Median LOS Research Articles

P385 Candida auris: a growing threat to global health

Poster session 3, September 23, 2022, 12:30 PM - 1:30 PM Background and ObjectivesThe emerging pathogen, C. auris, has been associated with nosocomial outbreaks in recent times. The true scale of the problem is difficult to comprehend due to several issues with the identification of C. auris using both phenotypic and molecular techniques. Most commonly, these isolates have been misidentified as C. haemulonii. Biofilm formation is strongly suggested given its association with intensive care settings, especially in patients with CVCs and long-term urinary catheters. Many isolates of C. auris have also shown raised MICs to multiple classes of antifungal agents, raising the possibility of pan-drug resistance.ObjectiveTo study the demographic characteristics, risk factors, and outcomes in patients with C. auris infection.MethodologyThis is a retrospective study from a tertiary care hospital (JPNATC, AIIMS) including all patients from the time period of 2018-2022 that showed growth of C. auris in any site. C. auris was identified using conventional methods (pale-pink growth on chromogenic medium, no pseudohyphae on germ-tube test, growth in presence of 10% NaCl) and VITEK-2. To reduce the misidentification and the intertest variability, the results were confirmed with MALDI-TOF. The risk factors and other patient information were taken from the HIS. Statistical analysis was performed.ResultsDuring the study period, a total of 31 patients had a C. auris infection. The most common age group was 20-40 years (n = 11,44%) with a preponderance in males (n = 23,74%). A total of 74% of the infections were found in blood, which was the most common site of infection followed by urine (10%). The other sites were pus-from-wound (n = 2), groin, nailbeds, and CVP tip (n = 1). Most of the cases were ICU patients (86%). All the patients with candidemia due to C. auris (n = 17 100%) had CVC, had surgery within the past 30 days, and were on broad-spectrum antibiotics and TPN. 71% (n = 12) had a history of immunosuppression and 18% (n = 14) had a history of prior antifungal therapy. Although 100% (n = 17) had the presence of an indwelling urinary catheter, none of them had candiduria due to C. auris. No patient with C. auris infection had neutropenia. The median LOS was 34.5 days. Most of the isolates were resistant to fluconazole (n = 13,93%), amphotericin B (n = 13,93%), voriconazole (n = 6,55%), flucytosine (n = 10,71%). A total of 87% (n = 12,87%) of isolates were sensitive to caspofungin and micafungin by VITEK-2 (limitation of this study). In all, 28% (n = 7) of the patients died whereas 40% (n = 10) were discharged. A total of 75% patients had clearing of the persistent candidemia when treated with caspofungin whereas only 25% patients had clearing of the candidemia when treated with voriconazole.ConclusionMost cases of C. auris infection were found in critical patients with the most common presentation being candidemia. The risk factors are similar to any other Candida infection. C.auris is the leading antimicrobial-resistant fungi and poses an additional burden to the healthcare system. The fungus has a high crude-mortality rate and we are running out of treatment options. A comprehensive intervention program with ongoing surveillance and good AMR practices is the need of the hour to reduce the burden of this dangerous pathogen.

Ambient temperature and atmospheric pressure at discharge as precipitating factors in immediate adverse events in patients treated for decompensated heart failure.

To investigate the relationship of ambient temperature and atmospheric pressure (AP) at patient discharge after an episode of acute heart failure (AHF) with very early post-discharge adverse outcomes. We analyzed 14,656 patients discharged after an AHF episode from 26 hospitals in 16 Spanish cities. The primary outcome was the 7-day post-discharge combined adverse event (emergency department -ED- revisit or hospitalization due to AHF, or all-cause death), and secondary outcomes were these three adverse events considered individually. Associations (adjusted for patient and demographic conditions, and length of stay -LOS- during the AHF index episode) of temperature and AP with the primary and secondary outcomes were investigated. We used restricted cubic splines to model the continuous non-linear association of temperature and AP with each endpoint. Some sensitivity analyses were performed. Patients were discharged after a median LOS of 5days (IQR = 1-10). The highest temperature at discharge ranged from -2 to 41.6°C, and AP was from 892 to 1037hPa. The 7-day post-discharge combined event occurred in 1242 patients (8.4%), with percentages of 7-day ED-revisit, hospitalization and death of 7.8%, 5.1% and 0.9%, respectively. We found no association between the maximal temperature and AP on the day of discharge and the primary or secondary outcomes. Similarly, there were no significant associations when the analyses were restricted to hospitalized patients (median LOS = 7days, IQR = 4-11) during the index event, or when lag-1, lag-2 or the mean of the 3 post-discharge days (instead of point estimation) of ambient temperature and AP were considered. Temperature and AP on the day of patient discharge are not independently associated with the risk of very early adverse events during the vulnerable post-discharge period in patients discharged after an AHF episode.

