Mean Hospital Days Research Articles

Laparoscopic Versus Open Rectopexy for Rectal Prolapse: A Randomized Controlled Trial.

IntroductionMost of the patients with rectal prolapse complain of fecal incontinence followed by constipation. Surgery is the only definitive treatment option for rectal prolapse. There are two approaches: either transanal/perineal or transabdominal. The abdominal procedures can be done in the open laparotomy method or laparoscopically. Suture rectopexy is a very old and popular method of treating rectal prolapse. Nowadays, rectopexy by laparoscopic approach is considered the gold standard treatment for rectal prolapse. The study has been conducted to compare both the procedures and their outcomes in terms of conditions associated with rectal prolapse.MethodsAll consecutive patients with full-thickness rectal prolapse who had attended the surgery outpatient department were included in the study. The patients had undergone either open suture rectopexy or laparoscopic rectopexy after randomization. Assessment of postoperative pain, mean days of hospital stay, constipation, and incontinence score along with operative time, recurrence within six months of follow-up, and time to resume bowel activity were done. The patients were followed up for 18 months at regular intervals.ResultsA total of 58 patients were included in the study: 27 in the open group and 31 in the laparoscopic group. The operative time was 102 minutes versus 129 minutes (p=0.0001) in the open and laparoscopic groups, respectively. The laparoscopic group had an earlier resumption of bowel activity (3.1 days vs. 1.4 days [p=0.0001]); fewer days of hospital stay (6.8 days vs. 2.5 days [p=0.0001]), less postoperative pain (mean visual analogue scale score for pain on postoperative day one 4.0 versus 3.1 [p=0.0035] and on postoperative day two 3.8 versus 2.2 [p=0.0001]). There was no significant difference in postoperative constipation score and incontinence score between the two groups.ConclusionLaparoscopic rectopexy results in lesser postoperative pain, lesser hospital stay, and better patient satisfaction than open rectopexy.

Clinical application of a digital thoracic drainage system for objectifying and quantifying air leak versus the traditional vacuum system: a retrospective observational study.

BackgroundDigital thoracic drainage systems have recently been introduced and widely used in clinical practices in developed countries. These systems can monitor intrathoracic pressure changes and air leaks in real time, and also allow for objective and quantitative analyses, which aid in managing patients with a prolonged persistent air leak into the pleural space. We investigated the feasibility and effectiveness of such a new device versus the traditional vacuum system for treating patients with pneumothorax.MethodsClosed thoracostomy drainage was carried out on 100 adult patients with primary or secondary pneumothorax between January 2017 and December 2018. All the patients were aged ≥18 years and treated with a chest tube at a single medical center by the same cardiothoracic surgeons and intensivists. Patients who underwent closed thoracostomy drainage using an indwelling 24-French chest tube were divided into 2 groups immediately before closed thoracostomy: the digital thoracic drainage group (digital group, n=50) and the traditional analogue thoracic drainage group (analogue group, n=50). The detailed information about demographic data, treatment outcome, duration of indwelling catheterization., hospital days, cost-effectiveness and patient satisfaction was evaluated. We also evaluated whether digitally recorded intrapleural pressure changes and air leaks would predict chest tube removal timing and outcome.ResultsThe baseline parameters of the 2 groups were comparable with no significant differences in sex, age, weight or body mass index. The mean hospital day was shorter in the digital group than in the analogue group (17.96±12.23 vs. 18.32±16.64, P=0.902), and there was no statistically significant difference in the hospital length of stay between the 2 groups. Air leaks through the chest tube and duration of chest tube indwelling hours showed no significant statistical differences between the digital and analogue groups (213.47±219.80 vs. 261.94±184.47, P=0.235 and 223.44±218.75 vs 275.29±186.06, P=0.205, respectively). Total drainage amount and ambulation time per day were significantly higher in the digital group than in the analogue group [209.62±139.63 vs. 162.48±80.42 (P=0.042) and 6.42±3.62 vs.3.94±1.74 (P<0.001), respectively]. Hours of full expansion were significantly shorter and sleep disturbance caused by the noise of chest tube drainage was less in the digital group than in the analogue group [25.64±14.55 vs. 46.52±25.53 (P<0.001) and 2.38±1.03 vs. 5.70±2.87 (P<0.001), respectively].ConclusionsTo date, there is no definite consensus and guidelines on the standardized digital suction system in pneumothorax. This study proposed the guidelines for the application of digital thoracic drainage systems in pneumothorax and also suggested that digital thoracic drainage systems might be a valuable tool to determine chest tube removal timing and reducing the length of hospital stay in patients with pneumothorax.

Laparoscopic versus open appendectomy: A retrospective cohort study on the management of acute appendicitis (simple and complicated) in children under 13 years of age.

