low hospital surgical volume groups (63.5% vs 62.6%, 58.5% vs 57.5%; p = 0.74, 0.71, respectively). ConclusionOur research demonstrated that an increase in hospital surgical volume significantly reduced the incidence of secondary revision surgery after a certain inflection point, but not significantly improved short-term physical functions.

Redefining High-Volume Gastric Cancer Centers: The Impact of Operative Volume on Surgical Outcomes.

Performance of technically complex surgery at high-volume (HV) centers is associated with improved outcomes. The aim of this study was to assess whether hospital gastrectomy volume is associated with surgical outcomes, and what threshold of case volume meaningfully impacts surgical outcomes. We conducted a retrospective review of adult NCDB patients with gastric adenocarcinoma undergoing gastrectomy between 2004 and 2015. A multivariable Cox proportional hazards model with restricted cubic splines was used to examine the association of annual hospital gastrectomy volume and overall survival. Bootstrap simulation was used to estimate the cut-point corresponding to maximum change in log hazard ratio. Hospitals were divided into HV (≥ 17cases/year) and low-volume (LV; < 17cases/year) groups. We examined the relationship between volume groups and adequate nodal examination, R0 resection, unplanned readmission, and 30- and 90-day mortality. Our cohort consisted of 29,559 patients (7.8% treated at an HV center). Treatment at an HV center was associated with an increased likelihood of adequate nodal examination [odds ratio (OR) 2.12, 95% confidence interval (CI) 1.94-2.32] and R0 resection among patients with cardia tumors (OR 1.42, 95% CI 1.07-1.88). Patients treated at HV centers had decreased 30- and 90-day postoperative mortality, which was more pronounced in those undergoing total gastrectomy. Treatment at an HV gastrectomy center is associated with improved surgical outcomes. Our study identified 17cases/year as a clinically meaningful distinction between HV and LV centers. This definition of an HV center should be considered when evaluating regionalization of gastric cancer care to improve patient outcomes.

Impact of hospital volume on clinical outcomes of hospitalized heart failure patients: analysis of a nationwide database including 447,818 patients with heart failure

BackgroundHospital volume is known to be associated with outcomes of patients requiring complicated medical care. However, the relationship between hospital volume and prognosis of hospitalized patients with heart failure (HF) remains not fully understood. We aimed to clarify the impact of hospital volume on clinical outcomes of hospitalized HF patients using a nationwide inpatient database.Methods and resultsWe studied 447,818 hospitalized HF patients who were admitted from January 2010 and discharged until March 2018 included in the Japanese Diagnosis Procedure Combination database. According to the number of patients, patients were categorized into three groups; those treated in low-, medium-, and high-volume centers. The median age was 81 years and 238,192 patients (53%) were men. Patients who had New York Heart Association class IV symptom and requiring inotropic agent within two days were more common in high volume centers than in low volume centers. Respiratory support, hemodialysis, and intra-aortic balloon pumping were more frequently performed in high volume centers. As a result, length of hospital stay was shorter, and in-hospital mortality was lower in high volume centers. Lower in-hospital mortality was associated with higher hospital volume. Multivariable logistic regression analysis fitted with generalized estimating equation indicated that medium-volume group (Odds ratio 0.91, p = 0.035) and high-volume group (Odds ratio 0.86, p = 0.004) had lower in-hospital mortality compared to the low-volume group. Subgroup analysis showed that this association between hospital volume and in-hospital mortality among overall population was seen in all subgroups according to age, presence of chronic renal failure, and New York Heart Association class.ConclusionHospital volume was independently associated with ameliorated clinical outcomes of hospitalized patients with HF.

Abstract 14579: Impact of Hospital MitraClip Volume on Short-term Outcomes of Transcatheter Mitral Valve Replacement