Contemporary outcomes of pancreaticoduodenectomy for benign and precancerous cystic lesions.

The decision to undertake pancreaticoduodenectomy for benign and precancerous lesions has historically relied on outcomes data from operations for cancer. We aimed to describe risks for these specific patients and identify the highest risk groups. The ACS-NSQIP pancreatic targeted data was queried for pancreaticoduodenectomies for benign and pre-cancerous neoplasms from 2014 to 2018. Baseline characteristics, operative techniques and outcomes were examined. Multivariate regression was performed to identify predictors of major complications. 748 patients underwent pancreaticoduodenectomy for (n=541,72.3%) IPMN, (n=87,11.6%) MCN, (n=78,10.4%) serous cystadenoma, and (n=42,5.6%) solid pseudopapillary neoplasm. Median LOS was 8 days. Major complications (n=135,18.0%), non-home discharges (n=83,11.1%) and readmissions (n=153,20.5%) occurred frequently. In patients≥80 years of age (n=37), major complications (n=11,29.7%) and non-home discharge (n=9,24.3%) were quite common. 5-item modified frailty index≥0.4 (OR 1.84,95%CI 1.06-3.19,p=0.030), Male sex (OR 1.729,95%CI 1.152-2.595,p=0.008), Age≥65 (OR 1.63,95%CI 1.05-2.54,p=0.29) and African-American race (OR 2.50,95%CI 1.22-5.16,p=0.013) were independent predictors of major morbidity. Pancreaticoduodenectomies in this setting have high rates of major complications. Morbidity extends beyond the index hospitalization, with frequent readmission and non-home discharge. Patient specific factors, rather than technical or disease factors predicted outcomes. In certain patients, particularly those older than 80, the morbidity of this operation may exceed the cancer prevention benefits.

420.6: Transplantation of Organs From SARS-CoV-2-Positive Donors To Uninfected (Non-lung) Solid Organ Transplant Recipients Has Not Resulted in Significant SARS-CoV-2 Related Morbidity Or Mortality

Introduction: The SARS-CoV-2 pandemic has conferred significant morbidity and mortality across the globe, especially for solid organ transplant (SOT) recipients. This has led to reluctance of using organs from SARS-CoV-2 infected donors due to concerns of disease transmission. However, this must be offset with an increase in wait list mortality. We sought to evaluate the use of organs from SARS-CoV-2 donors into (non-Lung) Solid Organ Transplant Recipients in a prospective fashion. Methods: We evaluated the use of organs from SARS-CoV-2 donors between 6/17/2021 to 2/24/2022. 18 patients were transplanted with SARS-CoV-2-positive donor (COVID+) organs: 3 heart, 4 liver, and 11 kidney recipients. SOT recipients were tested for presence of SARS-CoV-2 by RT-PCR prior to and after their operations. Induction immunosuppression was standard and not altered from protocol. Postoperatively, recipients were kept in modified droplet precautions and received post-exposure treatment recommended by Transplant Infectious Disease. Treatment regimens included remdesivir and monoclonal antibodies directed against SARS-CoV-2 (Figure 1). Perioperative and post discharge care was administered by a multidisciplinary care team with no significant alterations in care protocols. Results: SOT recipients of COVID+ organs at our institution have not experienced any significant morbidity or mortality from SARS-CoV-2. All patients are alive at current follow up with excellent allograft function with a median follow up for heart, liver, and kidney recipients of 235, 67, and 86 days respectively. All patients were vaccinated except for one liver patient who was status 1A due to fulminant acute liver failure. 13/18 patients had post-operative nasopharyngeal swabbing for RT-PCR based viral testing and two tested positive for SARS-CoV-2 at POD #8. Neither patient experience clinical symptoms of disease. Use of of SARS-CoV-2 did not appear to increase inpatient hospital stay. Median LOS for heart, liver, and kidney recipients was 40, 12.3, and 7.4 days respectively. Neither pre-transplant vaccination, use of COVID+ organs, nor post exposure prophylaxis resulted in increased risk of immunologic complications as only one recipient (heart) has experienced an acute cellular rejection episode to date Conclusion: Our experience indicates that COVID+ organs can be utilized successfully. The decision to use these organs was based on organ quality, individual patient need at the time the organ offer was made and whether a potential similar quality, COVID negative organ would be available to the patient in the near future. As evidenced by our data, successful use of COVID+ organs is dependent on multidisciplinary wait list and perioperative management to ensure appropriate donor:recipient selection and mitigation of transmission risk with use of post-exposure prophylaxis.

Pelvic ring injuries after road and mountain bike accidents.

