Median Days Of Hospitalization Research Articles

Comparison of repeated surgical resection and radiofrequency ablation for small recurrent hepatocellular carcinoma after primary resection.

There is controversy concerning whether radiofrequency ablation (RFA) or surgical resection (SR) is a better treatment option for recurrent HCC after resection. In Kaohsiung Veteran General Hospital, from January 2002 to September 2014, a total of 100 consecutive patients who developed recurrent HCCs with a tumor size ≦ 3 cm and tumor numbers ≦ 3 after surgical resection were enrolled. Among these patients, 57 patients received RFA and 43 patients underwent repeated SR. Baseline characteristics at the time of recurrence after hepatic resection and clinical outcomes following treatment of recurrent HCC were compared between the two groups. The baseline data of initial HCC and the first recurrence of HCC were comparable in both groups. The 1-, 3-, 5-year overall survival rates following treatment of the first recurrence of HCC were 97.6%, 82.7%, 56.4% in the repeated SR group and 98.2%, 77.2%, 52.6% in the RFA group (p = 0.69). The 1-, 3-, 5-year disease-free survival rates were 57.0%, 32.1%, 28.6% in the repeated SR group and 60.8%, 26.6%, 16.6% in the RFA group ((p = 0.89). There was a trend whereby patients who underwent repeated SR had more procedure-related morbidity than patients who underwent RFA (16% vs. 7%, p = 0.14). The median total hospital days were longer in the repeated SR group than that in the RFA group (13 vs. 5 days, p < 0.05). In the small recurrent HCCs after SR, RFA achieved similar overall survival and disease-free survival than those with repeated SR as well as having a shorter hospital stay.

Haemophilus Influenzae Type B Invasive Disease in a Pediatric Hospital of Argentina

BackgroundSinceThe vaccination strategy is a three-dose primary series (at two,Active surveillance is important to opportunely detect variations on these trends.MethodsCross-sectional study, including all hospitalized patients with Hib infection since 2012 to May 2017 at Hospital de Niños “Ricardo Gutiérrez” in Buenos Aires, Argentina.ResultsTwenty previously healthy children were admitted. Male/female ratio 1.8:1. Median age: 12 (range 45 days-114) months; 85% younger than 2 years and 35% younger than 6 months. Nine patients (45%) had complete vaccination schedule, with three or more doses of DTP-Hib-HBV vaccine. Hospitalization Hib infections by year in Table 1.YearHib admissions (n)Total hospital admissions (n)Hospitalization rates (per 100.000 admissions/year)201219,7641,02201329,3042,15(IC 95% 0.26–7.76)201439,0663,31(IC95% 0.68–13.81)201569,4506,35 (IC 95% 2.33–13.81)201689,7808,18 (IC 95% 3.5– 6.11)Clinical presentation: meningitis (14/20), pneumonia (6/20) and arthritis (5/20), osteomyelitis (1/20). All patients with meningitis, 25% of pneumonias and 50% of arthritis had positive blood cultures. Hib was isolated from blood in 17/20 cases, cerebrospinal fluid in 7/14, joint fluid in 3/5 and pleural fluid in 2/6. Median WBC: 12,400/mm3 (1,600–42,900) and median C-reactive protein level 111 mg/L (7–358). Median days of hospitalization was 13 (8–40). Nine patients required intensive care, four of them required mechanical ventilation. None patients died. Immunological studies ruled out immunodeficiency in 10 patients, although four continues under study.Conclusion(i) Burden of invasive Hib infections have increased over the last few years in our setting. (ii) Most of patient had adequate immunization schedule for age; (iii) Surveillance studies should be continued to confirm these preliminary results as well as to evaluate possible causes.Disclosures All authors: No reported disclosures.

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]

Classification and regression tree model for predicting tracheostomy in patients with traumatic cervical spinal cord injury.

In patients with cervical spinal cord injury (CSCI), respiratory compromise and the need for tracheostomy are common. The purpose of this study was to identify common risk factors for tracheostomy following traumatic CSCI and develop a decision tree for tracheostomy in traumatic CSCI patients without pulmonary function test. Data of 105 trauma patients with CSCI admitted in our institution from April, 2008 to February, 2014 were retrospectively analyzed. Patients who underwent tracheostomy were compared to those who did not. Stepwise logistic regression analysis and classification and regression tree model were used to predict the risk factors for tracheostomy. Tracheostomy was performed in 20% of patients with traumatic CSCI on median hospital day 4. Patients who underwent tracheostomy tended to be more severely injured (higher Injury Severity Score, lower Glasgow Coma Score, and lower systolic blood pressure on admission) which required more frequent intubation in the emergency room (ER) with a higher rate of complete CSCI compared to those who did not. Upon multiple logistic analysis, Age≥55years (OR: 6.86, p=0.037), Car accident (OR: 5.8, p=0.049), injury above C5 (OR: 28.95, p=0.009), ISS≥16 (OR: 12.6, p=0.004), intubation in the ER (OR: 23.87, p=0.001), and complete CSCI (OR: 62.14, p<0.001) were significant predictors for the need of tracheostomy after CSCI. These factors can predict whether a new patient needs future tracheostomy with 91.4% accuracy. Age≥55years, injury above C5, ISS≥16, Car accident, intubation in the ER, and complete CSCI were independently associated with tracheostomy after CSCI. CART analysis may provide an intuitive decision tree for tracheostomy.

