Mean Hospital Days Research Articles

Pattern of Pediatric Morbidity in Hospital Admitted Patients in Western Region of Nepal

Background: Pediatric age group comprises the important fraction of hospital admissions in our health care settings and it is the major challenge to address in the developing countries like ours. This study was carried out to find out the significant epidemiological trends and disease patterns of the admitted children in a pediatric ward.Methods: This retrospective study was carried out by reviewing hospital records of the patients admitted in the pediatric ward from July 2015 to January 2016 in Gandaki Medical College Teaching Hospital. The disease pattern was analyzed on the basis of age, sex, final diagnosis of the disease, duration of hospital stay and months of admission.Results: Among the 1348 admitted children during the study period, majority were males (65%) and below five years (74%). Lower respiratory tract infections (30%), enteric fever (10%) and acute gastroenteritis (7.7%) were the three major causes for admission. The mean days of hospital stay was 4.43 and maximum number of children was admitted during August/September.Conclusion: Infectious diseases are the major cause for morbidity and more were during the rainy season.J-GMC-N | Volume 11 | Issue 01 | January-June 2018, Page: 61-63

Epidemiology, clinical features and outcome of bacteriemia episodes by carbapenemase-producing and non carbapenemase-producing enterobacteriaceae

Background: Carbapenemase-producing Enterobacteriaceae (CPE) is a public health problem due to their spectrum of infections and their high mortality. The aim of this study was to describe the epidemiology, clinical features and outcome of bacteremia by CPE compared to non-CPE. Methods & Materials: Retrospective cohort study. Enterobacteriaceae bacteremia episodes from January 2015 to December 2016 were included. The presence of genes coding for major carbapenemases (I.e. blaVIM, blaNDM, blaIMP, blaKPC and blaOXA-48) was investigated by polymerase chain reaction using specific primer. Chi square analysis and Kruskal-Wallis test were used for categorical and for continuous variables, respectively. To identify risk factors for 7-day and 30-day mortality a multivariate stepwise logistic regression analysis was performed. Results: We included 67 episodes (67,2% male): 14 (23,2%) CPE and 53 (76,8%) non-CPE. CPE isolates were blaKPC (78,5%), blaOXA (14,2%) and blaNDM (7,14%). Klebsiella spp (CPE: 85,7% vs non-CPE: 41,5%) was the most frequently isolated pathogen. The mean days of hospitalization until bacteremia episode and ICU admission in CPE vs non-CPE were: 26,6 vs 8,2 (p = 0.016) and 78% vs 45% (p = 0.027) respectively. The most common source of bacteremia was catheter-related in the CPE group (45% vs 18%; p = 0,005) and intra-abdominal in the non-CPE group (52% vs 9,1%; p = 0,009). Adequate empirical antibiotic treatment was similar: 64% vs 77%; p = 0.31. The risk of death at 7-day was 6.8 times higher in the CPE group compared to the non-CPE group (OR 6.8 CI 95% 1.1-40; p = 0,006) and mortality at 30-day was also higher in the CPE group (OR 4.9, 95% CI 1.1-20, p = 0.011). In multivariate analysis, Pitt bacteremia score > 4 (OR 20, 95% CI = 3,7- 40, p = < 0,0001), APACHE II score > 15 (OR 19, 95% CI 2,5-46, p = 0,0004), shock (OR 36, 95% CI 4,5-55, p = < 0,0001), CPE (OR 4,8, 95% CI 1,1-20, p = 0,01) were risk factors for 30-day mortality. Conclusion: Patients with Enterobacteriaceae bacteremia were slightly different regarding epidemiology and clinical presentation. CPE episodes had a much higher early and late mortality than non CPE, and was one of the independent prognostic factors. It is essential to improve early diagnosis and adequate treatment in patients at risk.