Introduction:Acute appendicitis is the most common surgical emergency with a lifetime incidence of 7%–8%. There are two operative modalities that are currently used for the management of this condition in the paediatric population. The objective of this cohort study was to review the outcome of the management of paediatric surgical patients presenting with acute appendicitis after either an open appendectomy (OA) or laparoscopic appendectomy (LA) was performed.Methods:This was a 2-year retrospective study conducted from 01 January 2016 until 31 December 2017 on paediatric surgical patients < 13 years of age undergoing appendectomies. Eighty-one (n = 81) files of patients were reviewed, and data analysis was performed on two comparative groups namely the OA group and LA group, with the aid of the SAS system with statistical significance based on P < 0.05.Results:During the study period, 81 children (male: female ratio of 2:1) underwent appendectomies. Nearly 38% (n = 31) of the cases had an OA, with 62% (n = 50) of the cases having an LA. Seven (14%) LA cases were converted to OA. Simple appendicitis accounted for 16% (n = 13) of the patients, with complicated appendicitis accounting for 79% (n = 64) and other pathologies accounting for 5% (n = 4). There were no post-operative complications in the cases of simple appendicitis. Six cases (15.38%) in the LA group versus two cases (5.26%) in the OA group developed intra-abdominal collections, which was statistically significant (P = 0.018). One (2.56%) patient in the LA group versus two patients (7.89%) in the OA group developed intestinal ileus (P = 0.09). Two patients (5.13%) in the LA group versus six patients (15.79%) in the OA group developed surgical-site infection, which was statistically significant (P = 0.013). The mean days of hospital stay was 4.51 days in the LA group versus 5.34 days in the OA group, which was statistically significant (P = 0.016). There were no re-admissions or re-operations in the simple appendicitis group. In the complicated appendicitis cases, five cases (12.82%) were re-admitted in the LA group compared to five cases (13.16%) in the OA group (P = 0.943). Two (5.13%) cases had a re-operation in the LA group compared to one case (2.63%) in the OA group (P = 0.360).Conclusion:Considering that there was an increased incidence of complicated cases and operations being performed by trainees, LA appears feasible at a tertiary-level hospital in a developing country, as shown in this study. Therefore, cases of simple appendicitis can be performed laparoscopically; however with regard to complicated appendicitis, there is no superiority between the two operative modalities in this study, which is consistent with international literature. However, in this study, it can be postulated that the learning curve was a major contributory factor to the increased levels of complications, as all operations were performed by trainees. Therefore, we recommend implementation of adequate simulation practices in laparoscopy in the setting of a developing country to attain the laparoscopic expertise of our international counterparts in order to improve the standard of care.

A Review on Colonic Ischemia due to Vasoconstrictors

Intestinal ischemia results due to reduced blood flow to the intestine. Hypoperfusion of mesenteric vasculature can be due to occlusive or nonocclusive etiology. Nonocclusive mesenteric ischemia (NOMI) is due to arterial spasm from vasoconstrictors. Colon ischemia has a reported mortality rate ranging from 6 to 25%, depending upon the causal agent and comorbidities. This review's scope was to examine the body of published literature regarding outcomes of iatrogenic NOMI and compare cocaine-related NOMI with other causes of iatrogenic large bowel ischemia. A literature search was conducted on Pubmed and Google scholar, using "Mesenteric Ischemia" and "Vasoconstrictor" as the Mesh terms. Twenty-two articles (19 case reports, 3 case series) were finally included in our review. Among study subjects, Abdominal pain was the presenting complaint in 88.88% of patients, and bloody bowel movements were reported in 81.48% of patients. Diagnostic modalities used included colonoscopy (59.26%), sigmoidoscopy (23.07%), computed tomography (37.04%), plain abdominal films (11.54%), and laparotomy (19.23%). Combining findings from all the diagnostic modalities revealed pan-colonic involvement in 11.54% of patients, proximal colon in 23.08% of patients, 7.68% of patients had involvement of transverse colon and descending/ sigmoid colon were involved in 55.56%. Splenic flexure region involvement was noticed in 30.77% of cases. Most of the patients had more than one region of bowel involved. Findings of severe colon ischemia, including ulcers, hemorrhages, and gangrene, were found in 70.37% of patients on colonoscopy or autopsy. Nineteen patients (70.37%) were managed conservatively with broad-spectrum antibiotics, intravenous fluids, and bowel rest. Two of them died due to septic shock, while the remaining 17 recovered without any further complications. Eight patients (29.63%) required surgical management, and two of them had septic shock, causing death. In this series, nonoperative management had a success rate of 89%, while surgical management had a success rate of 75%. Based on the available reported dataset, mean hospitalization days for patients managed non-operatively were 4.31 (Range 2-10). For patients requiring surgery, it was 21 (range 4-60) due to sepsis and multiorgan failure, complicating the colon ischemia and prolonging the stay. Significant differences were found between cocaine and non-cocaine vasoconstrictor-induced large bowel NOMI regarding surgery and length of hospital stay (7 days vs 4 days), but the difference in mortality and hospital score did not reach statistical significance. Our article's message is that in patients with acute abdominal pain where a diagnosis of colon ischemia is being entertained, care should be taken not to miss out on the potential role of vasoconstrictors, including cocaine.