The purpose of this study was to compare patients with traumatic pelvic ring injuries sustained in road and mountain bicycling accidents to evaluate for differences in injury types and hospital courses. A retrospective review of 60 patients presenting with pelvic ring injuries after road (n = 46) and mountain (n = 14) bicycling accidents was performed to compare patient/injury characteristics and hospital course. LC1 injuries were the most common pelvic ring injury (n = 31, 51.7%), 38.7% (n = 12) of which were considered unstable, followed by isolated iliac wing (n = 11, 18.3%), pubic rami (n = 6, 10.0%), and sacral fractures (n = 6, 10.0%). Hospital admission was required for 41 (68.3%) patients. The median hospital LOS was 4days (IQR 2-9) and 12 (20%) patients received operative treatment. Patients in road versus mountain bicycling accidents were more likely to be older tobacco users and were similar in sex, body mass index, and injury severity score. Road bicycling resulted in more LC1 injuries (58.7% vs 28.6%, p = 0.04), while mountain bicycling resulted in more iliac wing fractures (42.9% vs. 10.9%, p = 0.01). Road cycling injuries required more days in the hospital to clear PT (median difference 2, CI 0-4, p = 0.04) and had longer hospital stays (median difference 2, CI 0-6, p = 0.02) but had no difference in the rate of admission, operative intervention, or discharge to rehabilitation facilities. The majority of pelvic ring injuries from road and mountain bicycling accidents were LC1 injuries that were frequently unstable and often required hospital admission and operative fixation.

Robotic parenchymal-sparing pancreatectomy and pancreas-sparing duodenectomy avoid pancreaticoduodenectomy for benign and low-grade malignant tumours.

Parenchymal-sparing pancreatectomy (PSP) or pancreas-sparing duodenectomy (PSD) is an alternative method for patients with benign or low-grade malignant tumours at the pancreatic head or duodenum. It avoids traumatic pancreaticoduodenectomy (PD) with pancreatic function preservation and improves quality of life. However, few studies have reported on robotic PSP (RPSP) or robotic PSD (RPSD). A retrospective analysis of 17 patients with benign and low-grade malignant pancreatic head and duodenal tumours who underwent RPSP or RPSD from January 2018 to February 2022 was conducted. The demographic, perioperative, and postoperative data of all patients were collected and analysed. The operations were successful for all seventeen patients without conversion, including 10 cases of RPSP and 7 cases of RPSD. For RPSP, eight patients underwent pancreatic enucleation, and two patients underwent uncinate process resection. For RPSD, five patients underwent local duodenectomy, and two patients underwent segmental duodenectomy, with five simultaneous jejunostomies and two distal gastrectomies. The median OT and EBL were 135min and 50mL for RPSP and 220min and 100mL for RPSD, respectively. The median LOS was 8days for RPSP and 19days for RPSD. The main postoperative complications for RPSP included POPF (grade B, 6 cases), DGE (grade B, 1 case), PPH (1 case), and intra-abdominal infection (1 case). The main postoperative complications for RPSD included DGE (grade B, 1 case, grade C, 3 cases), postoperative haemorrhage (1 case), intra-abdominal infection (1 case), and duodenal fistula (1 case). One patient underwent interventional drain placement after RPSP because of POPF. RPSP or RPSD is feasible for highly selected patients with benign and low-grade malignant pancreatic head and duodenal tumours, avoiding potential pancreaticoduodenectomy.

Cytoreduction with Hyperthermic Intraperitoneal Chemoperfusion for Pancreatic Cancer with Low-Volume Peritoneal Metastasis: Results from a Prospective Pilot Study.

Resection of oligometastatic pancreatic ductal adenocarcinoma (PDAC) has historically been ineffective, however modern systemic chemotherapy has improved survival. Thus, re-evaluating safety and outcomes of surgical resection in selected patients with limited peritoneal metastasis (PM) warrants consideration. From 2018 to 2021, patients with PDAC and positive cytology or limited PM without extraperitoneal metastasis and who had an objective response to ≥ 6 months of systemic chemotherapy were enrolled. Patients underwent laparoscopic hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin/mitomycin C. If amenable to a complete cytoreduction, patients went on to cytoreduction and HIPEC. Overall, 18 patients were enrolled and received a median of 14 (interquartile range [IQR] 12-17) cycles of chemotherapy; 16 (89%) patients received chemoradiation. Laparoscopic HIPEC was completed in 17 patients, with a median length of stay of 1day, and no grade III complications or hematological toxicities were observed. All 18 patients subsequently underwent a complete cytoreduction (CC-0) along with definitive treatment of the primary tumor, with formal resection (7/18), irreversible electroporation (IRE; 10/18), or intraoperative radiation therapy (IORT; 1/18). Median PCI was 2 (IQR 0-4), median LOS was 7 days (IQR 6-8), and 7 (39%) patients were readmitted. Eight (44%) patients experienced grade 3 or higher complications, including one 30-day mortality. At a median follow-up of 16 months, the median progression-free survival was 20 months and the median overall survival was 26 months. Cytoreduction and HIPEC for selected patients with low-volume PMfrom PDAC is safe and feasible with favorable short-term outcomes. A phase II trial (NCT04858009) is now enrolling to further assess this multimodality approach in select patients.