Necrotizing Fasciitis and Methicillin Resistant Staphylococcus Aureus

Necrotizing fasciitis (NF) is an aggressive and life-threatening infection of skin and soft tissue characterized by widespread fascial necrosis which leads to morbidity and mortality if left untreated. There is difficulty in managing this condition because there is a combination of difficulty in diagnosis, and also of early as well as late management. It can be caused by either a single organism or more frequently by a variety of microbes - both aerobic and anaerobic. Necrotizing fasciitis seems to have preponderance in males, perhaps due to increased incidence of trauma in males. Staphylococcus aureus is the most prevalent pathogen in hospitals and communities and MRSA has become a common isolate associated with skin and soft tissue infections over the past few years, monomicrobial MRSA necrotizing fasciitis has been reported only in a few studies. Early surgical intervention, early diagnosis and aggressive treatment should be done. Material and Methods: All patients were diagnosed as NF on surgical report. Surgical exploration is undertaken after resuscitation. Penicillin along with, an amino glycoside and clindamycin or metronidazole is administered preoperatively in moribund patients. Cefoxitin or imipenem or meropenem is used in more limited infections. Fair amount of desloughing is done without anesthesia. Overlying fat as patchy greenish-black liquefaction necrotic tissues are excised primarily, and specimen sent for culture in microbiology department. Cultures were processed the susceptibility of S. aureus isolates to antimicrobials was done. Results: A total of 200 hospitalized patients those who were surgically treated for NF were included in the study. Of the 200 patients 42 patients were culture positive for MRSA. In our study mean age was 56± 11.21 of which 124 (62%) were male , mean hospitalization days were 16.5± 6.2. patients with underlying diabetes mellitus were 66 (33%) and hypertension were 74(37%). In MRSA group (n=42) mean age was 53 ± 9.22. Male were 36 (73.81%) , mean hospitalization days were 17.6 ± 6.2. patients with underlying diabetes mellitus were 21 (50%) and hypertension were 19(45.24%).42 (21%) were MRSA, 31 (15.5%) were MSSA, 21 (10.5%) were coagulase negative staphylococcus, 4(2%) were Streptococcus group A, 11 (5.5%) were Streptococcus species, 6 (3%) were Bacillus species, 24 (12 %) were Escherichia coli, 19 (9.5%) were Acinetobacter species, 3 (1.5%) were Candida albicans and in 30 (15%) no growth was observed in culture. Discussion and Conclusion: Some experts recommend use of broad-spectrum empirical antimicrobial therapy for suspected cases of necrotizing fasciitis and therapy directed against MRSA is not a standard practice. For treatment selection of appropriate antimicrobial agents for any suspected necrotizing fasciitis must take into account the nature of patient's exposure and local epidemiologic data but no reliable epidemiological or clinical risk factors with MRSA from those infected with MSSA or non-S. aureus are available. In our study mean age of patients diagnosed NF was 53 ± 9.22. While male were 36 (73.81%). In study by Cheng NC et al. the median age was 62 years (range, 12-81 years) There was male predominance in NF by MRSA in our study . In our study lesions on extremities had better prognosis similar results were shown in other study. Necrotizing fasciitis caused by MRSA is a challenge to the treating surgeon. Prompt diagnosis and surgical management with empiric MRSA cover in areas where community acquired MRSA (CA-MRSA) is endemic. Lesions of extremities have better prognosis where MRSA infection is becoming endemic and empirical treatment of suspected necrotizing fasciitis or pneumonia should include active MRSA cover.

Efficacy of the Retrograde Intrarenal Surgery in Renal Stone: An Initial Clinical Experience

Objective The management of renal stone has changed radically over the recent decades mainly due to increasing use of flexible ureteroscopy. We report our initial experience of retrograde intrarenal surgery (RIRS) in treating renal stones. Methods Twenty-five patients (13 males and 12 females) who underwent RIRS for renal stone by a surgen between March 2016 to December 2017 were retrospectively reviewed. We analyzed the patients’ age, gender, stone location, stone burden, operative time, hospital stay, double J stent indwelling duration, success rates, and incidence of complications. Results The mean age of the patients was 54.9 years (range, 29–87 years). The locations of renal stones were nine cases in the renal pelvis, 14 in the renal calyx, and three in the renal diverticulum. The mean body mass index was 25.2 kg/m2 (range, 21.2–29.4 kg/m2). After 1 week since initial session, stone free rate was 72%, but 88% at 3-month follow-up. The mean stone burden was 45.7 mm (range, 16.4–189.3 mm), and mean operative time was 95.0 minutes (range, 30–125 minutes). The mean hospital day was 3.5 days (range, 3–6 days). Double J stent was inserted in all patient during operation and mean indwelling duration was 6.96 days (range, 4–14 days). Most common complication was fever and recovered with conservative therapy. Conclusion This study demonstrated that RIRS is safe and effective procedure for management of intrarenal stones with minimal complications. Our study suggests that renal stone burden is significant factor of success rate in RIRS. However, surgical experience and long-term follow-up are needed to confirm the factor of success rate. Key words: Nephrolithiasis; Kidney; Ureteroscopy

To explore the clinical effect of tension-free repair in the treatment of inguinal hernia in elderly patient

Objectives To explore the clinical effect of tension-free repair in the treatment of inguinal hernia in elderly patient. Methods A total of 124 elderly patients with inguinal hernia admitted in our hospital in 2016 were randomly divided into a study group(n=62)and a control group(n=62). The control group was treated with open tension-free inguinal hernia repair, whereas with laparoscopic tension-free inguinal hernia repair in the study group.The operation time, intraoperative blood loss, the postoperative pain relief-time, mean days of hospitalization, postoperative recurrence rate, and complications rates were compared between the two groups. Results The more significant improvements were found in study group versus control group in the intraoperative bleeding volume[(19.9±2.0)ml vs.(36.8±2.5)ml, t=41.564, P=0.000], in the mean hours of postoperative pain[(22.1±4.2)h vs.(35.3±7.0)h, t=12.732, P=0.000], in mean days of hospitalization[(5.5±1.0)d vs.(9.2±1.9)d, t=13.569, P=0.000], in incidence rate of postoperative recurrence(0.0% vs.6.5%, χ2=4.133, P=0.042), and in postoperative complications rate(3.2% vs.12.9%, χ2=3.916, P=0.048). Nevertheless, the operation time was longer in the study group than in the control group[(87.0±5.0)min vs.(55.5±4.2)min, t=-37.984, =0.000]. Conclusions As compared with open tension-free repair, the clinical efficacy of laparoscopic tension-free hernia repair is exactly sure in the treatment of inguinal hernia, with shorter postoperative hospitalization time and lower incidence of complications. Key words: Hernia, inguinal; Laparoscopic surgical procedures; Tension-free repair