Burden of illness among Medicare and non-Medicare US populations with acquired thrombotic thrombocytopenic purpura

Background Acquired thrombotic thrombocytopenic purpura (aTTP) is a rare hematologic disorder that can lead to serious life-threatening medical complications. Objective The aim of this study was to describe aTTP-related hospital resource utilization, cost, complications, and overall survival among US Medicare and non-Medicare populations following aTTP episodes prior to the US approval of caplacizumab. Methods This retrospective study utilized administrative claims data for Medicare Fee-for-Service (FFS) beneficiaries (100% sample) and a sample of commercial, managed Medicaid [MM], Medicare Advantage [MA] plan members from the Inovalon MORE2 Registry. aTTP patients ages 18+ were identified between 2010 and 2018 using a published validated algorithm: ≥1 hospitalization for thrombotic microangiopathy + therapeutic plasma exchange (TPE). 2,279 patients were identified; 65.2% were enrolled in Medicare FFS, 13.6% in commercial, 15.7% in MM, and 5.4% in MA. Mean hospitalization days for aTTP index episode ranged between 12 and 17 days; ∼60% of patients required intensive care. Mean payments for index hospitalization varied by payer [Medicare FFS: $29,024; MA: $12,860; commercial: $9,996 and MM: $10,470]. Among FFS patients, 15.7% died during initial hospitalization and 21.0% died within first 30 days of the event. During follow-up, 11.6–19.6% experienced aTTP-related exacerbation. Incidence rate of relapse and complications per 100 person-years was 5.6 [Medicare FFS: 3.6; MA: 8.7; commercial: 10.4 and MM: 14.7] and 16.7 [FFS: 15.5; MA: 20.5; commercial: 21.7 and MM: 19.1], respectively. Among Medicare patients with and without aTTP, mortality risk was 2.9 (95 % CI: 2.4–3.4) times higher for aTTP vs. non-aTTP patients. Conclusion This is the first real-world study evaluating burden of illness among aTTP patients in the US across payer types. Despite being treated with TPE, patients with aTTP have lower survival rates in comparison to a matched cohort without aTTP. These findings highlight the need for more effective and novel therapies to reduce disease burden for this population. Key points In US Medicare and managed care populations with aTTP between 2010 and 2018, aTTP can lead to significant utilization of ICU services due to clinical complications, and/or relapse following hospital discharge. Despite treatment with therapeutic plasma exchange, acute mortality remains high (15.7%) indicating the need for more effective and novel treatments.

Clinical Course for Patients With Trisomy 13 and 18 Pursuing Life-Prolonging Therapies Versus Comfort-Directed Care.

Care for infants with Trisomy 13 and 18 is evolving with more children being offered medical and surgical interventions. Parents and clinicians of children diagnosed with trisomy 13 and 18 would benefit from understanding how parental goals of care correlate with the subsequent clinical course of children with these conditions. To describe and compare parental goals of care (GOC) and clinical course in infants with trisomy 13 and 18. Single center, retrospective (2013-19) analysis of electronic health record repository at a birthing center and a tertiary care hospital. ICD-9/10 codes were used to identify patients with trisomy 13 or 18 born between 2013-2019. Their records were abstracted for their diagnosis, hospitalization days, interventions, GOC, death location and length of life. Twenty-eight total patients were identified; trisomy 13, mosaic trisomy 13 and trisomy 18 were diagnosed in 9, 2 and 17 patients respectively. Among the 26 patients with complete trisomy 13 or 18, 8 had life-prolonging and 18 had comfort care goals at birth/diagnosis. Life-prolonging goals were not associated with longer life (p = 0.36) but were associated with more mean hospital days (70 vs. 12, p = 0.01), ICU days (66 vs. 9, p = 0.009), intubation (7/8 vs 7/18, p = 0.04), and death in ICU (7/7 vs. 10/17, p = 0.02). Zero patients underwent cardiac surgery. Parental GOC did not affect length of life in children with complete trisomy, but did alter treatment intensity. This may inform decision making for patients with trisomy 13 or 18.

Clinical characteristics and evolution of pediatric patients with acute leukemia and SARS-COV2 virus infection in a third level hospital in Mexico

IntroductionReports have revealed that people susceptible to severe forms of COVID-19 are older adults with comorbidities; However, the pediatric population has also been affected, considering children with underlying conditions such as onco-hematological conditions to be high risk. We present a cases series in a third level hospital. Material and methodsWe conducted a retrospective study in children under the age of 16 years with a diagnosis of acute leukemia and infection with the SARS-CoV2 virus. Descriptive statistics with means and percentages were used. To show differences between the groups, Chi-square test, Student t test and Mann-Whitney U test were used depending on the type of variable and its distribution. ResultsSARS-CoV2 virus infection was confirmed in 15 children diagnosed with acute leukemia, at different stages of treatment. The mean age was 7.5 years, 8 male and 7 female, 11 of them diagnosed with acute B-cell lymphoblastic leukemia, one with acute T-cell lymphoblastic leukemia and 3 with acute myeloid leukemia. The mean days of hospital stay at the diagnosis of COVID-19 was 22. Thirteen of the children had fever and neutropenia. 7 patients died. There was a statistically significant correlation with the outcome in patients who presented a prolongation of aPTT, an increase in D-dimer, an increase in liver enzymes and severe respiratory distress with the need for mechanical ventilation. ConclusionThe risk of death in children with leukemia and COVID-19 was associated with prolonged aPTT, increased D-dimer, increased liver enzymes, respiratory distress, and the need for mechanical ventilation.

Impact of right ventricular systolic pressure in elderly patients admitted to intensive care unit after femur fracture surgery: A retrospective observational study.