Continuous Pneumococcal Invasive Disease Reduction, High Impact on Pneumococcal Empyemas and Meningitis, and Serotype 19A Disappearance Following PCV-13 Vaccination in Children: Eleven and a Half Years of Active Surveillance in a Mexican Hospital on the U.S. Border

BackgroundThe Tijuana, Mexico and San Diego, California, is the world’s most transited frontier. We have previously published pneumococcal serotype replacement following PCV-7 introduction, especially by serotypes 19-A, 3 and 6A/C. Since May/2012 universal vaccination with PCV-13 was introduced for all children. This study analyzes the effectiveness of PCV-13 after its implementation in the region.MethodsSince October/2005 until March/2017 (11.5 years) we underwent an active surveillance for all Invasive Pneumococcal Diseases (IPD) in children < 16 years admitted at the Tijuana General Hospital. Only culture-confirmed cases were included. Following identification, serotyping was performed using the Quellung Reaction (Statens Serum Institute® Copenhagen, Denmark). Descriptive analysis was performed using Excel®.ResultsFifty-seven cases of confirmed IPD were found. Clinical diagnosis were pleural empyemas (PPE) (45.6%), meningitis (PM) (28%), otomastoiditis (15.7%), only sepsis (7%), and bacteremic pneumonia (3.5%). Median age was of 3.9 years (2 days – 15.9 years), median hospitalization days was of 14 (1–90). Overall mortality was of 6 (10.5%). Following PCV13 introduction there was a decreased on overall IPD mortality by 73.29%, overall IPD by 68%, PPE by 68.1%, and PM by 55.4%. However, during 2015–16, we had three PM cases, two of which were immunocompromised patients, and none vaccinated with PCV13. From an average of 1.75 yearly cases due to pneumococcal serotype 19-A before PCV13 implementation, there had been no patients with IPD’s caused by this serotype. (See Figure 1). After PCV13 vaccination, serotypes associated with IPD cases had been as follow: Two 22F, and one each by 6A, 18C, 3, 7F, 15, 7B, 35B, 24F and 33F.ConclusionThis is the first Mexican study based on active surveillance that shows consistent effectiveness of PCV-13 on reduction of overall IPD, disappearance of pneumococcal serotype 19-A, and strong impact on PPE in children. Effectiveness on PM is still above 50%, however, during 2015–16 there had been three cases, but with particular conditions (immunodeficiencies and no vaccination). Continuous active surveillance is mandatory.Disclosures All authors: No reported disclosures.

Infections Are Associated with Higher Risk of Venous Thromboembolism in Hospitalized Children with Nephrotic Syndrome

