Significant Difference In Length Of Hospital Stay Research Articles

Efficacy and Safety of Azvudine in Patients With COVID-19 in China: A Meta-Analysis of Observational Studies.

Azvudine (FNC) is a novel small molecule antiviral drug for treating COVID-19 that is available only on the Chinese market. Despite being recommended for treating COVID-19 by the Chinese guidelines, its efficacy and safety are still unclear. This study aimed to evaluate the protective effect of FNC on COVID-19 outcomes and its safety. We followed the PRISMA 2020 guidelines and searched the PubMed, Embase, Web of Science, Scopus, and China National Knowledge Infrastructure (CNKI) databases to evaluate studies on the effectiveness of FNC in treating COVID-19 in China, focusing on mortality and overall outcomes. Additionally, its impact on the length of hospital stay (LOHS), time to first nucleic acid negative conversion (T-FNANC), and adverse events was evaluated. The inclusion criterion was that the studies were published from July 2021 to April 10, 2024. This study uses the ROBINS-I tool to assess bias risk and employs the GRADE approach to evaluate the certainty of the evidence. The meta-analysis included 24 retrospective studies involving a total of 11 830 patients. Low-certainty evidence revealed no significant difference in mortality (OR = 0.91, 95% CI: 0.76-1.08) or LOHS (WMD = -0.24, 95% CI: -0.83 to 0.35) between FNC and Paxlovid in COVID-19 patients. Low-certainty evidence shows that the T-FNANC was longer (WMD = 1.95, 95% CI: 0.36-3.53). Compared with the Paxlovid group, low-certainty evidence shows the FNC group exhibited a worse composite outcome (OR = 0.77, 95% CI: 0.63-0.95) and fewer adverse events (OR = 0.63, 95% CI: 0.46-0.85). Compared with supportive treatment, low certainty shows FNC significantly reduced the mortality rate in COVID-19 patients (OR = 0.61, 95% CI: 0.51-0.74) and decreased the composite outcome (OR = 0.67, 95% CI: 0.50-0.91), and very low certainty evidence shows significantly decreased the T-FNANC (WMD = -4.62, 95% CI: -8.08 to -1.15). However, in very low certainty, there was no significant difference in LOHS (WMD = -0.70, 95% CI: -3.32 to 1.91) or adverse events (OR = 1.97, 95% CI: 0.48-8.17). FNC appears to be a safe and potentially effective treatment for COVID-19 in China, but further research with larger, high-quality studies is necessary to confirm these findings. Due to the certainty of the evidence and the specific context of the studies conducted in China, caution should be exercised when considering whether the results are applicable worldwide. PROSPERO number: CRD42024520565.

The Burden of Cerebral Venous Thrombosis in a Romanian Population across a 5-Year Period.

Health policies in transitioning health systems are rarely informed by the social burden and the incidence shifts in disease epidemiology. Cerebral venous thrombosis (CVT) is a type of stroke more often affecting younger adults and women, with higher incidences being reported in recent studies. A retrospective, hospital-based population study was conducted at Cluj-Napoca Emergency County Hospital across a 5-year period between 2017 and 2021. The overall incidence and the rates in distinctive gender and age groups were assessed. Length of hospital stay (LHS), modified Rankin score (mRS) and mortality at discharge and at 3 months were calculated. Fifty-three patients were included. The median age was 45 years, and 64.2% were women. In our population of 3,043,998 person-years, 53 CVT cases resulted in an incidence of 1.74 per 100,000 (95% CI 1.30-2.27). CVT incidence was higher in women (2.13 per 100,000, 95% CI 1.47-2.07). There was a statistically significant difference in LHS between patients with different intracranial complications (Kruskal-Wallis, p = 0.008). The discharge mRS correlated with increasing age (rs = 0.334, p = 0.015), transient risk factors (Fisher's exact test, p = 0.023) and intracranial complications (Fisher's exact test, p = 0.022). In addition, the mRS at 3 months was statistically associated with increasing age (rs = 0.372, p = 0.006) and transient risk factors (Fisher's exact test, p = 0.012). In-hospital mortality was 5.7%, and mortality at follow up was 7.5%, with higher rates in women (5.9% and 8.8%, respectively). Our findings may provide insight regarding the epidemiological features of certain patient groups more prone to developing CVT and its complications, informing local and central stakeholders' efforts to improve standards of care.