Effect of Using Staples on Early Functional and Surgical Outcomes in Anterior Vertebral Body Tethering

Bant ile gerdirme yöntemi, adölesan idiyopatik skolyozda füzyon cerrahisine umut verici bir alternatiftir. Ameliyattaki düzelmeyi takipte büyümeye bağlı ek düzelme izler. Çalışmanın amacı, bant ile gerdirmede vida yerleştirilirken pul kullanımının erken dönem cerrahi ve işlevsel sonuçlar ve implantla ilişkili komplikasyonlar üzerindeki etkisini incelemektir. Gereç ve Yöntem: Çalışmaya ≥3 aylık izlemi olan ardışık 27 hasta alındı. Hastalar pul kullanımına göre 2 gruba ayrıldı. Günlük yaşam aktivitelerine dönüş, cerrahi sonuçlar, yaşam kalite anket sonuçları ve komplikasyonlar kaydedildi. Pul kullanımının etkileri Mann-Whitney U testi kullanılarak karşılaştırıldı. Sonuçlar: Hastanede kalış ve okula dönüş süreleri iki grupta benzerdi. Her iki grupta yaşam kalite anketlerinde işlevsel aktivite, ağrı, görünüm algısı ve ruh sağlığı alanlarında benzer iyileşmeler saptandı. Tüm hastalar rehabilitasyon hedeflerine ulaştı. Pul kullanılmayan gruptaki hastalar daha sıklıkla implantla ilişkili komplikasyon yaşadı. Tartışma: Bant ile gerdirme yönteminde vidalar yerleştirilirken pul kullanılması implantla ilişkili komplikasyonları azaltabilir. Bu cerrahi yöntem pul kullanımından bağımsız olarak erken dönemde iyi işlevsel ve cerrahi sonuçlar ve yüksek hasta memnuniyeti sağlamıştır. Bu çalışmada elde edilen bulgular ışığında vidalar yerleştirilirken pul kullanılan ve kullanılmayan gruplarda biyomekanik yüklere karşı dirençte öne sürülen farklılık hastaların ameliyat sonrası rehabilitasyon süreçlerinin planlanmasında önemli olabilir.

Does the Presence of Subdural Hemorrhage Increase the Risk of Intracranial Hemorrhage Expansion after the Initiation of Antithrombotic Medication?

Patients with traumatic intracranial hemorrhage (ICH) with a clinical indication for antithrombotic medication present a clinical dilemma, burdened by the task of weighing the risks of hemorrhage expansion against the risk of thrombosis. We sought to determine the effect of subdural hemorrhage on the risk of hemorrhage expansion after administration of antithrombotic medication. Medical records of 1626 trauma patients admitted with traumatic ICH between March 1, 2008, and March 31, 2013, to a Level I trauma center were retrospectively reviewed. The pharmacy database was queried to determine which patients were administered anticoagulant or antiplatelet medication during their hospitalization, leaving a sample of 97 patients that met inclusion criteria. Patients presenting with subdural hemorrhage were compared with patients without subdural hemorrhage. Demographic data, clinically significant expansion of hematoma, postinjury day of initiation, and mortality were analyzed. A total of 97 patients met inclusion criteria with 55 patients in the subdural hemorrhage group and 42 in the other ICH group. There were no significant differences in age, gender, injury severity score, admission Glasgow coma score, or mean hospital day of antithrombotic administration between the groups. Patients with subdural hemorrhage had a significantly higher rate of ICH expansion (9.1 vs 0%, P = 0.045). There was no difference in overall hospital mortality between the two groups. Incidence of ICH expansion was higher in patients with subdural hemorrhage. It may be prudent to use special caution when administering antiplatelet or anticoagulant medication in this group of patients after injury.