Introduction: Although it is known that children with nephrotic syndrome (NS) are at greater risk for certain complications, the frequency of these complications and predisposing risk factors are poorly defined. In particular, nephrotic syndrome has long been considered a hypercoagulable state. Risk for development of venous thromboembolism (VTE) is known to be increased in the setting of an active infection. The objective of this study was to determine the prevalence of infection and VTE among a cohort of hospitalized children with NS, and the association of these complications on outcomes.Methods: Records of hospitalized children with NS admitted to any of 17 participating pediatric hospitals across North America from 2010-2012 were included. Data including demographics, clinical pattern of NS, renal biopsy results, number of hospitalizations, nephrotoxic medication usage, infection and VTE history were recorded. Descriptive statistics were used to determine prevalence of infection and VTE. Wilcoxon rank sum was used to perform comparisons between groups. Logistic regression analysis was utilized to determine predictors of VTE development.Results: Seven-hundred thirty hospitalizations occurred among 370 children. One-hundred forty-eight children (40%) had at least 1 infection with a total of 211 infectious episodes; 11 (3%) had VTE. Those with infection were more likely to have VTE (p = 0.0457). Infections associated with VTE were C. difficile (1 subject), methicillin sensitive S. Aureus (2), Streptococcus pneumoniae (1), and unknown (3). There were no differences between those with and without infection regarding gender or ethnicity. Those with infection were younger at NS diagnosis (3.0 vs. 4.0 years; p = 0.008), and steroid resistant NS was more highly associated with infection than all other clinical diagnoses (steroid-sensitive NS, steroid-dependent NS, other) (p = 0.003). The most common types of infections encountered included peritonitis (23%), pneumonia (22%), and bacteremia (16%). Bacterial pathogens (Streptococcus pneumoniae 41%, Escherichia coli 16%, Clostridium difficile 10%) were most commonly identified. Children with VTE, infection, or both, also required significantly more days in hospital. The median hospital stay for those without infection was 5 days vs. 10 in those with infection (p< 0.0001). Similarly, median hospital days for those without VTE were 6 days as compared to 22 in those with VTE (p < 0.0001). Of those with infection, 13% had an ICU stay compared with 3.3% of those without. Those with VTE also had a median of 4 days in the intensive care unit as compared to 0 days in those without VTE (p < 0.0001). In a logistic regression analysis, only the number of ICU days was predictive of the presence of VTE (OR 1.074, 95% CI 1.013 - 1.138).Conclusions: Children with NS who are hospitalized have high rates of infection. While the rate of VTE was not high in this cohort, presence of VTE was associated with infection. Both infection and VTE were associated with longer hospitalizations and intensive care unit stays. Streptococcus pneumoniae remains the most commonly identified bacterial pathogen in children with nephrotic syndrome, though methicillin sensitive S. Aureus was identified in 2 of 11 patients with VTE. Further studies are needed to identify potentially modifiable risk factors that could minimize these complications in this already high risk population. DisclosuresNo relevant conflicts of interest to declare.

Early thrombin formation capacity in trauma patients and association with venous thromboembolism

Incidence of venous thromboembolism (VTE) in adult trauma patients is high despite mechanical and pharmacologic prophylaxis. We hypothesized that thrombin formation capacity as measured by calibrated automated thrombogram (CAT) is increased early in hospitalization and is associated with the development of VTE. MethodsWe conducted a prospective study in adult, critically ill trauma patients. Plasma was generated from whole blood samples collected within the first 3days of hospital admission. CAT was used to determine lag time, thrombin peak, time to thrombin peak, endogenous thrombin potential (ETP), and velocity index in plasma samples from patients, and in control samples of platelet-poor, pooled normal plasma. ResultsThere were 35 trauma patients and 35 controls included in this pilot analysis. Patients were a mean (SD) age of 45 (19) years, and 23 (66%) were male. The most common mechanism of injury was motor vehicle crash followed by falls, and the median (IQR) injury severity score was 17 (12–27). Three patients (8.6%) had deep vein thrombosis (DVT) confirmed by Doppler ultrasound on median hospital day 7. Compared to control samples, patients had significantly longer lag times (3.1min vs. 2.7min, p=0.02) and significantly higher ETP (1136nM∗min vs. 1019nM∗min, p=0.007), peak thrombin generation (239nM vs. 176nM, p<0.001), and velocity index (108nM/min vs. 57nM/min, p<0.001) (Fig. 1). There was no difference in the time to peak thrombin generation between the two groups (5.5min vs. 5.7min, p=0.22). In the 3 patients with VTE compared to controls, lag times were shorter and velocity index was higher while ETP and peak thrombin generation were similar. There were no statistically significant differences in thrombin generation parameters in patients with or without VTE, but lag time was numerically shorter, and thrombin peak, time to peak and area-under-the-curve (ETP) were numerically lower in patients with DVT. ConclusionsWe observed a thrombin generation profile in critically ill trauma patients consistent with an early hypercoagulable state; however, thrombin generation parameters did not discriminate patients with VTE.

Nutrition in Toxic Epidermal Necrolysis: A Multicenter Review.

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe exfoliative diseases treated in burn centers due to large skin losses. Literature on SJS/TEN refers to parenteral nutrition (PN) as the preferred route of nutrition support. This study describes nutrition support interventions in SJS/TEN patients admitted to burn centers. Seven burn centers participated in this Institutional Review Board-exempted retrospective chart review of adults with SJS/TEN admitted from 2000-2012. This analysis included 171 patients with SJS/TEN. Median total body surface area involvement was 35% (n = 145; interquartile range [IQR], 16%-62%). The majority required mechanical ventilation (n = 105). Based on indirect calorimetry, measured energy needs were 24.2 kcal/kg of admit weight (n = 58; IQR, 19.4-29.9). Thirty-one patients did not require enteral nutrition (EN) and started oral intake on hospital day 1 (IQR, 1-2), and 81% required EN support due to inadequate oral intake and remained on EN until day 16 (median hospital day, 16; IQR, 9-25). High-protein enteral formulas predominated. PN was rarely used (n = 12, 7%). Most patients were discharged home (57%), with 14% still requiring EN. Nutrition support should be considered in patients with SJS/TEN due to increased metabolic needs and an inability to meet these needs orally. Most SJS/TEN patients continued on EN and did not require escalation to PN.