Abstract 241: Length Of Hospital Stay Is Lessened In Patients That Present With Chest Pain When Serial Troponins Are Measured Every Three Hours Compared To Every Six Hours

Troponins have close to 100% sensitivity when drawn 6 to 12 hours after the start of chest pain in acute coronary syndrome (ACS). Length of hospital stay (LOS) is a marker of efficient hospital management. Since troponin measurements at 3 (Q3H) and 6-hour (Q6H) intervals have comparable efficacy for ACS, we suggest considering Q3H troponins as opposed to Q6H in chest pain admissions to shorten LOS. A retrospective review of 389 patients who presented to Stony Brook Southampton Hospital in 2020 and 2021 with chest pain was conducted. Two patient care strategies were examined, one involved collecting troponins Q6H and the other Q3H. 319 patients with the Q6H strategy were analyzed and 61.1% were ruled in for ACS. For the Q3H strategy, 70 patients were analyzed in which 42.9% were ruled in for ACS. LOS was defined as hours between triage and submission of discharge instructions. A two-sample t-test was performed to find correlation between frequency of troponins and LOS. A two-sample t-test assuming unequal variance was conducted to compare LOS in hours between Q6H and Q3H strategies. There was a significant difference in LOS for Q6H (M = 123, SD = 201) and Q3H (M = 66, SD = 135) troponins; t = 2.91, p = 0.002. These results suggest that LOS is lessened when troponin intervals are shorter. The variance was elevated (40249,18343), possibly due to patients who stayed longer for other needs, but mean LOS and standard deviation remained decreased both when excluding patients that stayed longer than one week, and when including all patients in the analysis. Optimizing LOS has a variety of benefits. In patients with chest pain, shortening the interval of troponin collection can lessen LOS. Studies of comparable efficacy of shorter troponin intervals in evaluation of ACS have led to the practice of trending at Q3H intervals in Europe. Our study demonstrates that trending troponins Q3H is viable in a community hospital in the United States and should be further investigated and considered in the future.

Does 3D Printing-Assisted Acetabular or Pelvic Fracture Surgery Shorten Hospitalization Durations among Older Adults?

Acetabular or anterior pelvic ring fractures are rare but extremely complicated and challenging injuries for orthopedic trauma surgeons. Three-dimensional (3D) printing technology is widely used in the management of these two fracture types for surgical benefits. Our study aimed to explore whether 3D printing-assisted acetabular or pelvic surgery is beneficial in terms of shortening the length of hospital stay (LHS) and intensive care unit (ICU) stay (ICU LS) for older patients. This retrospective study included two groups of 76 participants over 60 years old who underwent operations with (n = 41) or without (n = 35) guidance by 3D printing. The Mann–Whitney U test was used to analyze continuous variables. Chi-square analysis was applied for categorical variables. Univariable and multivariable linear regression models were used to analyze the factors associated with LHS. The median LHS in the group without 3D printing assistance was 16 (12–21) days, and the median ICU LS was 0 (0–2) days. The median LHS in the group with 3D printing assistance was 17 (12.5–22.5) days, and the median ICU LS was 0 (0–3) days. There was no significant difference in LHS associated with 3D printing assistance vs. that without 3D printing among patients who underwent open reduction and internal fixation for pelvic or acetabular fractures. The LHS positively correlated with the ICU LS whether the operation was 3D printing assisted or not. For fracture surgery in older patients, in addition to the advancement of surgical treatment and techniques, medical teams require more detailed preoperative evaluations, and more personalized medical plans regarding postoperative care to achieve the goals of shortening LHS, reducing healthcare costs, and reducing complication rates.

Efficacy and Safety Assessment of Rivaroxaban for the Treatment of Cerebral Venous Sinus Thrombosis in a Chinese Population.

We aimed to investigate the efficacy and safety of rivaroxaban for acute and long-term management of cerebral venous sinus thrombosis (CVST). This study reviewed CVST-diagnosed patients admitted to the First Affiliated Hospital of Guangxi Medical University from January 2015 to December 2020. The primary outcome was a composite of recurrent thrombosis or major bleeding events. The secondary efficacy outcomes included a disease recovery time (DRT) presenting the time from admission to the endpoint as recovery (the modified Rankin scale [mRS] score [0-1]) within 30 and 90 days, and length of hospital stay (LHS). Patients treated with rivaroxaban (38) and warfarin (45) were enrolled in the final analysis. The primary outcome had no significant difference (5.3% vs 11.1%, P = .576) between the 2 groups. The secondary efficacy outcome regarding the median 30-d DRT was 17 days (95% confidence interval [CI], 14.6-19.4) in the rivaroxaban group, compared with 26.0 days (95% CI, 16.8-35.2) in the warfarin group (hazard ratio, 1.806; 95% CI, 1.051-3.103; log-rank P = .026). Two groups have a significant difference in LHS (P = .041). Patients with cerebral edema, intracerebral hemorrhage, and mild/moderate disability (admission mRS score [2-3]) treated with rivaroxaban recovered faster than those with warfarin (log-rank P < .05). Patients with cerebral edema, intracerebral hemorrhage, and mild/moderate disability treated with rivaroxaban had a shorter recovery time than those treated with warfarin within 1 month from admission, indicating that rivaroxaban a promising convenient therapy for CVST, helping them speedily restore social functions.

