Significant Differences In Causes Research Articles

An Institutional Analysis of Early Postoperative Free Tissue Transfer Takeback Procedures.

Postoperative free tissue transfer reexploration procedures are relatively infrequent but associated with increased overall failure rates. This study examines the differences between flaps requiring takeback versus no takeback, as well as trends in reexploration techniques that may increase the odds of successful salvage. A retrospective review was conducted on all free tissue transfers performed at our institution from 2011 to 2022. Patients who underwent flap reexploration within 30 days of the original procedure were compared with a randomly selected control group who underwent free flap procedures without reexploration (1:2 cases to controls). Univariate and multivariate logistic regression analyses were performed. From 1,213 free tissue transfers performed in the study period, 187 patients were included in the analysis. Of the total flaps performed, 62 (0.05%) required takeback, and 125 were randomly selected as a control group. Free flap indication, flap type, reconstruction location, and number of venous anastomoses differed significantly between the two groups. Among the reexplored flaps, 8 (4.3% of the total) had a subsequent failure while 54 (87.10%) were salvaged, with significant differences in cause of initial flap failure, affected vessel type, and salvage technique. Free tissue transfers least prone to reexploration involved breast reconstruction in patients without predisposition to hypercoagulability or reconstruction history. When takeback operations were required, salvage was more likely in those without microvascular compromise or with an isolated venous injury who required a single exploratory operation.

Postoperative Discomfort Among Laparotomy Patients from a Selected Hospital at Mangaluru: An Observational Study

Abstract Background Factors causing postoperative discomfort after laparotomy are numerous and must be explored in depth. The postoperative distress may significantly affect the patient's state of well-being. Hence, the present study aims to assess the factors contributing to discomfort after laparotomy. Aim The aim was to assess and compare the discomfort between open and laparoscopic abdominal surgery. Objectives of the Study 1. To analyze the causes of patient's discomfort after abdominal surgery.2. To compare the discomfort between open and laparoscopic abdominal surgery.3. To determine the association between pain and selected variables among open and laparoscopic abdominal surgery. Materials and Methods An exploratory approach with a prospective observational design was adopted for this study. Using the purposive sampling technique, 100 patients were selected to open and 100 to laparoscopic abdominal surgery groups. Data were collected using demographic and clinical proforma and standardized postoperative discomfort inventory 6 and 24 hours after the surgery. The assessment focused on the study variables such as symptoms after the surgery and the factors contributing to the postoperative discomfort. Statistical Analysis The collected data were analyzed using descriptive and inferential statistics using the SPSS software version 20. Results Among 200 participants, most of the open (68%) and laparoscopic abdominal surgeries (42%) belong to 25 to 35 years of age. Also, 54% and 13% were diabetic in open and laparoscopic abdominal surgery groups, respectively. Most samples (56% in open and 68% in laparoscopic surgery) stayed 5 and 10 hours in postoperative ICU. In open and laparoscopic abdominal surgeries, pain is the primary (100%) cause of postoperative discomfort after 6 hours of surgery. Movement restriction is also the reason for significant discomfort both in open (98%) and laparoscopic (100%) abdominal surgeries.In contrast, pain (99% and 100%), movement restriction (92% and 95%), and abdominal distention (61% and 34%) were the major problems contributing to the patient's discomfort after 24 hours of both open and laparoscopic surgeries too. There was a significant difference in causes of patient discomfort between open and laparoscopic abdominal surgery after 6 hours (P < 0.05), except for discomfort related to IV drip (P = 0.852), constipation (P = 0.2), and chills (P = 0.6). Conclusion Even though pain is the major distressing factor both in open and laparoscopic surgeries, the current study highlights a few other factors that affect postoperative recovery. Nurses' attention to such distressing factors will fasten patients' recovery and quality of life after abdominal surgery.