Abstract WP283: Temporal Changes in Mortality and Hospitalization Days in Nationwide Hospital Cohort According to Stroke Subtype and Comprehensive Stroke Care Capabilities: J-aspect Study

Introduction: Evidences of comprehensive stroke center regarding mortality and hospitalization days are insufficient. Hypothesis: To examine temporal changes in mortality and hospitalization days in patients with ischemic and hemorrhagic stroke according to stroke subtype and comprehensive stroke care capabilities in a nationwide hospital cohort in Japan. Methods: We conducted annual nationwide survey from 2011 to 2014 using data from the Japanese Diagnosis Procedure Combination database on patients hospitalized with ischemic and hemorrhagic stroke in a nationwide hospital cohort in Japan (J-ASPECT Study). Comprehensive stroke care capabilities were evaluated by 25-items score (Comprehensive stroke center (CSC) score) developed by this study group based on the institutional survey conducted in 2011, including 5 subcategories: personnel, diagnostic techniques, specific expertise, infrastructure, and education. The effect of year on stroke mortality and hospitalization days was analyzed by mixed effect model with age, gender, Japan Coma Scale, and CSC score as a fixed effect, and hospital as a random effect. Results: The total numbers of patients were 252,940 in ischemic stroke (IS), 97,236 in intracerebral hemorrhage (ICH), and 30,521 in subarachnoid hemorrhage (SAH). The mortality in IS decreased from 6.3% to 5.7% over the four years (P &lt; 0.001 for trend), and the effect of year was larger in hospitals with high CSC score (&lt;17) than low CSC score (≧17); adjusted odds ratios (95% confidence interval) per year were 0.92 (0.90 - 0.95) and 0.96 (0.93 - 0.98) respectively. The mortality of patients with ICH and SAH did not show significant change as from 15.1 to 16.9 and 25.9 to 26.2, respectively. The median hospitalization days changed from 19 to 17 in IS, from 28 to 24 in SAH, and from 21 to 22 in ICH. Conclusion: Over the last four years, mortality in patients with ischemic but not hemorrhagic, stroke significantly decreased, especially in hospitals with higher comprehensive stroke care capabilities in Japan. The hospitalization days decreased in IS and SAH patients through four years.

Evaluation of Institutional Non-Core Chemotherapy Regimens Approved for the Treatment of Leukemia and Multiple Myeloma

The University of Wisconsin Chemotherapy Council (UWCC) monitors the uniformity and appropriateness of chemotherapy administration at the University of Wisconsin Hospital and Clinics through a peer-review process. One aspect involves approval of "patient specific requests" (PSRs) that involve treatments not included in the institution's core regimens. Providers are asked to submit published evidence, information regarding pt. comorbidities, and clinical justification to support the application. However there is no current stipulation regarding demonstration of value, although implicit in this review process is to avoid futile, expensive or potentially harmful treatments. Given the ever burgeoning chemotherapeutic choices available for patients with any stage of disease, and the complexity of selecting an optimal therapeutic regimen, we hypothesized that some approved PSRs might have provided limited benefit to the pts who received them. Therefore, we undertook an analysis of PSRs specifically submitted for patients with leukemia and multiple myeloma (MM) between 1/1/2011 and 7/31/2014 to exam reasons for the submission as well as outcomes after the new therapy was initiated. METHODSA total of 307 PSRs were reviewed by the UWCCC during this time period. Forty-one were specifically submitted and approved for patients with leukemia or MM. Reason for PSR, status at initiation, previous transplant, and days of hospitalization after PSR and 1 year survival were calculated. Table 1DiagnosisNumberStatus at time of PSRPrevious TransplantMedian No previous regimensReason for PSR submissionPSR RegimenMean Survival After PSR starts1 yr. survivalAML, relapsed8Refractory relapse88%3No SOC1Various236d (range 88-575d)12%AML, other2Remission01Nonstandard Transplant regimenTransplant regimen533 d100%CML, relapsed2RefractoryNo3Failed all previous regimensTransplant regimen289d50%ALL, newly diagnosed5UntreatedNA0Adult treated on pediatric regimen (n=3); elderly (n=2)Various551d (range 365-981d)100%ALL, relapsed5Relapsed20%3 (range 1-8)No SOC1CVP2, TKI3 based;, BFM4408d (range 167-735d)40%MM15Relapsed, refractory (n=15) 100%73% (auto)7 (range 2-10)Not core regimen (n=13) Rare subtype(n=2)PCP5 (n=3); CRD6 (n-4) other272 d ( range 74-661)60%APL4untreatedN/AN/ANot Core RegimenATRA/Arsenic, other788d (range 692-910d)100%1SOC; 2cyclophosphamide, vincristine prednisone; 3tyrosine kinase inhibitor; 4Berlin/Frankfurt/Munich; 5Pomalidomide, cyclophosphamide, prednisone; 6carfilzomib, lenalidomide dexamethasone RESULTSA total of 41 PSRs were examined. The most common reasons for submission of the PSR was request for a non-core regimen including a recently FDA approved use of an agent (n= 11); no current SOC established (n=13); salvage therapy with older regimen ((n=2). Median 1 yr. survival varied from 12% to 100% depending on diagnosis. Not surprisingly, APL pts displayed the best overall survival, followed by AML, transplanted with a nonstandard conditioning regimen. AML patients relapsing after previous allogeneic transplant had the worst survival, regardless of salvage regimen; only 1 pt. survived longer than 6 months. The median length of hospital stay in these patients following start of PSR was 43 d (range 14-54). Relapsed ALL pts also fared poorly, with 1 year survival of 40% and median days of hospitalization after PSR of 48d (range 0-117). Relapsed refractory MM pts had a variable outcome, with some pts surviving more than 3 years and others for only several months. CONCLUSIONUse of peer reviewed PSRs resulted in reasonable outcomes in most patients with leukemia and myeloma. However, pts with AML relapsing after allogeneic transplant and those with relapsed ALL fared particularly poorly despite treatment with a peer reviewed treatment plan, presumably chosen for best outcome. Furthermore, these salvage treatments were associated with lengthy hospital stays. Such patients are unlikely to benefit from any currently available regimens and may be more appropriately considered for clinical trials or supportive/ palliative care at time of relapse. DisclosuresNo relevant conflicts of interest to declare.