Introduction: Transcatheter mitral valve replacement (TMVR) is an alternative to surgical mitral valve replacement for patients at prohibitive or high surgical risk. Both transseptal TMVR and MitraClip procedures require transseptal puncture and subsequent manipulation of a catheter within the left atrium and ventricle. Hypothesis: Higher MitraClip experience leads to better procedural outcomes of transseptal TMVR. Methods: We retrospectively identified patients who underwent transseptal-TMVR using the Nationwide Readmissions Database 2016-2017. We defined hospital volume as the annual number of MitraClip cases in each hospital and categorized hospitals into high- (≥26 cases/year) and low- (&lt;26 cases/year) volume groups by the median value. We compared the in-hospital and 30-day outcomes between the two groups. Results: A total of 1,023 TMVR patients (median 74 years; female 56.1%) were divided into the high- (n=487) and low- (n=536) volume groups. The high-volume group had a higher prevalence of prior valve implantation (30.8% vs. 24.8%; p=0.036), prior coronary artery bypass grafting (28.7% vs. 22.7%; p=0.031), and heart failure (86.7% vs. 79.5%; p=0.003) than the low-volume group. There was no significant difference in the rates of in-hospital death (9.0% vs. 9.5%; p=0.830), stroke (2.1% vs. 3.2%; p=0.330), and pacemaker implantation (2.5% vs. 4.5%; p=0.091), while surgical bailout was less frequent in the high-volume group (2.5% vs. 6.5%; p=0.002). Multivariable logistic regression analyses showed that high volume was significantly associated with a lower risk of surgical bailout, prolonged hospital stay, cardiovascular-cause readmission, but not with other outcomes including in-hospital death (Figure). Conclusions: Centers with greater MitraClip experience had a lower risk of surgical bailout, prolonged hospital stay, and early readmission after transseptal-TMVR, although mortality was high irrespective of MitraClip experience.

The association between hospital case volume and in-hospital and one-year mortality after hip fracture surgery.

Hospital case volume is shown to be associated with postoperative outcomes in various types of surgery. However, conflicting results of volume-outcome relationship have been reported in hip fracture surgery. This retrospective cohort study aimed to evaluate the association between hospital case volume and postoperative outcomes in patients who had hip fracture surgery. We hypothesized that higher case volume would be associated with lower risk of in-hospital and one-year mortality after hip fracture surgery. Data for all patients who underwent surgery for hip fracture from January 2008 to December 2016 were extracted from the Korean National Healthcare Insurance Service database. According to mean annual case volume of surgery for hip fracture, hospitals were classified into very low (< 30 cases/year), low (30 to 50 cases/year), intermediate (50 to 100 cases/year), high (100 to 150 cases/year), or very high (> 150 cases/year) groups. The association between hospital case volume and in-hospital mortality or one-year mortality was assessed using the logistic regression model to adjust for age, sex, type of fracture, type of anaesthesia, transfusion, comorbidities, and year of surgery. Between January 2008 and December 2016, 269,535 patients underwent hip fracture surgery in 1,567 hospitals in Korea. Compared to hospitals with very high volume, in-hospital mortality rates were significantly higher in those with high volume (odds ratio (OR) 1.10, 95% confidence interval ((CI) 1.02 to 1.17, p = 0.011), low volume (OR 1.22, 95% CI 1.14 to 1.32, p < 0.001), and very low volume (OR 1.25, 95% CI 1.16 to 1.34, p < 0.001). Similarly, hospitals with lower case volume showed higher one-year mortality rates compared to hospitals with very high case volume (low volume group, OR 1.15, 95% CI 1.11 to 1.19, p < 0.001; very low volume group, OR 1.10, 95% CI 1.07 to 1.14, p < 0.001). Higher hospital case volume of hip fracture surgery was associated with lower in-hospital mortality and one-year mortality in a dose-response fashion. Cite this article: Bone Joint J 2020;102-B(10):1384-1391.

The impact of surgeon volume on total thyroidectomy outcomes among otolaryngologists.

To evaluate the impact of surgeon volume on total thyroidectomy complications and outcomes among otolaryngologists. This state-wide, multi-hospital retrospective review identified patients who underwent total thyroidectomy (TT) (ICD9-06.4) through the Statewide Planning and Research Cooperative System (SPARCS) between 1995 and 2015. Surgeons were categorized into high (>100), medium (10-99), and low (<10) volume groups and differences in complication rates were analyzed. Statistical analysis employed Spearman's rank correlation, Kruskal-Wallis testing, and chi-squared testing. 32,133 TT performed by 1032 otolaryngologists were identified. Overall complication rate in our cohort was 9.83% (CI: 9.48-10.18). The most common complication identified overall was hypocalcemia occurring in 3.85% of cases. Surgeons in the high volume group had a complication rate of 9.6%, compared to 10.0% and 11.6% in the medium and low volume groups. This represents a moderate, but statistically significant difference (rho: -0.4, p<0.0001; KW p≤0.0001). When looking at individual complications, temporary tracheostomy rate was higher in the low volume group (5.1%, p=0.001). Other variables such as advanced age, sex, non-white race, or thyroid malignancy were not predictors of increased complication rates for TT. Otolaryngologists who perform a high volume of total thyroidectomy were found to have overall less perioperative complications than those with less volume. In particular, the risk of temporary tracheostomy is higher among low volume surgeons. These findings are consistent with previous studies of the effect of thyroidectomy volume on surgical complications.