Childhood Poisoning, A Rising Epidemic in Developing Nations: Large Single Centre Study

Introduction: Poisoning is a major problem in children. The aims of this study were to determine the pattern of poisoning in children along with seasonal incidence, duration of treatment and outcome in referral centre of eastern India.Materials and Methods: All the children admitted to paediatric ward of MKCG Medical college and hospital from 1st April 2015 to 31st March 2016 (1 year) with history or suspicion of poisoning and animal bites were included in the study. Brought dead patients and the children with side effects due to ingested drugs in prescribed amount were excluded from the study.Results: Total 530 cases were documented with highest incidence in rainy season. 1-6 years children were mostly vulnerable (42.6%). Accidental mode was the major cause in small children and suicidal, in older. Animal bites and stings (n=241) were the commonest followed by chemical poisonings. Kraits were commonest culprit in snake envenomation group. Alprazolam was most common drug causing drug overdose. Total numbers of death were 27. Major cause of death was organo- phosphorus poisoning (OP) and snakebite. Mean days of hospitalization was 2.5 days and death after hospitalization was 1.8 days.Conclusion: Most of the childhood poisonings were due to accidental cause. Animal bites were mostly due to snakes. Maximum numbers of deaths were due to OP poisoning. Watchful observation, clean and clear environment, understanding the problems of adolescence, friendly atmosphere in home can prevent most of the poisonings and animal bites in children.

Comparing Surgical Site Infection and Scar Cosmesis Between Conventional Linear Skin Closure Versus Purse-string Skin Closure in Stoma Reversal - A Randomized Controlled Trial.

IntroductionStoma closure is one of the most frequently performed surgeries. The common complications are surgical site infection (SSI) and poor scar cosmesis. Purse-string sutures are expected to have less incidence of SSI due to the free drainage of secretions from the wound and possibly the early detection of a wound infection. Compared to the conventional linear closure, the purse-string closure technique is expected to have less wound infection, improved scar cosmesis, and good patient satisfaction because of a smaller size scar. Hence, a well-structured study is required to substantiate the advantage of this technique.MethodologyThis randomized control trial was carried out for two years in a tertiary care centre in Southern India. Patients with various stoma reversals, including colostomy, as well as ileostomy reversal, were included in the study. Patients were divided into Group I - conventional linear skin suturing (n = 40) and Group II - purse-string closure (n = 40). After the closure of rectus muscle, the skin is closed using the purse-string method (subcuticular) in the experimental group.ResultsBoth the groups were comparable with respect to age, gender, body mass index (BMI), the presence of co-morbidities, and indication for surgery. Stomal procedures were done (26.3%) for malignant cases. The difference in mean hospital days for both groups were statistically insignificant (11.95 vs. 9.9; p = 0.927). The incidence of SSI between the groups were statistically significant (17 vs. 3; p = 0.003). The mean Patient and Observer Scar Assessment Scoring (POSAS) scores between the groups (65.30 vs. 83.40; p = 0.012) were statistically significant. This proved significant improvement in scar cosmesis in purse-string skin closure. At one month postoperative, the purse-string group had better patient satisfaction (3.08 vs. 4.48; p = 0.001), which was evidenced by a mean Likert 3 scale score. The mean visual analogue scale (VAS) score did not show any significant difference in pain between the groups.ConclusionPurse-string skin closure for stoma reversal had significantly less incidence of SSI. The duration of antibiotic therapy was also less in purse-string skin closure patients as compared to linear skin closure patients. Purse-string skin closures significantly improved the scar outcome and patient satisfaction.

Everolimus and transarterial embolization (TAE) for hepatic metastasis in neuroendocrine tumors (NET).

485 Background: TAE of hepatic metastases is effective loco-regional therapy for neuroendocrine tumor (NET) patients. Transarterial chemotherapy (TACE) and transarterial radiotherapy (TARE) are other options in controlling hepatic metastases but deliver cytotoxic agents only at the time of the procedure. Systemic therapies such as everolimus or sunitinib are often held 2-4 weeks prior to and after the procedure. We hypothesize that concurrent oral treatment with everolimus and transarterial hepatic embolization is safe. Methods: Medical records of all NET patients (pts) treated at the Markey Cancer Center between July 2016 to July 2017 with concurrent transarterial embolization and everolimus were reviewed. Results: Total number of pts eligible for analysis was 15. Mean age of study cohort was 57.5 years (31-77). Seven pts were small bowel, 4 were pancreatic and remaining 4 were unknown NET primaries. Nine patients had grade 1 (Ki 67 &lt; 2%) and 6 patients had grade 2 NETs (Ki-67 between 2-20%). Mean duration of treatment with everolimus prior to embolization was 3.8 months and mean dose was 10 mg orally every other day. Mean days of hospitalization were 1.46. Eleven (73%) pts were discharged the day after procedure. Ten (67%) pts reported nausea, 9 (60%) reported abdominal pain, 5 (30%) reported emesis. One patient had hematemesis immediately post procedure. Thirteen (87%) pts had no significant change in hemoglobin pre and post procedure (within one numerical point). No patient developed infectious complications. Conclusions: Combining everolimus with TAE is safe and does not result in longer hospitalizations or toxicities greater than that expected from TAE alone.