Prevalence and Clinical Feature of Coagulation Syndrome After Endoscopic Submucosal Dissection for Gastric Neoplasm

Introduction: Although endoscopic submucosal dissection(ESD) is a well-established procedure characterized by en-bloc resection of gastric neoplasm, there are some complications related to ESD, such as bleeding and perforation. Among them, coagulation syndrome after ESD is not well known because of self-limiting clinical course regardless of their frequency. The aims of this study were to investigate the prevalence and the clinical features of post-ESD coagulation syndrome. Methods: A retrospective analysis was performed in 289 patients who were treated with ESD for gastric neoplasm between May 2012 and September 2014 in our hospital. The patients who presented fever, abdominal pain and abdominal tenderness after ESD without perforation or definite infections were considered as post ESD coagulation syndrome. The patients diagnosed post-ESD coagulation syndrome were analyzed to clarify clinical outcomes. And clinicopathological characteristics related post-ESD coagulation syndrome were examined. Results: There were 13 patients showed coagulation syndrome after ESD for gastric neoplasm. In patients with post-ESD coagulation syndrome, the median duration of pyrexia was 8.6±6.3 hours and the median days of hospitalization were 7.1±3.5 days (vs. 5.8±1.9 days for patients without post-ESD coagulation syndrome). All patients with post-ESD coagulation syndrome were improved in about 1 week with medical treatment, regardless of antibiotics use. There is no statistically significant differences in the demographic, endoscopic and procedure related characteristics such as age, sex, comorbidity, procedure time, coagulation time, size of the lesion, difference in pathology, between the patients with and without post-ESD coagulation syndrome. Conclusion: The incidence of coagulation syndrome after ESD for gastric neoplasm was 4.5%. And patients with post-ESD coagulation syndrome presented favorable clinical course in 1 week. There were no significant predictive factors of post-ESD coagulation syndrome.

Associations Between Day of Admission and Day of Surgery on Outcome and Resource Utilization in Infants With Hypoplastic Left Heart Syndrome Who Underwent Stage I Palliation (from the Single Ventricle Reconstruction Trial)

Newborns with hypoplastic left heart syndrome and other single right ventricular variants require substantial health care resources. Weekend acute care has been associated with worse outcomes and increased resource use in other populations but has not been studied in patients with single ventricle. Subjects of the Single Ventricle Reconstruction trial were classified by whether they had a weekend admission and by day of the week of Norwood procedure. The primary outcome was hospital length of stay (LOS); secondary outcomes included transplant-free survival, intensive care unit (ICU) LOS, and days of mechanical ventilation. The Student's t test with log transformation and the Wilcoxon rank-sum test were used to analyze associations. Admission day was categorized for 533 of 549 subjects (13% weekend). The day of the Norwood was Thursday/Friday in 39%. There was no difference in median hospital LOS, transplant-free survival, ICU LOS, or days ventilated for weekend versus non-weekend admissions. Day of the Norwood procedure was not associated with a difference in hospital LOS, transplant-free survival, ICU LOS, or days ventilated. Prenatally diagnosed infants born on the weekend had lower mean birth weight, younger gestational age, and were more likely to be intubated but did not have a difference in measured outcomes. In conclusion, in this cohort of patients with single right ventricle, neither weekend admission nor end-of-the-week Norwood procedure was associated with increased use of hospital resources or poorer outcomes. We speculate that the complex postoperative course following the Norwood procedure outweighs any impact that day of admission or operation may have on these outcomes.