Transfusion of blood components containing ABO-incompatible plasma does not lead to higher mortality in civilian trauma patients.

This study investigated the effect on mortality of transfusing ABO-incompatible plasma from all sources during trauma resuscitation. Demographic, transfusion, and survival data were retrospectively extracted on civilian trauma patients. Patients were divided by receipt of any quantity of ABO-incompatible plasma from any blood product (incompatible group) or receipt of solely ABO-compatible plasma (compatible group). The primary outcome was 30-day mortality, while other outcomes included 6- and 24-hour mortality. Mixed-effects logistic regression was used to model the effect of various predictor variables, including receipt of incompatible plasma, on mortality outcomes. Nine hospitals contributed data on a total of 2618 trauma patients. There were 1282 patients in the incompatible group and 1336 patients in the compatible group. In both the unadjusted and adjusted models, the 6-hour, 24-hour, and 30-day mortality rates were not significantly different between these groups. The patients in the incompatible group were then divided into high volume (>342 mL) and low volume (≤342 mL) incompatible plasma recipients. In the adjusted model, the high-volume group had higher 24-hour mortality when the Trauma Injury Severity Score survival prediction was >50%. Mortality at 6 hours and 30 days was not higher in this model. The low-volume group did not have increased mortality at any of the time points in this adjusted model. The transfusion of incompatible plasma in civilian trauma resuscitation does not lead to higher 30-day mortality. The finding of higher mortality in a select group of recipients in the secondary analysis warrants further study.

Effect of Intraoperative Low Tidal Volume vs Conventional Tidal Volume on Postoperative Pulmonary Complications in Patients Undergoing Major Surgery

In patients who undergo mechanical ventilation during surgery, the ideal tidal volume is unclear. To determine whether low-tidal-volume ventilation compared with conventional ventilation during major surgery decreases postoperative pulmonary complications. Single-center, assessor-blinded, randomized clinical trial of 1236 patients older than 40 years undergoing major noncardiothoracic, nonintracranial surgery under general anesthesia lasting more than 2 hours in a tertiary hospital in Melbourne, Australia, from February 2015 to February 2019. The last date of follow-up was February 17, 2019. Patients were randomized to receive a tidal volume of 6 mL/kg predicted body weight (n = 614; low tidal volume group) or a tidal volume of 10 mL/kg predicted body weight (n = 592; conventional tidal volume group). All patients received positive end-expiratory pressure (PEEP) at 5 cm H2O. The primary outcome was a composite of postoperative pulmonary complications within the first 7 postoperative days, including pneumonia, bronchospasm, atelectasis, pulmonary congestion, respiratory failure, pleural effusion, pneumothorax, or unplanned requirement for postoperative invasive or noninvasive ventilation. Secondary outcomes were postoperative pulmonary complications including development of pulmonary embolism, acute respiratory distress syndrome, systemic inflammatory response syndrome, sepsis, acute kidney injury, wound infection (superficial and deep), rate of intraoperative need for vasopressor, incidence of unplanned intensive care unit admission, rate of need for rapid response team call, intensive care unit length of stay, hospital length of stay, and in-hospital mortality. Among 1236 patients who were randomized, 1206 (98.9%) completed the trial (mean age, 63.5 years; 494 [40.9%] women; 681 [56.4%] undergoing abdominal surgery). The primary outcome occurred in 231 of 608 patients (38%) in the low tidal volume group compared with 232 of 590 patients (39%) in the conventional tidal volume group (difference, -1.3% [95% CI, -6.8% to 4.2%]; risk ratio, 0.97 [95% CI, 0.84-1.11]; P = .64). There were no significant differences in any of the secondary outcomes. Among adult patients undergoing major surgery, intraoperative ventilation with low tidal volume compared with conventional tidal volume, with PEEP applied equally between groups, did not significantly reduce pulmonary complications within the first 7 postoperative days. ANZCTR Identifier: ACTRN12614000790640.