S1637 Outcomes in Patient With Refractory Gastroparesis on Domperidone-A 12-Year Experience

Introduction: Domperidone (Domp), a prokinetic with less side effects than metoclopramide, the only FDA-approved medication for gastroparesis (GP), is only available via the FDA IND program. Our aim was to examine clinical response and side effects profiles of patients (pts) enrolled in our program to identify those most likely to benefit. Methods: Records of pts enrolled from 2010 through 2021 were examined. Pts who completed an initial (PAGI sym) were contacted for a repeat PAGI-sym. Pts self-reported quality of life. Records of disenrolled (DE) pts were reviewed for cause for disenrollment, adverse effects if any and improvement of symptoms on Domp. Data is reported at percentages and mean ± SD. Variables were compared using Chi-squared test (categorical) and t-test. P< 0.05 was considered significant. Results: 301 pts (85.7% F), were consented. 189 pts were disenrolled (DE), of which 31 never started drug, and 67 charts were reviewed in detail. 41 pts still enrolled (E) had initial and followup PAGI-sym. Of these, 32 (78%) were female, mean age on entry was 50 yrs, with 70.1% older than 40 yrs. Mean treatment duration was 39±39.3 mo. Top GP causes were idiopathic (43.9%), diabetes (24.4%) and post-surgical (12.2%). There was no significant difference in causes or initial symptom severity between genders. There was significant improvement in the severity of all symptoms on PAGI-sym scale after Domp treatment (Table). Gender and age groups did not affect this improvement. Overall self-reported quality of life (QoL) improved regardless of gender, age group and use of psychotropic medication. Reasons for disenrollment for all 189 DE pts are shown in Figure. Six had QTc prolongation (3.2%). In the 67 pts with detailed review, the GP cause was similar in those with symptom remission as in all the DE and E pts. Treatment duration of DE pts was 22.2±22.8 months, shorter than the 41 E pts (P< 0.005). Pts with symptom remission were on Domp treatment for 45.7 ± 26.74 mo, longer than pts withdrawn for other reasons (mean 14.83±15.54 mo, P< 0.001). Most (72%) DE pts reported improvement in symptoms. Conclusion: In summary, Domp improves symptoms related to GP regardless of etiology. Nearly 2 thirds disenrolled over time, but very few have prolonged QTc. Detailed review in a subset of pts suggest no specific etiologies result in better symptom response to domperidone, or predict likelihood of adverse events. Symptom remission can take several years to be sufficient to discontinue treatment.Figure 1.: Reasons for Disenrollemnt in 189 DE Patients. Table 1. - Comparison of Symptom Improvement in All Enrolled Patients PAGISYM-1 (mean +/- SD) PAGISYM-2 (mean +/-SD) P value Regurgitation 2.23 +/- 1.55 1.27 +/- 1.1 < 0.001 Nausea 3 +/- 1.7 1.66 +/- 1.15 < 0.001 Upper Abdominal Pain 2.66 +/- 1.59 1.37 +/- 1.18 < 0.001 Stomach Fullness 3.45 +/- 1.48 2.41 +/- 1.32 0.003 Loss of Appetite 2.9 +/- 1.74 1.46 +/- 1.4 < 0.001 Upper Abdominal discomfort 2.7 +/- 1.54 1.46 +/- 1.29 < 0.001 Bloating 3.48 +/- 1.55 2.2 +/- 1.5 < 0.001 Retching 1.4 +/- 1.53 0.61 +/- 0.92 < 0.001 Stomach or Belly Visibly Larger 2.69 +/- 1.89 1.55 +/- 1.45 0.001 Vomiting 1.89 +/- 1.84 0.78 +/- 1.17 0.001 Not Able to Finish a Normal Sized Meal 3.5 +/- 1.52 2.05 +/- 1.45 < 0.001 Feeling Excessively Full After Meals 3.75 +/- 1.28 1.93 +/- 1.44 < 0.001

Causes of death through verbal autopsy: findings from a sub-study of single dose oral cholera vaccination in urban Dhaka, Bangladesh