Long‐term effectiveness of a community‐based model of care in Māori and Pacific patients with type 2 diabetes and chronic kidney disease: a 4‐year follow up of the DElay Future End Stage Nephropathy due to Diabetes (DEFEND) study

The Delay Future End Stage Nephropathy due to Diabetes study was a randomised controlled trial of Māori and Pacific patients with advanced diabetic nephropathy, comparing a community-based model of care with usual care. The intervention group achieved lower blood pressure (BP), proteinuria and less end-organ damage. After the intervention ended, all patients reverted to usual care, and were followed to review the sustainability of the intervention. A retrospective observation of 65 patients (aged 47-75 years) with type 2 diabetes, hypertension, chronic kidney disease 3/4 and proteinuria (>0.5 g/day) previously randomised to intervention/community care or usual care for 11-21 months. Follow up thereafter was until death, end-stage renal disease (ESRD) (estimated glomerular filtration rate (eGFR) ≤ 10 mL/min/1.73 m(2) )/dialysis or 1 February 2014. Primary end-points were death and ESRD/dialysis. Secondary outcomes were annualised glomerular filtration rate decline, non-fatal vascular events and hospitalisations. Median (interquartile ranges (IQR)) post-trial follow up was 49 (21-81) months and similar in both groups. The median (IQR) eGFR decline was -3.1 (-5.5, -2.3) and -5.5 (-7.1, -3.0) mL/min/year in the intervention and usual care groups respectively (P = 0.11). Similar number of deaths, renal and vascular events were observed in both groups. At the end of follow up, the number of prescribed antihypertensive medications was similar (3.4 ± 1.0 vs 3.3 ± 1.4; P = 0.78). There were fewer median (IQR) hospital days (8 (3, 18) vs 15.5 (6, 49) days, P = 0.03) in the intervention group. Short-term intensive BP control followed by usual care did not translate into reduction in long-term mortality or ESRD rates, but was associated with reduced hospitalisations.

Repair of congenital diaphragmatic hernia under high-frequency oscillatory ventilation in high-risk patients: an opportunity for earlier repair while minimizing lung injury.

BACKGROUNDRepair of congenital diaphragmatic hernia (CDH) is ideally delayed until ventilatory parameters are stabilized and patients are switched to conventional ventilation. However, in selected high-risk patients, repair can be performed earlier while they are still on high-frequency oscillatory ventilation (HFOV).DESIGN AND SETTINGSA retrospective review of all CDH cases treated in our tertiary referral center between 1997 and 2013.METHODSIn 1997, we started repairing selected high-risk CDH cases under HFOV with or without inhaled nitric oxide (iNO). All repairs were performed once the infants’ blood gas levels were acceptable. The infants were gradually weaned to conventional ventilation followed by extubation as their ventilatory parameters improved. Their records were reviewed to determine the group-wide outcomes.RESULTSBetween 1997 and 2013, 55 infants with CDH were treated in our institute; of these 12 high-risk cases were repaired under HFOV/iNO combinations and 1 was repaired without iNO. All patients had significant pulmonary hypertension and 8 had herniated livers. The mean age at repair was 9.1 (6.3) days. Two mortalities occurred at the first and tenth postoperative days. Among the remaining 11 survivors, the median ventilation and hospitalization days were 29.5 (11–84) and 45.5 (25–107), respectively, and the median duration under HFOV and conventional ventilation days were 15 (9–40) and 12 (3–47), respectively.CONCLUSIONCDH repair can be performed earlier under HFOV and iNO. The possible advantages are earlier restoration of normal anatomy and earlier start of enteral feeding while minimizing the risk of lung injury.

Does the CT Enterography Really Lead to Better Improvement of Diagnostic Yield Than Conventional CT in Obscure Gastrointestinal Bleeding?