The number of femoral fractures is expected to continue to increase as the size of the older population rapidly grows. However, old age is accompanied by various comorbidities and is an important postoperative risk factor in itself, meaning that patients who undergo surgery for a femur fracture may require admission to an ICU. We investigated pulmonary complications in patients over the age of 65 admitted to the ICU after femur fracture surgery.In this single-center retrospective observational study, 289 patients over 65 years who admitted to the ICU after femur fracture surgery between June 2008 and December 2016 were investigated.Pulmonary complications occurred in 97 of these patients (33.6%) after surgery. Mean hospitalization days (34.1 ± 25.7 vs 23.1 ± 15.7, P < .001) and mean ICU length of stay (8.4 ± 16.1 vs 2.5 ± 1.1, P = .001) were significantly longer for patients with pulmonary complications than for patients without pulmonary complications after femur fracture surgery. Patients with pulmonary complications were significantly more likely to have pulmonary disease (19.6% vs 8.9%, P = .009) and exhibit sequelae on preoperative chest X-rays (9.3% vs 3.6%, P = .048) than were patients without pulmonary complications. In addition, significant differences were observed in the right ventricular systolic pressure (RVSP) measured during preoperative echocardiography (37.4 ± 10.9 mm Hg vs 40.7 ± 9.3 mm Hg for patients without and with pulmonary complications, P = .010) and in the proportion of each group that had an RVSP of >35 mm Hg, which is a marker for pulmonary hypertension (55.2% vs 76.3% for patients without and with pulmonary complications, P < .001). In multivariate analysis, an RVSP of >35 mm Hg during preoperative echocardiography was associated with pulmonary complications after femur fracture surgery (OR, 2.6; 95% CI, 1.45-4.53).In conclusion, Pulmonary complications in older patients admitted to the ICU after femur fracture surgery was associated with longer hospitalization and ICU stays. Preoperative RVSP measurement could identify those older patients with a high risk of pulmonary complications following transferal to the ICU after femur fracture surgery.

Prognostic Value of Preoperative Pro-B-Type Natriuretic Peptide: Early Predictor of Cardiovascular Complications and Mortality After Major Abdominal Surgery.

Background and objectivesIn surgical patients, coronary disease is the main cause of perioperative mortality. The incidence of serious cardiovascular complications is reported as 5% with a probability of 1-2% of death from the cardiac cause in major non-cardiac surgery. B-type natriuretic peptide (BNP) is a sensitive and specific predictor of left ventricular systolic dysfunction and predicts first cardiovascular event and death in the general population. The recent guidelines recommended the use of pro-BNP for independent perioperative prognosis in cardiac patients undergoing non-cardiac surgery. The aim of this study is to assess the predictive value of raised pro-BNP levels in patients who underwent major abdominal surgery and evaluate its relationship with cardiovascular complications and mortality occurring up to 30 days after surgery.Materials and methodsWe reviewed the medical records of patients undergone surgical procedures in the abdominal region lasting more than two hours, requiring postoperative high dependence or intensive care and an expected hospital stay of at least three days. All types of open or laparoscopic-assisted abdominal or pelvic surgeries that were evaluated for preoperative pro-BNP levels were included in the study. During the postoperative period, all patients were followed for cardiac complications and mortality for 30 days after surgery. Postoperative adverse cardiac events were predefined as angina pectoris, myocardial infarction, cardiogenic dyspnea, acute arrhythmias (atrial fibrillation/flutter, ventricular fibrillation/tachycardia), acute hypertensive event (hypertensive emergency or urgency), congestive heart failure, acute pulmonary edema, or primary cardiac death. While non-cardiac complications were also documented as either pulmonary, septic, postsurgical site infection, and other systemic complications. Subsequently, a survival analysis was done for the discretion of cardiovascular complications and mortality.ResultsThe mean age of the study population was found to be 50.22 ± 14.28 years, mean pro-BNP levels were 909.29 ± 3950.04, and mean days of hospital stay were 7.43 ± 4.49 days. The 30-day postoperative all-cause mortality was found to be 9.8%. Hypertension and diabetes were frequent comorbidities amongst the study population. The mean preoperative pro-BNP levels were found higher in the male gender (p=0.071), also found higher in those with cardiovascular complications (p=0.006) and mortality (p=0.057). Receiver operating characteristic (ROC) analysis showed cardiovascular outcomes with a cut-off value of pro-BNP at 143 pg/ml, AUC of 0.891, at a sensitivity of 91%, positive predictive value (PPV) of 96%, a specificity of 75%, and negative predictive value (NPV) of 58%, while the same for mortality at a cut-off value of 164 pg/ml was found with AUC of 0.815, at a sensitivity of 84%, a specificity of 66%, PPV of 97%, and NPV of 21%. The unadjusted odds ratio for cardiovascular complications was found to be 17.857 (95% CI: 6.56-48.60) while that for mortality was 10.863 (95% Cl: 2.29-51.37). The Kaplan-Meier survival curves showing elevated pro-BNP levels were significantly associated with cardiovascular events, with 30 days mortality at a cut-off value of 164 pg/ml.ConclusionPro-BNP is a useful marker in postoperative patients for not only predicting cardiovascular outcomes as cited by many previous studies but also mortality.