63. Liposomal bupivacaine does not decrease postoperative opioid use or length of hospital stay in patients undergoing ACDF

<h3>BACKGROUND CONTEXT</h3> Liposomal bupivacaine (LB) is local anesthetic perioperatively infiltrated into the surgical site to promote postoperative analgesia. Despite its widespread use, definitive data demonstrating its efficacy is limited especially in patients undergoing anterior cervical discectomy and fusion (ACDF). <h3>PURPOSE</h3> To examine whether ACDF patients who received preoperative LB (LB group) exhibited decreased postoperative opioid use and length of hospital stay (LOS) compared to ACDF patients who did not receive preoperative LB (controls). <h3>STUDY DESIGN/SETTING</h3> Retrospective chart review. <h3>PATIENT SAMPLE</h3> Eighty-two patients who underwent primary ACDF (n = 82). <h3>OUTCOME MEASURES</h3> Surgical complications, postoperative opioid use, and LOS. <h3>METHODS</h3> Eighty-two patients who underwent primary ACDF by a single surgeon from 2016-2019 were retrospectively identified from an institutional database. Patient demographics, medical comorbidities, surgical complications, postoperative opioid use and LOS were collected. Data were analyzed using independent t-tests, chi-square tests and multiple linear regression. <h3>RESULTS</h3> Fifty-nine patients received preoperative LB (LB group) while 23 patients did not (controls). Univariate analysis revealed that the LB group did not require significantly fewer opioids on postoperative day (POD) 0 (p = 0.471), POD1 (p = 0.970), POD2 (p = 0.914), throughout the entire hospital course (p = 0.845), or throughout the entire hospital course after normalizing by LOS (p = 0.538). There was also no significant difference in LOS between groups (p =0.833). Multivariate analysis showed that the number of cervical vertebrae involved in the operation significantly predicted opioid use on POD0 (p = 0.005) and throughout the hospital course after normalizing by LOS (p = 0.024) but LB use, age, and body mass index (BMI) did not. For every additional vertebral level involved, approximately 225 additional morphine milligram equivalents (MMEs) were utilized on POD0 while 156 additional MMEs were utilized throughout the hospital course after normalizing by LOS. <h3>CONCLUSIONS</h3> ACDF patients who received preoperative LB did not require fewer postoperative opioids or exhibit a decreased LOS compared to controls. Patients whose procedures involved a greater number of cervical vertebrae were associated with greater opioid use on POD0 and throughout the hospital course after normalizing by LOS. The results of this study suggest that ACDF patients, especially those with a high number of vertebrae involved, may require additional or alternative analgesia to LB. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

LENGTH OF HOSPITAL STAY OF ORTHOPAEDIC INPATIENTS IN A TERTIARY CARE TEACHING HOSPITAL IN NEPAL

Background: Length of Hospital Stay (LOHS) can have important effects on the cost of treatment and patient outcomes. The aim of this study was to determine the length of hospital stay among orthopaedic inpatients and assess its association with different socio-demographic and clinical factors. Methods: A retrospective study was conducted at College of Medical Sciences and Teaching Hospital, Nepal, wherein, clinical records of patients admitted and treated as inpatients between January and December 2019 were retrieved. Demographic data, diagnosis, treatment details, LOHS, co-morbidities, treatment modality and mode of payment were documented and data was analyzed using SPSS software 16.0. Median was calculated for skewed continuous data and frequency analysis was done for categorical variables. P value &lt;0.05 was considered statistically significant. Results: In a total of 1248 patients with mean age of 33.8±18.7 years, 72.4 % (n=904) were male. Most of them (34.9%, n=435) were students and majority (62.5%, n=780) were from outside Chitwan. The median LOHS was 5.0 (3.0–10.0) days. It was significantly greater in cases from outside Chitwan, those with trauma, infection, associated injury, and complications (p&lt;0.05). Moreover, there was significant difference in LOHS among various age quintiles, occupations, fracture types, modes of payment and treatment modalities (p&lt;0.05). However, LOHS did not differ significantly between patients with or without co-morbidity and gender (p&gt;0.05). Conclusions: This study identified that the LOHS was significantly associated with various clinico demographic factors except gender and co-morbidity. More studies can be conducted to assess the relationships further.