Early postoperative outcomes of coronary artery bypass grafting patients on-pump versus off-pump

Coronary artery bypass grafting (CABG) is defined as “open-heart surgery in which a section of a blood vessel is grafted from the aorta to the coronary artery to bypass the blocked section of the coronary artery. Cardiac surgery became more feasible in the late 1930s with the development of the heart-lung machine by Dr. John Gibbon which enabled cardiopulmonary bypass (CPB). This study aimed at comparing early postoperative outcomes between patients undergone CABG on-pump versus off-pump. The study was done on 40 patients, 20 of them was done by on-pump technique and the other 20 was done by off-pump technique. All the patients were transferred to intensive care unit and were observed for the following criteria: Early postoperative bleeding, Cardiac support (Medical or Mechanical), Different types of Arrythmias, Renal function and Hospital stay. Early postoperative bleeding: appears to be more with On-pump technique in the first 3 post operative days. Cardiac support (Medical or Mechanical): No significant difference with both techniques. Different types of Arrythmias: No significant difference with both techniques. Renal function: No significant difference with both techniques except of only one patient needed renal dialysis was done by on-pump technique. Hospital stay: No significant difference with both techniques with mean days of hospital stay for all patients of 8 days. In conclusion, our trial did not show any overall advantage to the use of the off-pump as compared with the on-pump cardiac surgical approach for coronary bypass grafting.

The impact to operation safety of preoperative renal artery embolization for management of diameter≥10 cm renal cell carcinoma

Objective: To study the impact to operation safety of preoperative renal artery embolization for management of ≥10 cm renal cell carcinoma. Methods: The clinical data of 239 cases with ≥10 cm renal cell carcinoma which all had underwent operation in Department of Urology, Peking University First Hospital from January 2002 to December 2014 were retrospectively analyzed. Fifty-three patients underwent preoperative renal artery embolization (therapeutic group) and 186 patients did not (control group). The effect of embolization on operative time, transfusion requirements, hospitalization, ICU stay and perioperative complications were analyzed by comparing the two groups using rank sum test and χ(2) test or Fisher exact test. Results: Comparing the therapeutic group and control group, there was significant difference in tumor location (on the left or right). The mean age, sex, mean primary tumor size, and TNM stage were similar in both groups. Comparing the therapeutic group and control group, there were more open surgeries in therapeutic group (96.2% vs. 82.3%, χ(2)=6.438, P=0.013). There were no significant differences in mean operative time (238 (525) minutes vs. 208 (583) minutes, Z=-2.182, P=0.062). The mean blood transfusion (700 (1 900) ml vs. 925 (8 800) ml, Z=-1.064, P=0.006) had significant difference. The therapeutic group had a longer mean hospitalization (21 (50) days vs. 15 (79) days, Z=-4.322, P=0.000) and higher rate of intensive care unit stay (54.7% vs. 34.4%, χ(2)=6.103, P=0.027). There was no significant difference in perioperative complications between two groups (0 vs.3.2%, P=0.408). Conclusion: Preoperative renal artery embolization in ≥10 cm renal cell carcinoma patients undergoing operation provides benefit in increasing operation safety and reducing perioperative death.

70 Multicenter Trial of Rivaroxaban for Early Discharge of Pulmonary Embolism from the Emergency Department

Hospitalization after an ED diagnosis of a pulmonary embolism (PE) is common, expensive, and of questionable clinical benefit in low-risk patients. Our purpose was to determine if low-risk PE patients, discharged home from the ED on rivaroxaban, have a different total number of hospital days through day 30 vs standard of care (SOC). This was a multicenter, prospective, open label, randomized clinical trial of patients ≥18 years of age with an ED diagnosis of low risk PE (defined by HESTIA criteria). After consent subjects were randomized by a central computer to SOC, which was determined by the ED attending, or ED discharge on rivaroxaban, and followed for 90 days. Our primary outcome was the total number of initial hospital days, plus days of hospitalization related to bleeding or VTE, during the 30 days after a low risk ED PE diagnosis in patients discharged on rivaroxaban vs SOC. A 90-day composite safety endpoint was defined as International Society of Thrombosis and Hemostasis (ISTH) major bleeding, clinically relevant non-major bleeding, and mortality. Cohorts were compared using descriptive statistics and 95% confidence intervals for mean differences. We randomized 114 subjects, 51 to rivaroxaban and 63 SOC. Most were white (67.5%), female (51.8%), with a median (IQR) age of 50 (36, 61) yrs. Of 112 (98.2%) receiving at least 1 dose of study drug, 99 (86.8%) completed the study. There were 15 (13.2%) discontinuations; 7 (6.1%) lost to follow-up, 4 (3.5%) adverse events, and 2 (1.8%) consent withdrawal. Median (IQR) therapy duration was 91 (89, 94), and 89 (85, 93) days for rivaroxaban vs SOC. The intent to treat primary endpoint was 4.6 hours for rivaroxaban vs 33.4 hours for SOC (mean difference -1.20 days, 95% CI -1.773, -0.630). Mean total hospital days (for any reason) at 90 days after randomization were significantly shorter for rivaroxaban than SOC; 0.8 vs. 1.8 days (mean difference between groups was -0.8 days; 95% CI: -0.963, -0.605). At 90 days follow-up there were no ISTH bleeding events, recurrent VTE, or deaths. Unplanned VTE and bleeding related hospital or doctor visits within 90 days were numerically lower with rivaroxaban; 2 (3.9%) vs. 4 (6.3%); difference in proportions -0.02 (95% CI: -0.21 to 0.16). The composite safety endpoint was similar in both groups; difference in proportions 0.005 (95% CI: -0.181 to 0.191). There were numerically more adverse events (AEs) with rivaroxaban than SOC, 59.2% vs. 39.7%, however, the overall rate of serious AEs, AEs leading to hospitalization, and AEs leading to study drug discontinuation were similar between cohorts (p>0.05). In this prospective, open label, randomized standard-therapy controlled trial, low risk ED PE patients discharged on rivaroxaban had similar outcomes as SOC but spent fewer total days in the hospital in the month following their ED discharge.