Critical appraisal of minimally invasive keyhole surgery for intracranial meningioma in a large case series.

Meningioma surgery has evolved over the last 20 years with increased use of minimally invasive approaches including the endoscopic endonasal route and endoscope-assisted and gravity-assisted transcranial approaches. As the "keyhole" concept remains controversial, we present detailed outcomes in a cohort series. Retrospective analysis was done for all patients undergoing meningioma removal at a tertiary brain tumor referral center from 2008-2021. Keyhole approaches were defined as: use of a minimally invasive "retractorless" approach for a given meningioma in which a traditional larger approach is often used instead. The surgical goal was maximal safe removal including conservative (subtotal) removal for some invasive locations. Primary outcomes were resection rates, complications, length of stay and Karnofsky Performance Scale (KPS). Secondary outcomes were endoscopy use, perioperative treatments, tumor control and acute MRI FLAIR/T2 changes to assess for brain manipulation and retraction injury. Of 329 patients, keyhole approaches were utilized in 193(59%) patients (mean age 59±13; 30 (15.5%) had prior surgery) who underwent 213 operations; 205(96%) were skull base location. Approaches included: endoscopic endonasal (n = 74,35%), supraorbital (n = 73,34%), retromastoid (n = 38,18%), mini-pterional (n = 20,9%), suboccipital (n = 4,2%), and contralateral transfalcine (n = 4,2%). Primary outcomes: Gross total/near total (>90%) resection was achieved in 125(59%) (5% for petroclival, cavernous sinus/Meckel's cave, spheno-cavernous locations vs 77% for all other locations). Major complications included: permanent neurological worsening 12(6%), CSF leak 2(1%) meningitis 2(1%). There were no DVTs, PEs, MIs or 30-day mortality. Median LOS decreased from 3 to 2 days in the last 2 years; 94% were discharged to home with favorable 90-day KPS in 176(96%) patients. Secondary outcomes: Increased FLAIR/T2 changes were noted on POD#1/2 MRI in 36/213(17%) cases, resolving in all but 11 (5.2%). Endoscopy was used in 87/139(63%) craniotomies, facilitating additional tumor removal in 55%. Tumor progression occurred in 26(13%) patients, mean follow-up 42±36 months. Our experience suggests minimally invasive keyhole transcranial and endoscopic endonasal meningioma removal is associated with comparable resection rates and low complication rates, short hospitalizations and high 90-day performance scores in comparison to prior reports using traditional skull base approaches. Subtotal removal may be appropriate for invasive/adherent meningiomas to avoid neurological deficits and other post-operative complications, although longer follow-up is needed. With careful patient selection and requisite experience, these approaches may be considered reasonable alternatives to traditional transcranial approaches.

Immunonutrition reduces complications rate and length of stay after laparoscopic total gastrectomy: a single unit retrospective study

BackgroundPreoperative immunonutrition (IN) reduces the incidence of postoperative complications in malnourished patients undergoing upper gastrointestinal surgery. However, its effect in norm-nourished patients remains unclear. Furthermore, patients with gastric cancer undergoing laparoscopic total gastrectomy (LTG) are not routinely included in protocols of enhanced recovery after surgery (ERAS).ObjectiveThe aim of this study was to investigate the effects of perioperative IN in patients undergoing laparoscopic total gastrectomy (LTG) within an established ERAS pathway.MethodsA comparative retrospective study of patients undergoing LTG, receiving an immune-enhancing feed plus maltodextrin load the day of surgery (Group A) versus patients who had the same operation but no IN nor fast track management (group B).ResultsThere were no significant differences in patient demographic characteristics between the two groups but the medium age of patients in group A was older. Thirty-days postoperative complications were respectively 8.7% in Group A and 33.3% in Group B (p 0.04). Mean and median LOS for Group A and B were also significantly different: 7.2 ± 4.4 vs 10.3 ± 5.4 and 7 vs 10 days respectively.ConclusionPreoperative IN associated with ERAS protocol in normo-nourished patient undergoing LTG seems to reduce postoperative complications. Reduction in LOS is possibly associated to the ERAS protocol.Clinical trial registration Clinical trials.gov: NCT05259488

Vitamin D Levels and Length of Hospitalization in Indian Patients With COVID-19: A Single-Center Prospective Study.