Timing of referral for palliative radiation therapy and length of hospital stay.

57 Background: Palliative radiation therapy (PRT) offers effective symptomatic relief to cancer patients. Increased focus on quality of care and healthcare efficiency necessitate a better understanding of the temporal relationships between consultation for/initiation of PRT and length of hospital stay (LOS). This study aims to assess whether durations from admission to PRT consult/PRT initiation affect LOS. Methods: In an institutional review of patients who received PRT as inpatients between January 2017 and December 2018, 67 met inclusion criteria. Duration of time from admission to consultation or start of PRT were categorized using various thresholds. LOS was compared across groups using the Wilcoxon rank sum test and factors were evaluated as predictors of LOS using bivariate linear regression. Results: PRT was given for pain (37%), neurologic deficits/brain metastases (31%), and respiratory symptoms (19%). Multiple sites were treated in 31%; treatment sites included spine (45%), non-spine bone (27%), chest (22%), abdomen/pelvis (12%), brain (10%) and soft tissue (6%). At admission, patients had known metastases (66%), no prior cancer diagnosis (19%), or known primary cancer (15%). Median LOS was 12 days (IQR 7-18) for all patients. There was a significant difference in LOS for patients referred for PRT within 3 days of admission versus greater than 3 days (11 v. 21 days, p &lt; 0.01). This difference was slightly greater using a threshold of 4 days (11 v. 25 days, p &lt; 0.01) and 5 days (11 v. 26 days, p &lt; 0.01), both of which remained significant when analyzing only patients with prior cancer diagnosis (n = 54). There was no difference in LOS using a threshold of 1 or 2 days. As a continuous variable, duration from admission to PRT was associated with LOS (OR 2.40, p &lt; 0.01). Similar patterns were noted when analyzing by time from admission to PRT start. Conclusions: Earlier radiation oncology consultation for PRT is associated with shorter LOS in patients treated with PRT for symptomatic malignancy. Further research is needed to better define this relationship and improve systematic processes to facilitate early consultation and treatment. A palliative radiation oncology clinic was recently developed to address these issues at our institution.

Elevated Troponin: A Marker for Noncardiac Complications After Resection of Head and Neck Cancers.

To examine if troponin positivity (TP) in patients who undergo head and neck cancer mucosal resections (HNS) predicts noncardiac complications (NCC). Major HNSs are arduous operations that place stress on the patient's hemodynamic system. TP after noncardiac surgery previously has been shown in up to 25% of patients, which may signal cardiac complications (CC) or NCC. Although CC after HNS has been observed, no study has investigated the relationship of TP to NCC. All patients who underwent HNS at a tertiary-care cancer center from July 2014 to July 2016 were included and underwent postoperative troponin measurements as part of an institutional cardiac protocol. Comparative and multivariate regression analysis were used to compare TP and troponin-negative (TN) patients for NCC. One hundred seventy-two patients underwent HNS. Of those, 15% developed TP during the postoperative period. There was no significant difference between TP and TN for gender, tumor-node-metastasis staging, Charlson comorbidity index, and smoking status. Risk of NCC in TP was 73.1% versus 28.1% in TN (P < 0.001). A significant difference (P < 0.05) in wound complications, length of hospital stay (LOHS), and incidence of pneumonia was found between both groups. Nonparametric testing confirmed significant difference in pneumonia (Z = -3.469, P = 0.001) and LOHS (-3.110, P = 0.002). Multivariate regression analysis confirmed a significant difference in LOHS independent of CC (R2 = 0.122, P < 0.0001). TP is not an uncommon occurrence after HNS and is associated with statistically significant increases in wound complications, LOHS, and pneumonia. However, the overall significance of these findings remains unclear, and further research is warranted to determine if outcomes may be improved by closely monitoring these patients for TP. 4 Laryngoscope, 130:2148-2152, 2020.