Application of computer-assisted pre-operation plan for the treatment of geriatric intertrochanteric femoral fractures

Objective To discuss the curative effect of computer assisted pre-operation plan (CAPP) in treating the geriatric intertrochanteric femoral fracture. Methods The data of intertrochanteric fractures treated with PFNA-II between March 2012 and June 2015 were retrospectively analyzed. They were divided into two groups by preoperative design. One group was the CAPP group consisting of 53 patients with a mean age of 75.3 years (range, 60-92 years). According to the Evans Classification, there were 12 Evans type Ib, 9 Evans type Ic, 15 Evans type Id and 17 Evans type II fractures. The other group was the non-CAPP group consisting of 74 patients with a mean age of 76.6 years (range, 62-95 years). There were 18 Evans type Ib, 15 Evans type Ic, 20 Evans type Id and 21 Evans type II fractures. Operation time, intraoperative blood loss, times of fluoroscopy during operation and days of hospital stay were compared. The hip joint function was evaluated by Harris score at the final follow-up. Results The CAPP meanly cost 24.7 min. The consistency of the surgery and CAPP was up to 100%. In the CAPP group, the average operation time was 46.8±6.5 min; the average times of fluoroscopy during operation were 12.0±2.3 times; and the average blood loss was 154.4±27.6 ml. In the non-CAPP group, the average operation time was 57.8±10.3 min; the average times of fluoroscopy during operation was 20.9±3.2; and the average blood loss was 235.0±65.8 ml. All above data in the CAPP group were significantly lower than those in the non-CAPP group. The mean days of hospital stay were 13.9±1.3 days in the CAPP group and 14.3±1.4 days in non-CAPP group. The days of hospital stay had no significant difference between the two groups. Forty-five patients with an average follow-up period of 18.3 months were reviewed in the CAPP group. Fifty patients were followed up with an average period of 19.2 months in the non-CAPP group. At the final follow-up, the average Harris score was 88.6±2.8 points (range, 84-96 points) in the CAPP group and 87.5±3.2 points (range, 80-95 points) in the non-CAPP group. Conclusion CAPP system is convenient and efficient. It can facilitate the treatment of intertrochanteric fracture effectively. Key words: Hip; Fractures, bone; Fracture fixation, internal; Computer-aided design; Imaging, three-dimensional

Treatment Of Intra-Articular Calcaneal Fractures Using Sinus Tarsi Approach And Only Screws

Category: Hindfoot, Trauma Introduction/Purpose: Displaced intra-articular calcaneal fracture have been usually treated with open reduction and internal fixation using extensile lateral approach, however this management has been associated with high rates of soft tissues complications. Minimally invasive approaches might be an alternative to reduce these complications and improve the outcomes. Our aims were to describe the radiological and clinical outcomes of patients with intra-articular calcaneal fractures treated with a minimally invasive surgical technique. To determine if the Böhler’s angle is restored and maintained through the time. To determine the posterior facet joint reduction using CT scan. To report the frequency the soft tissue complications, days of hospitalization after the surgery, and the need of secondary procedures or additional admissions using this technique. Methods: Retrospective review of patients with intra-articular calcaneal fractures treated with sinus tarsi approach and fixation only with screws between January 2014 and July 2016. Twenty fractures in 15 patients were included. The clinical files and imagenology studies were analized. Results: The mean age was 47 years. Eighteen males and 2 females. One open fracture. Ten smoker patients. Two with diabetes mellitus. Ten cases were joint depression fractures and 10 were tongue fractures of the Essex Lopresti classification. Ten cases were Sanders II and 10 Sanders III. The mean Böhler’s angle was 2º preoperative, 22º in the postoperative and 19º at the last follow up. Postoperative posterior facet joint reduction was good o excellent in 19 cases. The mean days of hospitalization was 2.9. Two cases needed hardware removal. One patient had minor soft tissue complications. No patient had major complications. Conclusion: Our experience showed a low soft tissue complications rate, an adequate correction of the posterior facet joint reduction and adecuate correction and maintenance of the Böhler’s angle, few days of hospitalization after the surgery, and no need of secondary surgical procedures due to acute complications. We conclude this is a suitable alternative in order to reduce the soft tissue complications with accurate correction and preservation of the radiological parameters.