Pediatric Empyema Thoracis: Jabalpur Image-Based Staging and Stage-Directed Decision-Making Algorithm

Pneumonia in the pediatric age group is common and it can commonly progress to pediatric empyema thoracis (PET). The American Thoracic Society has described three stages of PET which have been the following: exudative, fibrinopurulent, and organized. We describe a new Jabalpur image-based staging system for empyema thoracis in children which has allowed focused intervention and improved outcomes. Pre-empted focused observation, gaps in the treatment and outcomes, and the triangulation of these resulted in the evolution of a new, image-based staging system for pediatric empyema thoracis. From 2009 to 2014, our team was a participant-observer of the usual practices to treat children up to 18 years of age with pneumonia who developed empyema. The prevalent classification into exudative, fibrinopurulent, and organized empyema was treated as per practice. Patients with chronic empyema, empyema necessitans, and tubercular and those with incomplete data were excluded. A staging system purely based on ultrasound (US) and computed tomography (CT) findings was evolved, and we call it Jabalpur image-based staging (JIBS) system for pediatric empyema thoracis. A decision-making algorithm was further evolved using the JIBS system to provide stage-directed treatment. This staging system and algorithm after a pilot run was prospectively applied to a set of patients accrued from January 2015 to December 2019 with PET which was strictly allocated as per new evolved staging and treated with discrete choices by all the methods inclusive of general supportive care, nutritional support, tube drainage, and open and video-assisted thoracoscopic surgery (VATS). The successful early outcome was defined statistically significant reduction of mean ICTD days, the number of CXRs, and the mean hospital days, which reflects earlier recovery. The long-term successful outcome was defined as the absence of fever, breathlessness, and adequate weight gain (according to age) at a minimum follow-up of 3 months. On the prospective evaluation of JIBS and the stage-directed decision-making algorithm on a set of 187 children accrued from January 2015 to December 2019, there was a significant improvement in the success of drainage and the number of VATS procedures, and their success significantly improved. There was a significant reduction in mean preoperative stay, mean intercostal tube drainage (ICTD) days, the number of chest x-rays (CXRs), mean hospital stay, and the number of open procedures in the prospective group. Accuracy of a new staging system to identify exudative, fibrinopurulent, and organized stages of PET was found to be 94.65%, 94.65%, and 97.86% respectively. The long-term successful outcome was observed in 179 (95.72%) children while 8 patients had chest deformity and a minimum secondary scoliosis which was addressed with physiotherapy. This study proposes a simple image-based staging system and stage-directed decision-making algorithm for empyema thoracis in children, which sharply defines the stages and allows the selection of appropriate surgical modality in cases of PET.

Timing of Flap Surgery in Acute Burn Patients Does Not Affect Complications.

Pedicled and free flaps are occasionally necessary to reconstruct complex wounds in acute burn patients. Flap coverage has classically been delayed for concern of progressive tissue necrosis and flap failure. We aim to investigate flap complications in primary burn care leveraging national U.S. data. Acute burn patients with known % total body surface area(TBSA) were extracted from the Nationwide/National Inpatient Sample from 2002 to 2014 based on the International Classification of Disease (ICD) codes, ninth edition. Variables included age, sex, race, Elixhauser index, %TBSA, mechanism, inhalation injury, and location of burn. Flap complication was defined by ICD-9 procedure code 86.75, return to the operating room for flap revision. Multivariable analysis evaluated predictors of flap compromise using stepwise logistic regression with backward elimination. The weighted sample included 306,924 encounters of which 526 received a flap (0.17%). About 7.8% of flap encounters sustained electric injury compared to 2.7% of non-flap encounters (odds ratio [OR] 3.76, 95% confidence interval [CI] 1.95-7.24, P < .001). The mean hospital day of the flap procedure was 10.1 (SD 10.7) days. Flap complications occurred in 6.4% of cases. The timing of flap coverage was not associated with complications. The only independent predictor of flap complication was electrical injury (OR 40.49, 95% CI 2.98-550.64, P = .005). Electrical injury was an independent predictor of flap complications compared to other mechanisms. Flap timing was not associated with return to surgery for complications. This suggests that the use of flaps is safe in acute burn care to achieve burn wound closure with an understanding that electrical injuries may warrant particular consideration to avoid failure.

Children Infected With SARS-CoV-2 From Family Clusters.

Background: The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is ongoing globally. Limited data are available for children with SARS-CoV-2 infection.Methods: A retrospective case study was conducted in one designated hospital for children with SARS-CoV-2 infection in Wuhan.Results: Out of the 74 children with laboratory-confirmed SARS-CoV-2 infection, the median age was 5.8 years, with no notable variation based on gender. All of the children had had direct exposure to at least one family member with confirmed SARS-CoV-2 infection. The most common symptoms were cough in 41 (55.4%) and fever in 38 (51.4%). Typical CT patterns of viral pneumonia were exhibited in 40 (54.1%) children, including ground-glass opacity and interstitial abnormalities. However, 17 (23.0%) children were classified as asymptomatic carriers, with neither symptoms nor radiological findings. Also, 68 (91.9%) children recovered fully and showed negative results on RT-PCR assay by nasopharyngeal swabs during our observation period. In contrast to the negative result for nasopharyngeal swab, 34% of the anal swabs showed a continued positive result. The mean hospitalization days of the children discharged after full recovery was 10.0 days.Conclusion: Within family clusters that had SARS-CoV-2 infection, children had mild or even asymptomatic illness. Although CT is highly sensitive, it should be avoided in follow-up of the disease in consideration of the radiological hazards and limited clinical benefits for mild illness in children. Furthermore, it is advocated that both nasopharyngeal and anal swabs should be confirmed negative for viral load prior to declaring full recovery so as to avoid oral-fecal transmission. Asymptomatic children with family clusters are potentially a little-known source of COVID-19. This therefore warrants an urgent reassessment of the transmission dynamics of the current outbreak.