Changes in the utilization patterns of antifungal agents, medical cost and clinical outcomes of candidemia from the health-care benefit expansion to include newer antifungal agents

ObjectivesIn 2014, South Korea expanded its national health insurance coverage to include newer antifungal agents, such as echinocandins. This study aimed to investigate the effects of policy change on the prescription patterns of antifungals, medical costs and clinical outcomes of candidemia. MethodsThis retrospective cohort enrolled hospitalized patients with candidemia at three tertiary care hospitals in South Korea from January 2012 to December 2015. The utilization of antifungal agents, medical costs, length of hospital stay (LOS), and mortality before and after the health-care benefit expansion were compared, and the factors associated with all-cause 28-day mortality during the study period were analyzed. ResultsA total of 769 candidemia cases were identified. The incidence of candidemia did not significantly vary during the study period (P = 0.253). The proportion of echinocandins, as the initial antifungal agent, and medical costs associated with candidemia significantly increased since the change in insurance coverage (P < 0.001). There was no significant difference in LOS and mortality associated with candidemia before and after the health-care benefit expansion (P = 0.696 and 0.931, respectively). Multivariate logistic regression analysis showed that initial treatment with caspofungin was associated with decreased mortality (adjusted odds ratio: 0.784; 95% confidence interval: 0.681–0.902; reference: fluconazole). ConclusionsAlthough the utilization of newer antifungal agents and medical cost for candidemia has significantly increased since the health-care benefit expansion, there has been no change in the outcome of candidemia. However, the further increased use of newer antifungals may improve the outcome of candidemia in this country.

Defining the role of surgical drainage in paediatric deep neck space infections.

Surgical drainage is the traditional mainstay of treatment of paediatric deep neck space infection (DNSI), but recently non-operative management in selected cases has been advocated. We sought to identify any characteristics predictive of requirement for surgical intervention. Retrospective cohort study using receiver operating characteristics analyses. Tertiary referral paediatric hospital. Children (≤16years) with a radiologically confirmed diagnosis of retro- or parapharyngeal abscess over a ten-year period. Predictive value of clinical and radiological variables in determining the requirement for surgical intervention. Length of hospital stay (LoS) was also examined. Ninety-three children were studied, 15 (16.1%) of whom underwent immediate surgery, 42 (45.2%) of whom underwent delayed surgery following an initial period of conservative management, and 36 (38.7%) of whom were managed conservatively. Age, WCC and CRP were not predictive of the need for surgical drainage. Radiological abscess diameter, however, was predictive of requirement surgery (AUC=0.85 [95% CI±0.09] P=0.02), with a cut-off value of 2.5cm determined assuming equal weight to sensitivity and specificity. All DNSIs were successfully treated with no adverse outcomes, and there was no significant difference in LoS between groups. In those managed surgically, outcome and LoS did not depend on yield of pus. Selected paediatric DNSIs can be successfully managed conservatively, with abscess diameter >2.5cm a significant predictor of need for surgical intervention. Any benefit of surgery does not appear to depend on intra-operative yield of pus.

Primary Versus Delayed Primary Incision Closure in Contaminated Abdominal Surgery: A Meta-Analysis

BackgroundDebates still exist whether delayed primary incision closure (DPC) could bring more benefits to patients suffering contaminated abdominal surgery. So, we want to determine whether DPC has advantage over primary incision closure (PC) in contaminated abdominal surgery. MethodsEmbase, Medline, and the Cochrane Library databases were searched for eligible studies from January 1, 1980 to August 6, 2017. Bibliographies of potential eligibility were also retrieved. The primary outcome was the rate of surgical site infection (SSI) and the second outcome was length of hospital stay (LOS). A systematic review and meta-analysis of RCTs were performed. ResultsTwelve studies were included in the final quantitative synthesis. Of the 12 studies included, five were from third world countries (i.e., India and Pakistan), and all of these demonstrated an improvement in SSI rate with DPC. When the fixed-effect model used, compared with PC, SSI was significantly reduced in DPC with a risk ratio of 0.64 (0.51-0.79) (P < 0.0001), and a significant difference in LOS between DPC and PC was also identified with a mean difference of 0.39 (0.17-0.60) (P = 0.0004). Although the random-effect model was used, no significant difference in SSI between DPC and PC was observed with a risk ratio of 0.65 (0.38-1.12) (P = 0.12), and no significant difference in LOS between DPC and PC was found with a mean difference of 1.19 (−1.03 to 3.41) (P = 0.29). ConclusionsDPC may be the preferable choice in contaminated abdominal surgeries, especially in patients with high risk of infection, and particularly in resource constrained environments. In addition, more high-quality studies with well design are needed to provide clear evidence.