Hospitalization for patients in the United States (US) and European Union (EU) treated with inotuzumab ozogamicin (InO) vs standard of care (SOC) for relapsed/refractory acute lymphoblastic leukemia (R/R ALL) in a global phase 3 trial.

e18500 Background: InO, an anti-CD22 antibody-calicheamicin conjugate, with its once a week, 1-hour infusion schedule, has demonstrated lower hospital utilization in association with superior clinical activity, favorable patient-reported outcomes (PROs), and a generally manageable safety profile versus SOC (intensive chemotherapy) for R/R ALL in the phase 3 INO-VATE trial. Here, regional-specific hospitalizations in the trial are presented. Methods: Patients receiving study treatment and recruited from the US and the EU were included in the analyses. The total number of days hospitalized for each patient was calculated. Hospital days prior to randomization and those after the end of study treatment were excluded. Due to different treatment durations for InO and SOC (median 1 vs 3 cycles), calculations were reported for cycle 1 treatment period (randomization to end of cycle 1) and for the entire treatment period (all cycles - randomization to end of treatment). Results: A total of 281 patients were available for the analyses. 154 were from the US and 127 from 11 of the EU countries. The median and mean hospitalization days were shorter for patients in the InO arm compared to the SOC arm across both regions (Table). The difference between the two treatment arms appear to be greater in the US compared to the EU. Hospitalizations in the US appear to be shorter than in the EU, particularly for patients receiving InO. Conclusions: InO treatment in R/R ALL is associated with less hospitalization across both the US and EU compared to SOC, consistent with InO’s better efficacy, tolerability, PRO and dosing schedule. The finding that US has lower hospitalization than the EU might be explained by different patient care practices in the two regions. Given that hospitalization is the biggest cost driver in cancer care, the discrepancy may lead to greater cost-savings in healthcare systems where hospitalizations are strictly managed. Clinical trial information: NCT01564784. [Table: see text]

Medical costs of a low skeletal muscle mass are modulated by dietary diversity and physical activity in community-dwelling older Taiwanese: a longitudinal study

BackgroundAge-related loss of skeletal muscle mass (SMM) and function (sarcopenia) are associated with poor health outcomes and an economic burden on health care services. An appropriate diet and physical activity have been proposed for prevention and treatment of sarcopenia. Nevertheless, the effects on medical service utilization and costs remain unclear. This study determined the effects of SMM in conjunction with diet quality and physical activity on medical service utilization and expenditure in community-dwelling older Taiwanese.MethodsIn total, 1337 participants from the Elderly Nutrition and Health Survey in Taiwan (1999–2000) were enrolled. An SMM index [SMMI, calculated by dividing SMM (kg) by height (m2)] was used as the marker of sarcopenia. Participants with the lowest SMMI quartiles (<11.4 kg/m2 for men and 8.50 kg/m2 for women) comprised the high-risk group, and the remainder comprised the low-risk group. Dietary information (dietary diversity: low and high) and physical activity (low and moderate) were obtained at baseline. Annual medical service utilization and expenditure were calculated from National Health Insurance claims until December 31, 2006. Generalized linear models were used to determine the association between the SMMI and annual medical service utilization and costs in conjunction with dietary diversity or physical activity.ResultsAfter 8 follow-up years, regardless of gender, participants in the high-risk group reported significantly more hospitalization (days and expenditure) and total medical expenditure. Participants in the high-risk group who had low dietary diversity made fewer annual outpatient (14%), preventive care (19%), and dental (40%) visits, but exhibited longer hospitalization (102%) than did those who had a low SMMI and high dietary diversity. Similar patterns were observed in the corresponding medical expenditures. The findings were similar when considering physical activity. Being in the low-risk group in conjunction with having high dietary diversity or more physical activity was associated with the lowest annual adjusted mean hospitalization days with expenditure, and also total expenditure.ConclusionsA lower SMMI was associated with more hospitalization days and costs. However, high dietary diversity and more physical activity can attenuate the effects of lower SMMI on medical service utilization and expenditure.