IntroductionThe role of vitamin D deficiency in increasing susceptibility or modifying outcomes in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) illness is unclear, and data about the association is scant in low- and middle-income countries. We set out to investigate any correlation between baseline vitamin D status and the length of hospital stay in laboratory-confirmed SARS-CoV-2 patients in India.MethodsTwo hundred patients with SARS-CoV-2 infection requiring admission in a North Indian 1200-bedded tertiary care hospital were recruited prospectively from November 2020 to March 2021. Baseline serum 25 hydroxyvitamin D [25(OH)D] levels were measured within 24 hours of admission using chemiluminescent immunoassay. Patients were managed as per hospital management protocol for COVID-19. The primary outcome was the length of hospital stay; secondary outcomes were comparative clinical severity between two groups, rate of requirement of mechanical ventilation and/or non-invasive ventilation (NIV), and mortality. Vitamin D deficiency (VDD) was defined as baseline vitamin D levels of <30 ng/ml.Results Of the 200 recruited patients, 57.5% (n = 115) patients were vitamin D deficient, and the overall median length of hospital stay was around 12 days (IQR: 8-15 days). There was no statistically significant difference in the length of hospital stay between patients with normal serum vitamin D (VDS) and those with VDD, median LOS being 12 days (95% CI: 10, 12 days) in VDD cases and 11 days (95% CI: 10,13 days) in VDS cases (p = 0.176). No association between baseline 25(OH)D and any of the secondary outcomes could be established.ConclusionsIn Indian patients, baseline vitamin D levels are not associated with the length of hospital stay, need for mechanical ventilation, or mortality.

The Red Blanket Protocol in a tertiary centre in Aotearoa New Zealand: does this trauma protocol improve time to surgery and clinical outcomes?

Patients who are haemodynamically unstable from surgical emergencies require prompt surgical intervention, and delay to surgery may lead to poorer clinical outcomes. The Red Blanket Protocol (RBP) is a communication algorithm intended to facilitate surgery as expediently and safely as possible. By developing a protocol for these channels of communication, RBP may reduce the time to surgical intervention and improve patient outcomes. Our aim was to identify whether patient outcomes, including time to surgery, blood product use and survival were improved by the Red Blanket protocol. Haemodynamically unstable adults in Middlemore Hospital, Aotearoa New Zealand from 1/1/2014 to 31/12/2015 were compared with RBP patients from 1/4/2017 to 1/4/2020. Time from emergency department (ED) to knife-to-skin (KTS) was compared between the groups. The number of blood products used, LOS and 30- and 90-day survival were also compared between the pre-protocol and RBP groups. Thirty-two patients were identified in the pre-protocol group, and 25 in the RBP group. The median time from ED to KTS reduced from 84 to 70.5min after the implementation of RBP (P =0.044). The median number of blood products was 21 pre-protocol and 11.5 in the RBP group (P =0.102). The median LOS was 8 versus 4 days in the RBP group (P= 0.204). 30-day survival rate was comparable in the two groups (65% versus 60% (P 0.71)). RBP was associated with a shorter time to knife-to-skin for haemodynamically unstable patients. There was no significant difference in clinical outcomes between the two groups. Larger studies are required to assess clinical outcomes of the RBP.

Management of Acute Coronary Syndrome Indonesia : Insight from One ACS Multicenter Registry

Background&#x0D; Acute coronary syndrome (ACS) is a life-threatening disorder which contributes to high morbidity and mortality in the world. Registry of ACS offers a great guidance for improvement and research. We collated a multicentre registry to gain information about demographic, management, and outcomes of ACS in Indonesia.&#x0D; Methods&#x0D; IndONEsia Acute Coronary Syndrome Registry (One ACS Registry) was a prospective nationwide multicenter registry with 14 hospitals participating in submitting data of ACS via standardized electronic case report form (eCRF). Between July 2018 and June 2019, 7634 patients with ACS were registered. This registry recorded baseline characteristics; onset, awareness, and transfer time; physical examination and additional test; diagnosis; in-hospital medications and intervention; complications; and in-hospital outcomes.&#x0D; Results&#x0D; Nearly half of patients (48.8%) were diagnosed with STE-ACS. Most prevalent risk factors were male gender, smoking, hypertension. Patients with NSTE-ACS tended to have more concomitant diseases including diabetes mellitus, dyslipidemia, prior AMI, HF, PCI, and CABG. Majority of ACS patients in our registry (89.4%) were funded by national health coverage. Antiplatelet, anticoagulant, antihypertensive, and statins were prescribed as 24-hours therapy and discharge therapy; however presription of potent P2Y12 inhibitor was low. More STE-ACS patients underwent reperfusion therapy than non-reperfusion (65.2% vs. 34.8%), and primary PCI was the most common method (45.7%). Only 21.8% STE-ACS patients underwent reperfusion strategy within 0-3 hours of onset. Invasive strategy performed in 17.6% of NSTE-ACS patients, and only 6.7% performed early (within &lt;24 hours). Patients underwent early invasive strategy had a shorter median LoS than late invasive strategy (P&lt;0.001). A shorter median LoS also found in intermediate and low risk patients. Mortality rate in our ACS patients was 8.9%; STE-ACS patients showed higher mortality than NSTE-ACS (11.7 vs. 6.2%).&#x0D; Conclusion&#x0D; Our registry showed a comparable proportion between STE- and NSTE-ACS patients, with male gender predominant in middle age. Both STE- and NSTE-ACS sharing the same risk factors. We need an improvement in referral time, especially in patients with STE-ACS. Evidence from our registry showed that there are two issues that need to be addressed in order to improve ACS outcomes: optimal and adequate medical treatment and invasive strategy.