HIV seroprevalence and factors affecting clinical outcomes among patients with surgical acute abdomen in selected hospitals in Mwanza, north-western in Tanzania

Background: HIV infection has been reported to be prevalent in patients with surgical acute abdomen. This study aimed to establish HIV seroprevalence among patients with surgical acute abdomen and to identify factors affecting clinical outcomes among these patients at a tertiary care hospital in Tanzania Methods: This was a prospective cross-sectional study of patients with surgical acute abdomen admitted to three selected hospitals in Mwanza between February 2016 and July 2016.Results: Out of the 106 patients (M: F = 1.5:1) included in the study, 15 (14.2%) were HIV positive. Of these, nine were males and 6 were females. Surgical site infection was the most common postoperative compilation and was found to be significantly higher in HIV positive patients with CD 4+ count below 200 cells/μl (p&lt;0.001). The median length of hospital stay (LOS) was 16 days. There was no significant difference in LOS between HIV positive and negative patients (p=0.791). Mortality rate was 13.2% and it was significantly higher in patients with advanced age (&gt; 65 years), pre-existing medical illness, delayed presentation (&gt;48 hours), HIV positivity, high American Society of Anesthetists class, surgical site infections (p&lt; 0.001).Conclusion: This study has shown that HIV infection is prevalent among patients with surgical acute abdomen in our setting. Factors influencing the clinical outcome of these patients need to be addressed, in order to deliver optimal patient care and improve their treatment outcome.

Short-term outcomes after implementation of ERAS in liver surgery

Introduction: Enhanced recovery pathways have previously proven to reduce length of hospital stay (LOS) in many types of surgeries. Their use in liver surgery remains limited and formal guidelines have not been published. Methods: Using our institutional NSQIP data, we conducted a retrospective review of patients who underwent hepatectomies from 2013-2017. The liver ERAS program was implemented in 2015. Subjects were stratified into two categories: before and after ERAS. The primary outcome was LOS after surgery. Secondary outcomes included postoperative infection, transfusion, liver failure, UTI, sepsis, and readmission. Categorical variables were compared using Fischer exact or Pearson Chi-Square test. LOS was compared using Mann-Whitney U test. Statistical significance was defined as p value < 0.05. Results: 101 patients underwent major hepatectomies (52 traditional and 49 ERAS cases) and 288 patients underwent minor hepatectomies (186 traditional and 102 ERAS cases). There was no significant difference in LOS following major hepatectomy after implementation of ERAS (6.5 vs. 6 days, p=0.25). There was an increase in the rate of postoperative liver failure (3.8% vs. 14.3%, p=0.09). In contrast, there was a significant decrease in LOS for patients undergoing minor liver resection after the implementation of ERAS (5 vs. 3 days, p=0.008) with no difference in secondary outcomes. Conclusion: The implementation of a liver ERAS pathway notably decreased LOS for minor hepatectomies. We suspect that the higher rate of liver failure and unchanged LOS for major liver resections is likely due to increase case complexity and more aggressive oncologic resections.

Preoperative Hemoglobin Level is Associated with Increased Health Care Use After Elective Spinal Fusion (≥3 Levels) in Elderly Male Patients with Spine Deformity.

Measures of health care use such as length of hospital stay (LOS) are used as proxies for quality of care after spine surgery. Accordingly, hospitals and health systems are investing considerable resources into the preoperative identification of patients at risk for prolonged LOS. This study aims to investigate the impact of preoperative level on outcomes and LOS after spinal fusion. The medical records of 204 elderly (≥60 years) male patients undergoing elective spinal fusion (≥3 levels) at a major academic institution from 2005 to 2015 were reviewed. The lower hemoglobin (Hgb) level was designated as <13.5 g/dL. We identified 83 (40.7%) patients with preoperative lower Hgb levels and 121 (59.3%) with normal levels (low Hgb, n= 83; normal Hgb, n= 121). The primary outcomes investigated were complications and LOS. Demographics and comorbidities were similar between both groups, with mean Hgb levels being 12.3 ± 0.9 g/dL and 14.9 ± 1.0 g/dL for the low and normal cohorts, respectively. The lower Hgb cohort experienced higher rates of postoperative delirium (21.7% vs. 5.8%; P= 0.0007), non-wound infections (6.0% vs. 0.0%; P= 0.006), and hematoma formation (3.6% vs. 0.0%; P= 0.035). There was a significant difference in LOS between the cohorts, with the low Hgb cohort experiencing approximately a 2-fold increase (low Hgb, 8.1 ± 5.9 days vs. normal Hgb, 4.8 ± 2.5 days; P < 0.0001). Preoperative Hgb and hematocrit levels negatively correlated with LOS (Hgb, R= -0.388, P < 0.001 and Hct, R= -0.2883, P < 0.001). Our study shows that elderly male patients with lower preoperative Hgb levels have increased LOS and postoperative delirium after spinal fusion. Moreover, preoperative Hgb levels negatively correlate with LOS.