Introduction: The aim of the present study was to evaluate the diagnostic performance of conventional computed tomographic (CT) and CT enterography in identifying the source of obscure gastrointestinal bleeding (OGIB) and to investigate the types of diseases that CT enterography can detect better if CT enterography shows higher diagnostic yield than conventional CT. Methods: We retrospectively included 170 patients with OGIB who received conventional CT (126 patients) or CT enterography (44 patients). The median age of the patients was 57 years, and 57.6% of patients were male. The median hospital day was 13 days. Overt bleeding was 74.7%, and occult bleeding was 25.3%. Results: Based on all performed examinations, a definitive diagnosis was made for 141 patients (82.9%): ulcer in 45 (26.4%) patients, tumor in 29 (17%), angiodysplasia in 28 (16.4%), and Crohn’s disease in 20 (11.7%). The overall diagnostic yield of conventional CT and CT enterography was 29.6% and 45.4%. (OR= 2.25; 95% CI 1.106-4.595; p=0.02). The CT enterography had better diagnostic yield than conventional CT in all etiology mentioned above, but there was no statistically significant difference. Conclusion: CT enterography showed higher diagnostic yield in patients with OGIB than conventional CT. Therefore, we need further studies with more patients to identify who will benefit from the examinations.

ABSTRACT 58

Background: Fever-Neutropenia (FN) causes significant morbidity and mortality among cancer patients. Aims: We hypothesize that select serum proteins may generate a distinctive proteomic signature which could be used as biomarker to predict clinical outcome. Methods: High risk FN (HR-FN) patients defined with either clinical outcomes: prolonged hospitalization (>7 days) or clinical sepsis requiring Intensive care unit admission. Low risk FN (LR-FN) patients had none of above. Blood samples were collected upon FN presentation (40 FN events), pooled proteomic data were generated using mass spectroscopy and correlated with clinical outcome. Each candidate protein was compared between the HR-FN and LR-FN patients using exact nonparametric test. To measure false discovery rate, Q-values were calculated based on resulting p-values. Q-values equal to or less than 0.05 were considered to be statistically significant. Results: Subject’s median was age 11 years and malignancies included leukemia (52%), CNS(22%) and bone(17%). Median hospitalization days were 4 (LR-FN) and 11 (HR-FN). We identified a specific proteomic signature in the sera of patients with HR-FN in which median levels of C-reactive protein, beta-2-microglobulin, fibrinogen-like protein 1, intercellular adhesion molecule 1, amyloid A protein and tenascin were significantly elevated as compared to LR-FN patients. In contrast, median serum proteins levels for Protein S100-A9 were significantly higher in the LR-FN group compared to the HR-FN group (p-value 0.0079, Q-value 0.055). Conclusions: Serum proteomic analysis upon FN presentation demonstrates unique profile which coorelates with clinical outcomes. These profiles may be useful in FN risk stratification that may lead to timely interventions to decrease FN associated morbidity and mortality.

(794) - Lung Retransplantation for Early Graft Failure: Trends and Results in 112 Patients Over a 24-Year Period

In this study, we review trends and results of lung retransplantation for early graft failure (EGF) in the United States. Adult patients undergoing lung transplantation between 1987-2010 were identified in the United Network for Organ Sharing database. Patients undergoing redo lung transplantation for EGF (defined as within 90-days of original transplant) were compared to primary lung transplant patients (PLTx) and those undergoing redo lung transplantation for late graft failure (LGF). Trends were identified using three eras (1987-1994, 1995-2004, and 2005-2010). Postoperative complications were also compared between cohorts. Of 20,658 lung transplant recipients in the 24-year study period, 719(3%) were redo transplants (112 EGF, 607 LGF). The mean interval between initial transplant and redo transplant was 18.5±19.2 days for the EGF group and 1502.5±1201.7 days for the LGF group. The EGF cohort had significantly worse overall 1-year survival (49% versus 81% PLTx versus 68% LGF; p<0.001). Although 1-year survival significantly improved over time for the other cohorts (PLTx: 75% to 84%, p<0.001; LGF: 45% to 73%, p<0.001), this was not observed in the EGF patients (48% to 48%, p=0.88). Postoperative rates of renal failure requiring dialysis (31% versus 5% PLTx versus 11% LGF, p<0.001), stroke (5% versus 2% PLTx versus 1% LGF, p=0.05), reoperation (57% versus 19% PLTx versus 24% LGF, p<0.001), and infection (74% versus 44% PLTx versus 57% LGF, p<0.001) were higher in the EGF group. Median days of hospitalization were also longer in EGF (46 versus 24 in PLTx versus 31 in LGF, p<0.001). Redo lung transplant for EGF is associated with significantly high mortality and morbidity risk. Although overall outcomes in lung transplant recipients have improved over the last quarter century, this has not applied to the EGF subset. Judicious patient selection in this challenging cohort remains prudent in the modern era.