Effect of bilingualism on aphasia recovery

ABSTRACT Background The severity of post-stroke aphasia has also been reported to be less in bilingual patients compared to their monolingual counterparts Aim To analyze the effect of bilingualism on aphasia recovery during the early post-stroke phase. Methods Bengali version of Western Aphasia Battery (WAB)was used for language assessment. It was administered during the first week and 90–100 days post-stroke. Severity assessment was done by calculating aphasia quotient (AQ). We enrolled 155 monolingual and 53 bilingual patients with aphasia, of whom 120 monolingual and 43 bilingual participants were followed up. Results The probability of recovering was higher for bilinguals than in monolingual patients. When the location of stroke was analyzed, the percentage of patients recovering in the “medium” class was higher for bilingual than monolinguals by fair margins for sub-cortical and mixed cortico-subcortical strokes With respect to gender, bilingual patients present better recovery than monolinguals in both genders, but especially in males. The mean improvement of AQ in low age (p = 0.22), high volume (p = 0.05), and low AQ (p = 0.17) groups were found to be fairly higher for bilinguals in contrast to monolinguals. Conclusions This is, to our knowledge, the first study reporting differences in aphasia recovery between bilingual and monolingual subjects. Bilingual participants experienced better aphasia recovery following a stroke when viewed through the lens of different variables.

High Case Volume Predicts Greater Odds of Autograft Use and Meniscal Repair for Anterior Cruciate Ligament Reconstruction

To evaluate how both annual surgeon and facility volume affect the cost and outcomes of anterior cruciate ligament reconstruction surgery. We also aimed to identify trends in how surgeon caseload predicts graft selection. The 2014 State Ambulatory and Surgical Database from Florida was used. Every case with Current Procedural Terminology code 29888 ("Arthroscopic anterior cruciate ligament reconstruction") was selected. Surgeon and facility identifiers were used to separate high- and low-volume groups, defined as >25 cases for surgeons and >125 cases for facilities. Univariate analysis was performed for patient demographics and surgical characteristics. Multivariate analysis was performed on significant factors to determine how these variables impact cost and odds of allograft usage, postoperative admission, and meniscal repair. There were 7905 cases performed between January 1, 2014, and December 31, 2014 after excluding same-year revisions. High-volume surgeons had $6155 lower total charges, were 1.949 times more likely to use an autograft, and had 54.5% lower odds of postoperative admission (all P < .001). They were also 1.196 times more likely to perform a meniscal repair (P= .017). In patients younger than 18, low-volume surgeons were 3.7 times more likely to use an allograft (P < .001). Concomitant multiligamentous procedures were also performed at greater rates in the high-volume group. Postoperative admission added $18,698, and allografts added $9174 (both P < .001). We found that high-volume surgeons were more likely to perform a meniscal repair and less likely to have their patients admitted postoperatively, which was the second largest cost driver of anterior cruciate ligament reconstruction. They were also significantly less likely to use an allograft, especially in patients younger than the age of 18 years. High-volume surgeons had lower costs despite greater rates of concomitant procedures. III, retrospective cohort study.

Brain Infarction Volume Through Non-Contrast Head MSCT Scan In Various Plasma Fibrinogen Level

Ischemic stroke occurs due to a blockage of blood vessel flow caused by thrombus. One of elements that plays a crucial role in thrombus formation is fibrinogen. Multiple Slice Computed tomography (MSCT) scan is the main modality in diagnosing stroke. This study aims to evaluate brain infarction volume through non-contrast head MSCT Scan in various plasma fibrinogen level of acute ischemic stroke patient. This was a descriptive study with retrospective design conducted from July 2019 to February 2020 at Dr. Soetomo General Hospital, Surabaya, Indonesia. Sample of this study was ischemic stroke patients who met inclusion criteria. Data regarding plasma fibrinogen level was obtained through medical records. Brain infarction volume was measured using non-contrast head MSCT scan. There were 84 samples in this study. Infarction volume ranges from 1.64—350.35 mL. We divided the infarction volume into three groups: low, medium and high volume. Plasma fibrinogen levels ranges from 88.3 mg/dl to 723.4 mg/dl. The lowest and highest fibrinogen levels were found in low volume group. The highest mean value of fibrinogen levels (362.0 mg / dl) was in medium volume group, while the lowest (310.4 mg/dL) was in low volume group. Cerebral infarction volume through non-contrast head MSCT scan varied from 1.64 mL to 350.35 mL. Fibrinogen levels in acute ischemic stroke patients varied from 88.3 mg/dL to 723.4 mg / dL.

Visual outcomes of high-volume compared with low-volume manual small-incision cataract surgery in Nepal.