Laparoscopic-assisted approach for penetrating abdominal trauma: A solution for multiple bowel injuries

BackgroundTherapeutic laparoscopy (TL) for penetrating abdominal trauma (PAT) is controversial because the management of multiple bowel injuries is challenging and the conversion rate is high. However, the laparoscopic-assisted approach (LAA) allows easy management of multiple bowel injuries but not investigated in a trauma setting. The aim of this study was to investigate its role in management of multiple bowel injuries and to compare LAA with therapeutic laparoscopy performed fully laparoscopically (FTL). MethodsAll adult patients with PAT managed with TL over four-year period were analyzed. Intraoperative findings, trauma scoring, grading of bowel injuries, related procedures, outcomes and length of hospital stay (LOS) were compared between LAA and FTL groups. ResultsSeventy two (53%) patients were in the FTL group and 65 (47%) in the LAA group. The majority of patients presented with stab wounds. Colonic and small bowel injuries were more common in the LAA group (19 versus 17 and 47 versus 8, respectively). The higher number of bowel repairs, resections and anastomosis were performed in the LAA group. The ISS was higher in the FTL group (13 versus 11, p = 0.02), and the PATI was higher in the LAA group (6 versus 10, p < 0.001). Nine patients in the FTL group suffered Clavien-Dindo grade 3 complications and 11 patients in the LAA group. There was one death in each group. No missed injuries were reported. There was no significant difference in LOS between groups. ConclusionsThe LAA is safe in the management of stable patients with PAT. It can used for management of multiple bowel injuries instead of a conversion to laparotomy. It provides benefits of minimally invasive surgery and the speed and versatility of laparotomy. Moreover, the LAA seems not to be inferior to entirely laparoscopic therapeutic procedures. More studies are needed to compare LAA with FTL and laparotomy.

Operative Autonomy among Senior Surgical Trainees during Infrainguinal Bypass Operations Is Not Associated with Worse Long-term Patient Outcomes

In an era of rapidly evolving surgical training, intraoperative teaching remains paramount to the education of surgical trainees. The impact of surgical trainees' level of expertise on outcomes after infrainguinal bypass surgery, a technically demanding operation, remains unknown. The purpose of this study was to explore the effects of surgical residents' experience on outcomes after infrainguinal bypass surgery. Using the American College of Surgeons National Surgical Quality Improvement Program database, we identified patients who underwent infrainguinal bypass from 2005 to 2012. Patients were stratified according to the training level of the most senior operating trainee. Univariate and multivariate analyses, as well as propensity score matched analysis, were performed to compare patient cohorts on operative time, length of hospital stay (LOS), bleeding, early graft failure, unplanned readmission, and 30-day mortality. A total of 19,579 patients were identified, of which 35.6% were female and 64.4% were male; mean age was 67.6years. A PGY1 (postgraduate year) was the highest level trainee operating on 2.5%, a PGY2-4 for 26.2%, and a PGY5+ (postgraduate year 5 or greater) for 37.1%. Attending surgeons operated without trainees on 34.2%. PGY5+s were more likely to operate on patients who were younger, non-White, male, and on dialysis. In multivariable analysis, involvement of any surgical trainee was associated with procedures that took a greater length of time, had a greater odds of blood transfusion, and necessitated a longer hospital LOS relative to procedures performed by an attending surgeon alone. Only bypasses wherein PGY5+s were involved were associated with greater odds of early graft failure, unplanned readmission, and 30-day mortality when compared with procedures done without trainee involvement. After excluding lower extremity bypasses in which an attending surgeon operated without a trainee, propensity score matching analysis showed that patients operated on by PGY5+s had longer operative time (4.11 vs. 3.96hr, P<0.0001) and greater rates of postoperative bleeding (9.77% vs. 8.15%, P=0.004) relative to patients operated on by attendings assisted by PGY1-4s, but no statistically significant difference in LOS, early graft failure, unplanned readmission, and perioperative mortality. Operative involvement of senior trainees was associated with worse outcomes during infrainguinal bypass, potentially reflecting a lesser extent of attending surgeon involvement, but no difference in patient outcomes after bypass procedure.

Prospective audit and feedback in antimicrobial stewardship: Is there value in early reviewing within 48 h of antibiotic prescription?