Reducing Emergency Department Length of Stay in Critically Injured Pediatric Trauma Patients: A Quality Improvement Initiative.

Efficient transfer of adult trauma patients to the intensive care unit (ICU) is associated with decreased emergency department (ED) length of stay (ED LOS) and improved patient outcomes. While well studied in adults, quality improvement (QI) initiatives focused on the rapid transfer of pediatric trauma patients are lacking. We report the effect of institutional system changes directed at expediting the transfer of pediatric trauma patients to the pediatric ICU (PICU). This initiative commenced in 2013. Preliminary data regarding ED LOS for pediatric trauma patients were collected from January through December 2012 as the pre-implementation cohort. Using the plan-do-study-act (PDSA) framework of QI, the first PDSA cycle was implemented in January 2013. In subsequent PDSA cycles, we implemented the mandatory attendance of the PICU charge nurse and the PICU attending physician to all highest-level pediatric trauma activations. Throughout, ED LOS was collected and mapped on a run chart. ED LOS and variance were compared between all cycles of implementation. One hundred and fifty-one pediatric patients arrived or were upgraded to the highest-level pediatric trauma activation and admitted to the PICU from 2012 through 2019. We observed a decrease in median ED LOS of 105 minutes between the pre- and post-implementation groups. With each PDSA cycle, we observed a decrease in median ED LOS and variation. The inclusion of the PICU charge nurse and attending physician at highest-level pediatric trauma activations facilitated more rapid access to the PICU with decreased ED LOS.

A Clinical Profile of Acute Coronary Syndrome Patients in Kupang

Background: Cardiovascular diseases (CVDs) have been the leading cause of global deaths over the years. In Indonesia, coronary heart disease (CHD) is the most common CVDs, responsible for 29% of all deaths in 2017. East Nusa Tenggara is one of the provinces in Indonesia with the highest prevalence of CHD, which corresponded with growing cases of acute coronary syndromes (ACS). Therefore, we develop a registry to obtain patients' profiles as a basis for strategy development in ACS management.&#x0D; Methods: A retrospectively observational study was conducted on all patients who presented with ACS between January 2019 and September 2020 at a general hospital in Kupang, East Nusa Tenggara. Data collected include demography, patient awareness and transfer history, risk factors, physical findings, diagnosis, workup, treatment, and mortality.&#x0D; Results: A total of 282 patients with ACS (STEMI, 41,2%; NSTEACS, 58,8%) were included in this study. Most patients were male with a mean age of 58,2 ± 12,2 years and normal BMI (32.6%). Nearly 50% of all ACS patients have one or more comorbidities, followed by relatively low adherence to therapy. Half of the patients were referred, but only 16,9% of patients arrived at the first medical facility less than 1 hour after onset. Patients with NTSEACS had more risk factors than patients with STEMI. The median LOS was five days (range, 1-17 days) with 2,8% in-hospital death. The presence of patient and system delay might contribute to the low number of STEMI patients who received reperfusion therapy.&#x0D; Conclusions: This research serves as the primary data for the improvement of acute coronary syndrome management in Kupang and East Nusa Tenggara.

Outcomes of Anesthesiologist-Led Care of Patients Following Liver Transplantation During the COVID-19 Pandemic.