Esophageal cancer, five years of experience in a regional oncologic reference center in Mexico.

e16515 Background: Esophageal cancer is a highly lethal entity. Within this group of tumors, squamous cell carcinoma (SCC) and esophageal adenocarcinoma (ACE) represent 95% of the total. For most of the twentieth century, the SCC predominated throughout the world, however, this trend has changed dramatically in Western countries, including ours. Mexican patients with esophageal cancer are diagnosed at later stages of the disease and have worse therapeutic outcomes than reported in the world literature. Methods: Retrospective, observational and descriptive study. The research subjects were obtained from the population of patients who attended the service of the Centro Universitario Contra el Cancer of the University Hospital "Dr. José Eleuterio González” between 2012 and 2017 (sample size calculated n = 120).The clinical and demographic characteristics of patients with esophageal cancer in our population were described. The results from international guides (AIMS65, New International Score, Glasgow-Blatchford scale and Rockall pre-endoscopic) were used to compare cut-off points with our population and their correlation with mortality. Results: A total of 179 research subjects were included in the study. The average age was 55 years, 62% male and 38% female. Various demographic characteristics such as in-hospital mortality (n = 42, 23.5%), 30-day mortality (n = 36, 20.1%), re-bleeding (n = 49, 27.4%) and transfusions (n = 99, 55.3%) were studied as incidence of positive cases to the event. We also studied the mean days of hospital stay (4.6 days), systolic blood pressure (108 mmHg) and diastolic blood pressure (66mmHg), hemoglobin (8.9 g / dL), among others. The type of bleeding was variceal in 122 subjects, and non-variceal in 57. In total, 117 subjects were treated with endoscopic treatment and 53, without endoscopic treatment. The Glasgow Blatchford scale obtained a higher discriminative score (AUROC 0.73) to predict in-hospital mortality in our subjects, compared to ASA (0.72 p &lt; 0.001), New International score (0.76 p &lt; 0.001) and AIMS65 (0.66 p &lt; 0.001). Conclusions: The used scales had no positive predictive value for bleeding risk. The Glasgow Blatchford scale was the only score that showed an AUROC of 0.65 p &lt; 0.001 to predict the efficiency of transfusion in patients compared to the other scores that showed no significant value. ASA was the predictive discriminative score (AUROC 0.73) for a 30-day in-hospital mortality (p &lt; 0.001), followed by the Glasgow Blatchford scale (0.61 p &lt; 0.04).

Long-term Noninvasive Ventilation in Obesity Hypoventilation Syndrome Without Severe OSA: The Pickwick Randomized Controlled Trial

Noninvasive ventilation (NIV) is an effective form of treatment in obesity hypoventilation syndrome (OHS) with severe OSA. However, there is paucity of evidence in patients with OHS without severe OSA phenotype. Is NIV effective in OHS without severe OSA phenotype? In this multicenter, open-label parallel group clinical trial performed at 16 sites in Spain, we randomly assigned 98 stable ambulatory patients with untreated OHS and apnea-hypopnea index< 30 events/h (ie, no severe OSA) to NIV or lifestyle modification (control group) using simple randomization through an electronic database. The primary end point was hospitalization days per year. Secondary end points included other hospital resource utilization, incident cardiovascular events, mortality, respiratory functional tests, BP, quality of life, sleepiness, and other clinical symptoms. Both investigators and patients were aware of the treatment allocation; however, treating physicians from the routine care team were not aware of patients' enrollment in the clinical trial. The study was stopped early in its eighth year because of difficulty identifying patients with OHS without severe OSA. The analysis was performed according to intention-to-treat and per-protocol principles and by adherence subgroups. Forty-nine patients in the NIV group and 49 in the control group were randomized, and 48 patients in each group were analyzed. During a median follow-up of 4.98 years (interquartile range, 2.98-6.62), the mean hospitalization days per year ± SD was 2.60 ± 5.31 in the control group and 2.71 ± 4.52 in the NIV group (adjusted rate ratio, 1.07; 95%CI, 0.44-2.59; P= .882). NIV therapy, in contrast with the control group, produced significant longitudinal improvement in Paco2, pH, bicarbonate, quality of life (Medical Outcome Survey Short Form 36 physical component), and daytime sleepiness. Moreover, per-protocol analysis showed a statistically significant difference for the time until the first ED visit favoring NIV. In the subgroup with high NIV adherence, the time until the first event of hospital admission, ED visit, and mortality was longer than in the low adherence subgroup. Adverse events were similar between arms. In stable ambulatory patients with OHS without severe OSA, NIV and lifestyle modification had similar long-term hospitalization days per year. A more intensive program aimed at improving NIV adherence may lead to better outcomes. Larger studies are necessary to better determine the long-term benefit of NIV in this subgroup of OHS. ClinicalTrials.gov; No.: NCT01405976; URL: www.clinicaltrials.gov.