To study whether manual small-incision cataract surgery (MSICS) in a high-volume setting gives acceptable postoperative visual outcomes. Geta Eye Hospital, Kailali, Nepal. Single-center retrospective study. One-year records of all MSICS in adult patients without any other ocular comorbidity were analyzed retrospectively. Surgical outcomes of cataract cases when surgeons performed more than 72 surgeries (high volume) in a single operating session (1 day) were compared with when fewer than 30 surgeries (low volume) were performed in a single operating session (1 day). Of 23 717 cases in the study, 20 574 patients (87%) had preoperative visual acuity of less than 3/60; 15 632 patients (66%) achieved good visual outcome (uncorrected distance visual acuity of 6/18 or better) postoperatively. Patients operated during high-volume months achieved good visual outcomes in 9930 cases (66.9%) as compared with 5702 (64.3%) in low-volume months. However, 6235 patients (61.7%) operated on during high-volume days had good visual outcomes as compared with 3053 (71.4%) during low-volume days; 175 patients in the high-volume group and 73 patients in the low-volume group (1.7% each) achieved visual acuity worse than 3/60. There were comparable posterior capsular rupture rates (423 [1.78%]) during high- and low-volume months, and 21 cases (0.09%) of postoperative endophthalmitis were noted. MSICS can be used to reduce large cataract backlogs in developing countries as good visual outcomes could be achieved in high-volume settings if standard protocols for quality control are followed.

Clinical Outcomes of Enteral Feeding Protocol Via Percutaneous Endoscopic Gastrostomy: A Single-Center, Retrospective Study.

The development of the endoscopic technique has resulted in an increasing number of patients undergoing percutaneous endoscopic gastrostomy (PEG) insertion; however, the protocols for increasing the volume of feeding formula after PEG insertion have not been established. Therefore, we compared the clinical outcomes of patients receiving low- and high-volume increase in enteral feeding formula. A total of 215 patients who underwent PEG insertion between January 2016 and March 2019 were included. They were divided into 2 groups according to the increase in volume of feeding formula: the low-volume group (n = 135) received ≤150 mL/d, and the high-volume group (n = 80) received ≥300 mL/d. Patient characteristics, procedure, and feeding-related clinical outcomes were retrospectively reviewed using medical records. The adverse events of the feeding protocol did not significantly differ between the 2 groups. The number of days needed to attain the calorie targets was significantly lower in the high-volume group than in the low-volume group (5.4 ± 3.0 vs 2.4 ± 1.5; P < .001). The duration of supplemental parenteral nutrition and the length of hospitalization were also significantly lower in the high-volume group (3.9 ± 3.3 vs 1.2 ± 2.2; P < .001 and 5.8 ± 2.7 vs 4.6 ± 2.6; P = .007, respectively). To rapidly attain the calorie targets in appropriately selected patients with PEG insertion, a high-volume increase in daily feeding can safely be recommended given the favorable outcomes.

Death-associated Protein Kinase 1 Mediates Ventilator-induced Lung Injury in Mice by Promoting Alveolar Epithelial Cell Apoptosis

Alveolar epithelial cell apoptosis is implicated in the onset of ventilator-induced lung injury. Death-associated protein kinase 1 (DAPK1) is associated with cell apoptosis. The hypothesis was that DAPK1 participates in ventilator-induced lung injury through promoting alveolar epithelial cell apoptosis. Apoptosis of mouse alveolar epithelial cell was induced by cyclic stretch. DAPK1 expression was altered (knockdown or overexpressed) in vitro by using a small interfering RNA or a plasmid, respectively. C57/BL6 male mice (n = 6) received high tidal volume ventilation to establish a lung injury model. Adeno-associated virus transfection of short hairpin RNA and DAPK1 inhibitor repressed DAPK1 expression and activation in lungs, respectively. The primary outcomes were alveolar epithelial cell apoptosis and lung injury. Compared with the control group, the 24-h cyclic stretch group showed significantly higher alveolar epithelial cell apoptotic percentage (45 ± 4% fold vs. 6 ± 1% fold; P < 0.0001) and relative DAPK1 expression, and this group also demonstrated a reduced apoptotic percentage after DAPK1 knockdown (27 ± 5% fold vs. 53 ± 8% fold; P < 0.0001). A promoted apoptotic percentage in DAPK1 overexpression was observed without stretching (49 ± 6% fold vs. 14 ± 3% fold; P < 0.0001). Alterations in B-cell lymphoma 2 and B-cell lymphoma 2-associated X are associated with DAPK1 expression. The mice subjected to high tidal volume had higher DAPK1 expression and alveolar epithelial cell apoptotic percentage in lungs compared with the low tidal volume group (43 ± 6% fold vs. 4 ± 2% fold; P < 0.0001). Inhibition of DAPK1 through adeno-associated virus infection or DAPK1 inhibitor treatment appeared to be protective against lung injury with reduced lung injury score, resolved pulmonary inflammation, and repressed alveolar epithelial cell apoptotic percentage (47 ± 4% fold and 48 ± 6% fold; 35 ± 5% fold and 34 ± 4% fold; P < 0.0001, respectively). DAPK1 promotes the onset of ventilator-induced lung injury by triggering alveolar epithelial cell apoptosis through intrinsic apoptosis pathway in mice.