BackgroundDuring the COVID-19 pandemic, anesthesiologists were redeployed as transplant ICU intensivists and a postanesthesia care unit was converted to a novel transplant ICU. This study compared the outcomes of patients undergoing liver transplantation under the new model with the prepandemic model.MethodsAdult patients who underwent liver transplantation at an urban tertiary care center in the United States from December 28, 2015, through May 1, 2020, were identified and grouped according to date of procedure. Peri-COVID cases included transplants that were performed after March 3, 2020. Transplants performed before March 3, 2020, served as pre-COVID controls.ResultsA total of 523 liver transplant patients (30 study cases, 493 controls) were included. Kaplan-Meier survival analysis showed no significant difference in novel transplant ICU length of stay (N-TLOS) (median LOS 3.8 vs. 4.5 days, log-rank p = 0.60) and hospital length of stay (HLOS) (median LOS 14.2 vs. 14.5 days, log-rank p = 0.66). Cox proportional hazards regression with inverse probability of treatment weighting showed no difference in N-TLOS (hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.67–1.23, p = 0.55) or HLOS (HR 0.90, 95% CI 0.65–1.25, p = 0.52). In addition, there were no significant differences (pre-COVID vs. COVID) in time to extubation (median [interquartile range] 28.7 [20.6–50.7] vs. 26.8 [17.4–40.8] hours, p = 0.35), one-year patient survival (12.0% vs. 6.7%, p = 0.055), one-year graft survival (13.4% vs. 6.7%, p = 0.43), and readmission to the ICU (15.0% vs. 20.0%, p = 0.68).ConclusionCare provided by non-intensivist anesthesiologists to patients undergoing orthotopic liver transplantation during a pandemic emergency resulted in outcomes similar to those of care provided by intensivists.

Duloxetine overdose causes sympathomimetic and serotonin toxicity without major complications

Objective Duloxetine is a commonly used antidepressant that is a serotonin and norepinephrine reuptake inhibitor. We aimed to investigate the frequency and severity of clinical effects following duloxetine overdose. Methods We undertook a retrospective review of duloxetine overdoses (>120 mg) admitted to two tertiary toxicology units between March 2007 and May 2021. Demographic information, details of ingestion (dose, co-ingestants), clinical effects, investigations (ECG parameters including QT interval), complications (coma [GCS < 9], serotonin toxicity, seizures and cardiovascular effects), length of stay [LOS] and intensive care unit [ICU] admission were extracted from a clinical database. Results There were 241 duloxetine overdoses (>120 mg), median age 37 years (interquartile range [IQR]: 25–48 years) and there were 156 females (65%). The median dose was 735 mg (IQR: 405–1200 mg). In 177 patients, other medications were co-ingested, most commonly alcohol, paracetamol, quetiapine, diazepam, ibuprofen, pregabalin and oxycodone. These patients were more likely to be admitted to ICU (12 [7%] vs. none; p = 0.040), develop coma (16 [9%] vs. none; p = 0.008) and hypotension [systolic BP < 90 mmHg] (15 [8%] vs. one; p = 0.076). Sixty four patients ingested duloxetine alone with a median dose of 840 mg (180–4200 mg). The median LOS, in the duloxetine only group, was 13 h (IQR:8.3–18 h), which was significantly shorter than those taking coingestants, 19 h (IQR:12–31 h; p = 0.004). None of these patients were intubated. Six patients developed moderate serotonin toxicity, without complications and one had a single seizure. Tachycardia occurred in 31 patients (48%) and mild hypertension (systolic BP > 140 mmHg) in 29 (45%). One patient had persistent sympathomimetic toxicity, and one had hypotension after droperidol. Two patients of 63 with an ECG recorded had an abnormal QT: one QT 500 ms, HR 46 bpm, which resolved over 3.5 h and a second with tachycardia (QT 360 ms, HR 119 bpm). None of the 64 patients had an arrhythmia. Conclusion Duloxetine overdose most commonly caused sympathomimetic effects and serotonin toxicity, consistent with its pharmacology, and did not result in coma, arrhythmias or intensive care admission, when taken alone in overdose.

Stroke care in people with and without schizophrenia: a retrospective, observational study

IntroductionSerious mental illness tends to course with a higher prevalence of comorbidities and schizophrenia is a disabling disease that affects approximately 1% of the world population. Worldwide, cerebrovascular accidents are an important cause of mortality and disability and in Portugal they are one of the leading causes of death in the general population. There is growing evidence that the prevalence of strokes is higher in people with schizophrenia, with pronounced age and gender variations.ObjectivesTo describe the sociodemographic and clinical differences among patients hospitalized with a primary diagnosis of cerebrovascular disease with and without a secondary diagnosis of schizophrenia in Portugal.MethodsWe performed a retrospective observational study using a natiowide hopitalization database containing all hosptalizations registered in Portuguese hosptals from 2008 to 2015. Based on the International Classification of diseases version 9, clinical modification, hospitalizations with a primary diagnosis of stroke were selected (431;433;434), and from those, the ones with a secundary diagnosis of schizophrenia (295.xx) were isolated for a sociodemographic and clinical comparative study. Comorbidities were analysed using the Chalson index score.ResultsEpisodes associated with a secondary diagnosis of schizophrenia were younger (mean: 66 vs 73.7 years; p&lt;0.001) and had longer median LoS (10.0 vs 8.0 days; p&lt;0.001). In-hospital mortality was lower in patients with schizophrenia (11.7% vs 13.2%).ConclusionsThe understanding of the association of cerebrovascular accidents with schizophrenia is complex. Although some studies show conflicting evidence, more attention should be given to the investigation of the incidence, prevalence and impact of cerebrovascular diseases within this particular population.DisclosureNo significant relationships.