A prospective study on clinico-epidemiological profile and outcome in management of poisonous snake bite

Background: Snake bite is a major health problem in Nepal. According to WHO, annual morbidity due to snake bite is 162 out of 100,000 people in Nepal. Aim of the study is to observe epidemiology, clinical features, and analysis of possible relationship between time delay in administration of anti-snake venom (ASV) and mortality. Methods: This prospective observational study analyses the data of 81 patients admitted to the Lumbini zonal hospital, Butwal, Rupandehi, Nepal with history of snake bite between April to September, 2017.Results: In this study 56% patients were female. Patients of age group (15-30) years were maximum (38.27%). The study showed that 50.61% of snake bites were occurred outside home. Most of patients (84%) were from the Terai region. Average no. of vials used per case was (28±10) vials. Most of victims of snake bite were from rural areas. In most of cases we found that prothrombin time was prolonged. It was found that most of patients 57% reach hospital before 4 hours of snake bite. The mean days of hospital stay was 6±2.86. Most of case of snake bite was unknown (62%). The mortality rate in this study was 6.17%.Conclusions: There is a great need to improve in existing health care conditions for effective management of snake bite; it requires training of the personnel engaged in the emergency health care management, development of national guidelines based on the clinical trials, improving the distribution and easy availability of antivenom.

Clozapine use - has practice changed?

One-third of individuals with schizophrenia have treatment-resistant illness. Of these, up to 60% will respond to clozapine treatment. This study retrospectively examined clozapine prescribing patterns against National Institute for Health and Care Excellence (NICE) guidelines as treatment-resistant illness emerged in a first-episode psychosis cohort. A total of 339 individuals with a first-episode psychosis were included in the study. Clozapine prescribing patterns were compared against the NICE guidelines and the impact of clozapine use on one index of service utilisation (hospitalisation) was assessed. A total of 32 individuals (9.4%) from the cohort were prescribed clozapine. The mean time to clozapine trial was 2.1 years (SD 1.95; range 0.17-6.25). The mean number of adequate trials of antipsychotic prior to starting clozapine was 2.74 (SD 1.13; range 1-5). Following clozapine initiation, mean hospital admissions per year reduced from 2.3 to 0.3 (p=0.00). Mean hospital days pre- and post-clozapine also reduced (147 vs. 53; p=0.00). In total, 18 patients discontinued clozapine use during follow-up - 5 temporarily and 13 permanently. Patients are being prescribed clozapine earlier than previously demonstrated, though delays are still evident, and many patients discontinue treatment. More work needs to be undertaken to understand and address factors which lead to its discontinuation.

105 The Impact of Flap Timing and Mechanism of Injury on Flap Complications in Acute Burn Patients

Abstract Introduction Burn wounds are often amenable to excision and grafting, but pedicled and free flaps are sometimes necessary to achieve closure of complex wounds. Flap coverage of exposed bone, tendons and cartilage has classicaly been delayed in acute burn patients due to concern of progressive tissue necrosis, microvascular thrombosis and percieved high failure rates. More recently, a number of reports have demonstrated that the use of flaps is safe earlier in acute burn care. We aim to elucidate the role of flaps in primary burn woud coverage leveraging national US data. Methods Acute burn patients with known % total body surface area were extracted from the Nationwide/National Inpatient Sample from 2002–2014 based on International Classification of Disease (ICD) Codes 9th edition. Flap procedures were identified based on ICD-9 procedure codes. Flap and non-flapped patients were compared using multivariable analysis. Variables included age, gender, race, Elixhauser comorbidity index, %TBSA, burn mechanism, inhalation injury, and location of burn. Flap complication was defined by ICD-9 procedure code 8675, return to OR for revision of flap. Multivariable analysis evaluated predictors of flap compromise based on stepwise logistic regression with backwards elimination. Results The weighted sample included 306,924 encounters of which 526 received a flap (0.17%). The mean age of encounters receiving a flap was 45.0 (SD 21.2) years versus 35.5 (SD 24.2) years in the non flap group (p=0.023). 7.8% of patients who received a flap suffered electric injury compared to 2.7% of non-free flap encounters (OR 3.76, 95% CI 1.95–7.24, p&amp;lt; 0.001). Patients who underwent flap wound coverage were more likely to have a lower extremity burn; 55.3% of encounters versus 43.1% in non- flap patients (OR 2.26, 95% CI 1.05–2.15, p=0.024). There were no significant differences in gender, race, Elixhauser comorbidity index, %TBSA, or inhalation injury. The mean hospital day of the flap procedure was 10.1 (SD 10.7) days. Flap complications occurred in 6.4% of flap encounters. The only independent predictor of flap complication was electrical injury (OR 40.49, 95% OR 2.98–550.64, p=0.005). The time to flap coverage and location were not associated with complications. Conclusions Electrical injury was an independent predictor of flap complications compared to other mechanisms. Flap timing was not associated with return to surgery for complications. This suggests that the use of flaps is safe in acute burn care to achieve burn wound closure with an understanding that electrical injuries may deserve particular consideration to avoid failure. Applicability of Research to Practice Inform surgeon decision making when deciding candidacy for flap surgery in acute burn patients.

Lamellar Keratoplasty Combined with Amniotic Membrane Transplantation for the Treatment of Corneal Perforations: A Clinical and In Vivo Confocal Microscopy Study.