Health care resource utilization and costs of California Medicaid patients with schizophrenia treated with paliperidone palmitate once monthly or atypical oral antipsychotic treatment

Objective: To compare all-cause health care utilization and costs between patients with schizophrenia treated with once monthly paliperidone palmitate (PP1M; Invega Sustenna1) and atypical oral antipsychotic therapy (OAT).Methods: This was a retrospective claims-based analysis among adult California Medicaid (Medi-Cal) patients with schizophrenia having ≥2 claims for PP1M or OAT from 1 July 2009 to 31 December 2013 and continuous health plan enrollment for ≥1 year pre- and post-index date (PP1M or OAT initiation date). Baseline characteristics were reported descriptively. Propensity score matching with a 1:1 greedy match method was used to create two matched cohorts. Treatment patterns, all-cause health care utilization, and costs for the 12 month follow-up period were compared between the two matched cohorts.Results: Two well matched cohorts of 722 patients were produced with similar baseline characteristics. During the 12 month follow-up period, PP1M patients were significantly less likely to discontinue treatment (30.6% vs. 39.5%, p < .001) or switch to a new therapy (21.6% vs. 27.7%, p = .007). PP1M patients had fewer inpatient visits (5.0 vs. 7.9, p < .001), lower mean hospitalization days (15.0 vs. 27.7 days, p < .001) and inpatient costs ($5060 vs. $10,880, p < .001). While pharmacy costs were significantly higher in the PP1M cohort ($16,347 vs. $9115, p < .001), total costs were not significantly different between the matched cohorts ($25,546 vs. $25,307, p = 0.853).Conclusions: Patients with schizophrenia treated with PP1M had significantly fewer inpatient hospitalizations and associated costs with no significant difference in the total costs between the two cohorts. This study is subject to limitations associated with claims data such as miscoding, inability to examine clinical severity, etc.

Iranian Low-dose Escalating Prophylaxis Regimen in Children with Severe Hemophilia A and B.

Establishing an appropriate prophylaxis regimen for children with hemophilia is a critical challenge in developing countries. Barriers including availability and affordability, catheter-related complications, and inhibitor development risks have led to the introduction of new tailored prophylaxis regimens in different countries. This study emphasizes on the benefits of the Iranian low-dose escalating prophylaxis regimen in a Hemophilia Comprehensive Care Center in Iran. Referred patients with hemophilia less than 15 years of age, who were subject to prophylaxis regimen, are studied retrospectively. A once-weekly prophylaxis regimen of 25 IU/kg was started for the patients primarily. Their prophylaxis regimen was changed to 25 IU/kg twice a week and then 3 times a week when they experienced 3 joint bleedings, 4 soft tissue bleedings, or a 1 life-threatening bleed without a specific trauma history. Overall, 25 patients with severe hemophilia and at least 6-month history of on-demand (OD) treatment were studied. A mean of 1754 IU/kg/yr of coagulation factors, used for OD and prophylaxis purposes, was sufficient to decrease the mean annual bleeding rate (ABR) to 1.86 after prophylaxis. It also reduced the mean hospitalization days and the mean number of target joints to 0.24 and 0.16, respectively. Overall, 19 (76%) patients were continuing their once-weekly regimen at the end of the follow-up. None of the patients needed 3-times-a-week regimen or central venous catheterization and none developed inhibitors in the follow-up. Benefits of the Iranian low-dose escalating prophylaxis regimen prove equal to some of the previous 3-times-a-week prophylaxis regimens in reducing the ABR and hospitalizations.

加速康复外科护理在老年胃十二指肠溃疡急诊胃大部切除术的护理效果

目的：观察加速康复外科护理在老年胃十二指肠溃疡急诊胃大部切除术的护理效果。方法：入选2013年10月至2015年10月于我院行胃十二指肠溃疡急诊胃大部切除术的老年患者128例，随机分为对照组和观察组，对照组60例患者采用传统的胃大部切除术护理措施，观察组68例患者采用加速康复外科护理干预。观察比较两组术后恢复情况、并发症发生及平均住院时间。结果：观察组患者术后肠鸣音恢复时间、首次排气排便时间、体重下降情况、静脉营养时间及平均住院天数均明显低于对照组(P均 < 0.01)；观察组术后并发症11例(16.18%)，明显低于对照组18例(30%)，差异具有显著统计学意义(P < 0.05)。结论: 老年胃十二指肠溃疡急诊胃大部切除后行加速康复外科护理，明显降低术后并发症，促进患者恢复，值得临床应用及推广。 Object: To observe the nursing effects of fast tract surgery (FTS) nursing care on elderly patients with gastric and duodenal ulcer for emergent subtotal gastrectomy. Methods: One hundred and twenty-eight elder patients with gastric and duodenal ulcer for emergent subtotal gastrectomy, who were admitted to our hospital from October 2013 to October 2015, were randomly divided into the control group and the observation group. The control group (60 cases) was treated with routine nursing of emergent subtotal gastrectomy, and the observation group (68 cases) would receive the FTS nursing care. The surgical recovery, clinical complications and mean days of hospitalization were obtained after surgery. Results: The bowl sound recovery, the first time of aerofluxus and cacation, lessened weight, intravenous nutrition and mean days of hospitalization in the observation group were significantly decreased compared to the control group (both P < 0.01). In addition, there were 11 patients with complications (16.18%) in the observation group and 18 patients (30%) in the control group. The difference was obvious (P < 0.05). Conclusion: The FTS nursing care can significantly decrease clinical complications and improve rehabilitation after elder patients with gastric and duodenal ulcer were operated on emergent subtotal gastrectomy. Thus it is worthy of clinical application and promotion.