Antimicrobial stewardship programme (ASP) methodologies are not well defined, with most preferring to wait ≥72–96h following antibiotic prescription before reviewing patients. However, we hypothesise that early ASP reviews and interventions are beneficial and do not adversely impact patient safety. This study aimed to evaluate the impact of early ASP interventions within 48h of antibiotic prescription on patient outcomes and safety. A prospective review of ASP interventions made within 48h of antibiotic prescription in Singapore General Hospital (SGH) from January to December 2012 was conducted. Patient demographics and outcomes were extracted from the database maintained by the ASP team. For culture-directed treatment, there was a shorter mean duration of therapy (DOT) in the accepted group compared with the rejected group (2.26 days vs. 5.56 days; P<0.001). ASP interventions did not alter the length of hospital stay (LOS), 30-day mortality, 14-day Clostridium difficile infection (CDI), 30-day re-admissions and 14-day re-infection (all P>0.05). For empirical treatment, a shorter DOT (3.61 days vs. 6.25 days; P<0.001) and decreased 30-day all-cause mortality (P=0.003) and infection-related mortality (P=0.002) were observed among patients in the accepted group compared with the rejected group. There was no significant difference in LOS, 14-day CDI and 30-day re-admission (all P>0.05). In conclusion, acceptance of early interventions recommended by ASP in SGH was associated with a reduction in DOT without compromising patient safety. This is evident even during empirical therapy when not all clinical information was available.

Impaired cardiopulmonary reserve in an elderly population is related to postoperative morbidity and length of hospital stay after radical cystectomy

To determine the relationship of preoperatively measured cardiorespiratory function, to the development of postoperative complications and length of hospital stay (LOS) in a cohort of patients undergoing radical cystectomy (RC), as RC and conduit formation is curative but is associated with significant postoperative morbidity and mortality. Consecutive patients planned to have RC underwent cardiopulmonary exercise testing (CPET) to a standardised protocol. The results of the CPET were 'blinded' from the clinicians involved in the care of the patients. Patients were prospectively monitored for the primary outcome of postoperative complications, as defined by a validated classification (Clavien-Dindo). Secondary outcome included LOS and mortality. In all, 82 patients underwent CPET before RC. Eight patients did not subsequently undergo RC and a further five did not exercise sufficiently to allow for appropriate determination of the cardiopulmonary variables of interest. There was a significant difference in LOS between those patients who had a major perioperative complication (Clavien score > 3) and those that did not (16 vs 30 days; P < 0.001; hazard ratio [HR] 3.6, 95% confidence interval [CI] 2.1-6.3). The anaerobic threshold (AT) remained as the only significant independent predictor variable for the presence or absence of major postoperative complications (odds ratio 0.74, 95% CI 0.57-0.97; P = 0.03). When the optimal predictive value of AT of 12 mL/min/kg was used as a fitness marker, there was a significant relationship between fitness and LOS (median LOS: 'unfit' 22 days vs 'fit' 16 days; HR 0.47, 95% CI 0.28-0.80; P = 0.006) CONCLUSION: Impaired preoperative cardiopulmonary reserve was related to major morbidity, prolonged LOS and increased use of critical care resource after RC. This has important health and economic implications for risk assessment, rationalisation of postoperative resource and the potential for therapeutic preoperative intervention with exercise therapy.

Head-to-head comparison of fee-for-service and diagnosis related groups in two tertiary referral hospitals in Switzerland: an observational study

Reimbursement for inpatients in Switzerland differed among states until 2012. Some hospitals used diagnosis related groups (DRG) and others used fee-for-service (FFS). We compared length of hospital stay (LOS), patient satisfaction and quality of life between the two systems before a nation-wide implementation of DRG. In a prospective, two-centre observational cohort study, we identified all patients with a main diagnosis of either community-acquired pneumonia, exacerbation of chronic pulmonary obstructive disease, acute heart failure or hip fracture from January to June 2011 and performed a systematic questionnaire survey 2-4 months after hospital discharge. Of 1,093 inpatients, 450 were included. Mean age was 71.1 (±SD 19.5) years (48% male). Patients in the FFS hospital were older (mean age 74.8 vs. 65.2 years; p <0.001) and suffered from more co-morbidities. Mean LOS was 9 days and shorter in the all-patient DRG (AP-DRG) hospital (unadjusted mean 8.2 vs. 9.5 days, p = 0.04). After multivariate adjustment, no significant difference in LOS was found (p = 0.24). More patients from the FFS hospital were re-hospitalised for any reason (35% vs. 17.5%; p = 0.01), re-admitted to acute-care institutions (11.7% vs. 5.2%; p = 0.014), not satisfied with the discharge process (15.3% vs. 9.7%; p = 0.02), showed problems with self-care (93.8% vs. 88%; p = 0.03) and usual activities (79.3% vs. 76%; p = 0.02). This study suggested that the AP-DRG hospital showed higher patient satisfaction regarding discharge, lower re-hospitalisation rates and shorter LOS partly explained by a lower burden of co-morbidities and disease severity. This study needs validation in a larger cohort of patients and at multiple time points.