Local control and short-term outcomes after VATS segmentectomy vs lobectomy for pT1c pN0 NSCLC (2–3 cm)

Abstract Objective Pulmonary segmentectomy has shown comparable oncological results to lobectomy for non-small cell lung cancers (NSCLC) of less than 2 cm. However, controversy remains for tumors of larger size. The aim of this study was to compare short-term outcomes and local control in pT1c pN0 NSCLC that were intentionally treated by VATS segmentectomy or lobectomy. Methods Multicenter retrospective study from January 2014 to October 2021 of 162 consecutive patients undergoing complete (R0) anatomical resections for pT1c pN0 NSCLC. Two groups, VATS lobectomy (VL) or VATS segmentectomy (VS) were defined according to the extension of the resection. Patients’ characteristics, postoperative outcomes and survival were compared. Results In total, 162 patients underwent VL (n=81) or VS (n=81). Except for age (median of 68 vs 71 years, p=0.034) and past medical history of cancer (32% vs 48%, p=0.038), there was no difference between VL and VS in terms of demographics and comorbidities (table1). Segmentectomies were performed in upper lobes in 68% and single segments represented 46% of all cases. Conversion thoracotomy rate was 5% in both groups. Morbidity were similar in both groups (34% vs 30%, p=0.5). The median time for chest tube removal (3 vs 2 days, p=0.002) and median LOS (6 vs 5 days, p=0.039) were in favor of the VS group. Significantly larger tumor (25 mm vs 23.5 mm p=0.001) and an increased number of lymph nodes removal (median 14 vs 10, p&amp;lt;0.001) were found in the VL group. During the follow-up (median: 31 months), no statistical difference was found for local and distant recurrence in VL groups (12.3%) and VS group (6.2%) (p=0.414). Overall survival was comparable in-between both groups (p=0.166). Conclusion Despite a short follow-up, our preliminary data shows that local control is comparable for VATS lobectomy and VATS segmentectomy. Further prospective randomized trials are needed to corroborate these results.

Prognostic Value of Isolated Sarcopenia or Malnutrition-Sarcopenia Syndrome for Clinical Outcomes in Hospitalized Patients.

Malnutrition–sarcopenia syndrome (MSS) is frequent in the hospital setting. However, data on the predictive validity of sarcopenia and MSS are scarce. We evaluated the association between sarcopenia and MSS and clinical adverse outcomes (prolonged length of hospital stay—LOS, six-month readmission, and death) using a prospective cohort study involving adult hospitalized patients (n = 550, 55.3 ± 14.9 years, 53.1% males). Sarcopenia was diagnosed according to the EWGSOP2, and malnutrition according to the Subjective Global Assessment (SGA). Around 34% were malnourished, 7% probable sarcopenic, 15% sarcopenic, and 2.5% severe sarcopenic. In-hospital death occurred in 12 patients, and the median LOS was 10.0 days. Within six months from discharge, 7.9% of patients died, and 33.8% were readmitted to the hospital. Probable sarcopenia/sarcopenia had increased 3.95 times (95% CI 1.11–13.91) the risk of in-hospital death and in 3.25 times (95% CI 1.56–6.62) the chance of mortality in six months. MSS had increased the odds of prolonged LOS (OR = 2.73; 95% CI 1.42–5.25), readmission (OR = 7.64; 95% CI 3.06–19.06), and death (OR = 1.15; 95% CI 1.08–1.21) within six months after discharge. Sarcopenia and MSS were predictors of worse clinical outcomes in hospitalized patients.

Laparoscopic Heller Myotomy With EGD and Balloon Dilation: A Durable Solution for Achalasia.

Laparoscopic Heller myotomy (LHM) and esophageal balloon dilation (BD) are the two mainstays of achalasia treatment-this study examines the outcomes when they are performed simultaneously without fundoplication. All patients undergoing LHM&BD were reviewed for demographic and procedural data, and to see if additional procedures for achalasia had been performed. Patients were surveyed using the Eckardt score and the GERD quality-of-life score (GERD-HRQL) to assess the durability of repair. From 2013-2020, 66 patients underwent LHM&BD. There were no esophageal perforations and a median LOS of 1 day. Seven patients have required additional operations or procedures at median 4-years follow up. 31 patients (47%) responded to the survey. The average Eckardt score was 2.9 (goal<4) with mean GERD-HRQL of 14.4 (goal<25). LHM&BD allows for a safe, durable repair of achalasia. Reflux symptoms are manageable with PPI without fundoplication and the re-intervention rate similar to published values.