Effect of bowel preparation volume in inpatient colonoscopy. Results of a prospective, randomized, comparative pilot study

BackgroundInpatient status has been shown to be a predictor of poor bowel preparation for colonoscopy; however, the optimal bowel preparation regimen for hospitalized patients is unknown. Our aim was to compare the efficacy of bowel preparation volume size in hospitalized patients undergoing inpatient colonoscopy.MethodsThis prospective, single blinded (endoscopist), randomized controlled trial was conducted as a pilot study at a tertiary referral medical center. Hospitalized patients undergoing inpatient colonoscopy were assigned randomly to receive a high, medium, or low-volume preparation. Data collection included colon preparation quality, based on the Boston Bowel Preparation Scale, and a questionnaire given to all subjects evaluating the ability to completely finish bowel preparation and adverse effects (unpleasant taste, nausea, and vomiting).ResultsTwenty-five colonoscopies were performed in 25 subjects. Patients who received low-volume preparation averaged a higher mean total BBPS (7.4, SD 1.62), in comparison to patients who received high-volume (7.0, SD 1.41) and medium-volume prep (6.9, SD 1.55), P = 0.77. When evaluating taste a higher score meant worse taste. The low-volume group scored unpleasant taste as 0.6 (0.74), while the high-volume group gave unpleasant taste a score of 2.2 (0.97) and the medium-volume group gave a score of 2.1 (1.36), P < 0.01.ConclusionIn this pilot study we found that low-volume colon preparation may be preferred in the inpatient setting due its better rate of tolerability and comparable bowel cleanliness when compared to larger volume preparation, although we cannot overreach any definitive conclusion. Further more robust studies are required to confirm these findings.Trial registrationThe Affect of Low-Volume Bowel Preparation for Hospitalized Patients Colonoscopies. Trial registration: NCT01978509 (terminated). Retrospectively registered on November 07, 2013.

The effect of injection volume on long-term outcomes of US-guided subacromial bursa injections

PurposeLimited data exist on the efficacy of high- compared to low-volume US-guided corticosteroid injections (CI) in the subacromial-subdeltoid (SA-SD) bursa. Our purpose was to compare the short- and long-term efficacy of low- and high-volume injections, by using a capacity reference of SA-SD bursa volume, as assessed on cadaveric specimens. MethodWithin two years, 136 patients (63 males, 73 females; mean age: 46.11 ± 10.28 years) who underwent SA-SD bursa US-guided CI for subacromial impingement, rotator cuff tendinopathy or shoulder overuse were prospectively included. Patients were randomly assigned to low-volume (1 mL triamcinolone acetonide/40 mg) or high-volume (1 mL triamcinolone acetonide/40 mg, 9 mL anaesthetic agents) groups (67 and 69 patients, respectively). Visual Analogue Scores (VAS) were recorded at baseline, 30 min, 3 weeks, 3 months, 6 months and 1 year post-treatment. Predictors of complete recovery (VAS ≤ 2) at 1 year were analysed with multivariate Cox regression analysis. SA-SD bursa cadaveric dissection in 10 specimens was performed for volume assessment. ResultsInjection volume was the only predictor of complete pain resolution at 1 year. High-volume CI yielded higher chances of early pain recovery (2.837 HR, 95% CI 1.737–4.633, P < .001). Mean VAS scores at baseline and subsequent time-points were 6, 2.6, 2.2, 2, 1.6 and 1 for the high-volume and 7.8, 7.3, 4.7, 3.2, 2.5 and 1.8 for the low-volume group, respectively (P < .001, at all time-points). Cadaveric measurements showed a minimum SA-SD bursa volume of approximately 6.9 mL. ConclusionsHigh-compared to low-volume US-guided CI are superior for achieving early pain recovery.