Purpose To evaluate the clinical and in vivo confocal microscopy outcome of lamellar keratoplasty combined with amniotic membrane transplantation for the treatment of corneal perforations. Methods In this retrospective, noncomparative, and interventional case series, 13 eyes of 13 patients with corneal perforation were included. All eyes were treated with lamellar keratoplasty combined with amniotic membrane transplantation for corneal reconstruction. Age, underlying etiology, location, size of corneal ulcer, size of corneal perforation, hospitalization days and follow-up time, and corneal confocal microscopy were investigated. Aqueous leakage, anterior chamber formation, epithelial healing time, and visual acuity (VA) were monitored after operation. Results The cause of corneal perforation (n = 13) was classified as infectious (n = 13) was classified as infectious (n = 13) was classified as infectious (Conclusion Lamellar keratoplasty combined with amniotic membrane transplantation may be an alternative, safe, and effective surgical therapy in the treatment of corneal perforations in the absence of a fresh donor cornea. We recommend this surgery to treat with the size of corneal perforation of <4 mm in diameter no matter peripheral or central corneal perforation, especially who had immune-related diseases.

Efficacy & safety of Carica papaya leaf extract (CPLE) in severe thrombocytopenia (≤30,000/μl) in adult dengue - Results of a pilot study.

Severe thrombocytopenia in dengue often prompts platelet transfusion primarily to reduce bleeding risk. In India, about 11–43% of dengue patients report receiving platelet transfusions which is considered scarce and expensive especially in resource limited settings. Herein, we evaluated the efficacy and safety of Carica papaya leaf extract (CPLE) in the management of severe thrombocytopenia (≤30,000/μL) in dengue infection. 51 laboratory confirmed adult dengue patients with platelet counts ≤30,000/μL were randomly assigned to either treatment (n = 26) or placebo (n = 24) group. By day 3, CPLE treated patients reported significantly (p = 0.007) increased platelet counts (482%± 284) compared to placebo (331%±370) group. In the treatment group, fewer patients received platelet transfusions (1/26 v/s 2/24) and their median time for platelets to recover to ≥ 50,000/μL was 2 days (IQR 2–3) compared to 3 days (IQR 2–4) in placebo. Overall, CPLE was safe and well tolerated with no significant decrease in mean hospitalization days. Plasma cytokine profiling revealed that by day 3, mean percent increase in TNFα and IFNγ levels in treatment group was less compared to that observed in placebos; (TNFα: 58.6% v/s 127.5%; p = 0.25 and IFNγ: 1.93% v/s 62.6% for; p = 0.12). While a mean percent increase in IL-6 levels occurred in placebos (15.92%±29.93%) by day 3, a decrease was noted in CPLE group (12.95%±21.75%; p = 0.0232). Inversely, CPLE treated patients reported a mean percent increase compared to placebo by day 3 (143% ±115.7% v/s 12.03%± 48.4%; p = 0.006). Further, by day 3, a faster clearance kinetics of viral NS1 antigenemia occurred–mean NS1 titers in treatment group decreased to 97.3% compared to 88% in placebos (p = 0.023). This study demonstrates safety and efficacy of CPLE in increasing platelet counts in severe thrombocytopenia in dengue infections. A possible immunomodulatory and antiviral activity may be attributed to CPLE treatment. These findings merit validation in larger prospective studies.Trial registrationName of the registry: Clinical Trials Registry—India (CTRI)Registration No.: CTRI-REF/2017/02/013314

Sarcopenia is common in patients with cirrhosis and unresectable HCC treated by transarterial embolization but is not associated with increased rates of complications

Sarcopenia has been associated with higher rate of complications in patients with cirrhosis and hepatocellular carcinoma (HCC) undergoing resection or radiofrequency ablation. Little is known about its role in patients affected by unresectable HCC undergoing transarterial embolization (TAE). Patients who underwent the 1st TAE between March 2011 and July 2019 in our Unit were analyzed. Data about age, sex, stage of disease, hospitalization days, onset of complications and readmission during the 1st month were collected. The area of lean muscle mass at the level of the third lumbar vertebra, was segmented using regions of interest in the latest abdominal CT scan prior to TAE. To evaluate sarcopenia, the skeletal muscle index (SMI) was calculated by normalizing cross-sectional muscle area by height. SMI cut-off values were considered ≤39 cm2/m2 for women and ≤55 cm2/m2 for men. During the study period, 150 patients affected by unresectable HCC underwent TAE. Most of the patients were males (76.7 %) and the mean age at diagnosis was 73.1 ± 9.3 years (40-88). Main etiology of cirrhosis was HCV (45 %), followed by alcohol (23%); CPT class A was present in 81.8 % of patients. The average SMI was 41 ± 8.8 cm2/m2 with 128/150 patients (85.3 %) classified as sarcopenic. Mean days of hospitalization after TAE were 2 ± 1.67. Eleven patients (7.3 %) had early complications (6 had bleeding, 3 sepsis and 2 liver decompensation) and 9 (6 %) had unplanned readmission. At univariate analysis, no statistically significant differences were found between sarcopenic and non-sarcopenic patients: length of hospitalization (2 vs 1.6 days; p-value = 0.26), early complications rate (7.8 % vs 4.5 %; p = 0.58) and rate of readmission (6.3 % vs 4.5 %; p = 0.74). Sarcopenia is common in patients affected by unresectable HCC undergoing TAE. In this group, TAE can be considered a safe treatment option as it wasn’t associated with higher rates of early complications or readmission.