Nationwide Temporal Trends in Incidence of Hospitalization and Surgical Intestinal Resection in Pediatric Inflammatory Bowel Diseases in the United States from 1997 to 2009

Data are limited on temporal trends in outcomes of hospitalization and surgery in pediatric Crohn's disease (CD) and ulcerative colitis (UC). Thus, we evaluated the U.S. nationwide temporal trends for incidence of hospitalization and intestinal resection along with associated resource utilization. We used the Kids' Inpatient Database (1997, 2000, 2003, 2006, and 2009) to identify all admissions for children aged 18 years or younger with a primary CD (International Classification of Diseases, Ninth Revision [ICD-9]: 555.X) or UC (ICD-9: 556.X) diagnosis or a secondary CD or UC diagnosis and procedural code of intestinal resection. Poisson regression analysis was performed to evaluate time trends in the incidence of hospitalization, intestinal resection, and hospital resource utilization. The annual incidence of hospitalization was 5.7 and 3.5 per 100,000 children for CD and UC, respectively, with significant increases over time for CD (annual percent increase [API], 3.8%; 95% confidence interval [CI], 3.0%-4.5%) and UC (API, 4.5%; 95% CI, 4.3%-4.7%). Median hospital days per hospitalization for CD and UC remained stable, whereas median charge per hospitalization increased for CD (API, 4.1%; 95% CI, 2.6%-5.6%) and UC (API, 4.7%; 95% CI, 3.5%-5.9%). The annual incidence of intestinal resection remained stable for UC at 0.6 per 100,000 children but climbed for CD (API, 2.1%; 95% CI, 0.1-4.2). The annual incidence of hospitalization is climbing in pediatric inflammatory bowel diseases, accompanied by rising intestinal resection rates for CD and stable colectomy rates for UC. With escalating resource utilization, the economic and health burden of pediatric inflammatory bowel diseases is substantial.

The impact of vascular anastomosis time on early kidney transplant outcomes

BackgroundMost studies have found cold ischemic time to be an important predictor of delayed graft function in kidney transplantation. Relatively less is known about the warm time associated with vascular anastomosis and early outcomes.MethodsA retrospective cohort of 298 consecutive solitary deceased donor kidney recipients from January 2006 to August 2012 was analyzed to examine the association between anastomosis time and delayed graft function (need for dialysis) and length of hospital stay.ResultsDelayed graft function (DGF) was observed in 56 patients (18.8%). The median anastomosis time was 30 minutes (interquartile range 24, 45 minutes). Anastomosis time was independently associated with DGF in a multivariable, binary logistic regression analysis (odds Ratio (OR) 1.037 per minute, 95% CI 1.016, 1.057, P = 0.001). An anastomosis time >29 minutes was also associated with a 3.5 fold higher (OR 3.5, 95% CI 1.6, 7.3, P = 0.001) risk of DGF. Median days in hospital was 9 (interquartile range 7, 14 days). Every 5 minutes of longer anastomosis time (0.20 days per minute, 95% CI 0.13, 0.27, P <0.001) was associated with 1 extra day in hospital in a multivariable linear regression model. An anastomosis time >29 minutes was associated with 3.8 (95% CI 1.6, 6.0, P <0.001) more days in hospital.ConclusionAnastomosis time may be an underappreciated but modifiable variable in dictating use of hospital resources. The impact of anastomosis time on longer term outcomes deserves further study.

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Introduction: The aim of this study was to evaluate the impact of different parenteral nutrition delivery systems in critically ill and malnourished patients upon the time spend at the intensive care unit (ICU) and at the hospital. Hypothesis: Parenteral nutrition (PN) is provided to patients in several situations when the gastrointestinal tract is either non functional or when its absorptive capacity is impaired. It is an essential nutritional therapy but that has been associated with numerous problems including bloodstream infections (BSI). A recent study demonstrated that the delivery system can affect the incidence of BSI (Pontes-Arruda et al, JPEN 2012). Therefore, the PN delivery system may also have impact over other outcomes, such as time at the ICU and time of hospitalization. Methods: This was a prospective, international, multicenter, randomized and open-label study that included patients either moderately or severely malnourished and using 3-in-1 PN (containing lipids, aminoacids and dextrose). Patients were randomized to receive their PN using either a ready-to-use and multichamber bag (MCB) or a compounded PN (COM) (trial registration NCT#00798681). Baseline characteristics were collected as well as ICU and hospital days. Results: 316 patients were evaluated,156 in the MCB group and 160 in the COM group, all either moderately or severely malnourished in accordance with the subjective global assessment(SGA). Demographic characteristics of the patients in the two groups such as age; APACHE II score and SOFA score upon admission was considered adequately bal1anced. Both the time at the ICU and at the hospital was evaluated as statistically different. The median hospital days was 15 (13-21) and 18 (14-24) (p=.038); and median ICU days was 8 (6-11) and 11 (7-14) (p=.027) (all MCB vs. COM). Conclusions: The type of delivery system can produce a relevant impact upon the time malnourished and critically ill patients in need of PN spend both at the ICU and at the hospital, which can be translated into an important financial burden associated with PN.