Background Verbal autopsy can play a key crucial to identify significant causes of death in a developing country like Bangladesh where post-death pathological or forensic examination is not common. Single-dose Cholera Vaccination in Bangladesh (SCVB) was an individually randomized, placebo-controlled, double-blind study where verbal autopsy had been conducted for the participants who died within three months of receiving study agents This study aim was to determine the major causes of death through a verbal autopsy in a defined urban population. Methods The trial was conducted in urban slums of Dhaka among persons aged one year and older. A census was carried out bi-annually in the study area (Mirpur) including collecting death information from every household. Screening data on death was matched with the vaccination database to confirm whether the participants received the investigational products (IP) or not. The trained physician conducted a verbal autopsy usually within 7 days of notification. Results The screening period for verbal autopsy was from May 22 to July 18, 2014. Among 250 detected deaths, 99 received study agents (50 vaccines and 49 placeboes). The Verbal autopsy could not be completed for 10 deaths due to the unavailability of a next of kin respondent. Of the total of 240 verbal autopsies performed, 217 were in adults aged 18 years and above, 6 in 5-17 years of age, and rest were ≤ 5 years. The Most common causes of death were non-communicable diseases. 163 deaths occurred at home, 59 in a hospital and others died in different places. No significant difference in cause of death among vaccine and placebo group was found from this analysis. Conclusions Verbal autopsies usefully identified probable causes of death in participants in an oral cholera vaccine trial. The findings highlight that in this urban slum, noncommunicable diseases account for most of deaths.

Epidemiology of Firearm Injury in Children at US Trauma Centers

Epidemiology of Firearm Injury in Children at US Trauma Centers

Is There a Mortality “Weekend Effect” in Cardiac Transplantation - A Single Center Experience?

Purpose Cardiac transplant surgeries can be complicated, prolonged, resource-heavy procedures that may be affected by the timing of the surgery. We analyzed data from Ronald Reagan UCLA Medical Center (RRUCLA MC) to evaluate for a “weekend effect” on mortality comparing transplant surgeries that occurred on a weekday versus during the weekend. Methods We conducted a retrospective, cohort analysis of the RR UCLA MC data for all heart-only transplant patients between from 1987 to 2018 comparing mortality rates between weekday transplants (WDT) versus weekend transplants (WET). The exclusion criteria included age proportional hazard regression analysis (adjusted for age, sex, diabetes , race, ischemic time , need for dialysis, on life support, wait time, and HLA mismatch) was performed. Survival was censored at 12 years. Results 1,548 patients received heart transplants between 1987-2018 at RR UCLA MC, of which 1129 patients received a transplant on a weekday and 419 patients received a transplant during the weekend. Overall, the mortality for WDT and WET were 53.3% and 53.5% (p=0.89), respectively. The breakdown of cardiovascular and non-cardiovascular mortality were similar for both WDT (15.0%, 38.4%, respectively) and WET (15.3%, 38.2%) (p=0.54). Furthermore, there was no significant difference in cause of death between WDT vs WET, looking specifically at graft failure , rejection, infection, cardiovascular , malignancy, multi-organ failure , and other causes. Conclusion Based on this retrospective, cohort analysis of the RR UCLA MC data, there was no mortality “weekend effect” observed for cardiac transplantation surgeries.

Is There a Mortality “Weekend Effect” in Cardiac Transplantation?

Purpose Cardiac transplant surgeries can be complicated, prolonged, resource-heavy procedures that may be affected by the timing of the surgery. We analyzed the UNOS Organ Registry to evaluate for a “weekend effect” on mortality comparing transplant surgeries that occurred on a weekday versus during the weekend. Methods Conducted a retrospective, cohort analysis of the UNOS Organ Registry of all heart-only transplant patients from 1987 to 2018 comparing mortality rates between weekday transplants (WDT) versus weekend transplants (WET). The exclusion criteria included age Results 55,670 patients received heart transplants between 1987-2018 per the UNOS Organ Registry, of which 40,504 patients received a transplant on a weekday and 15,166 patients received a transplant during the weekend. Overall, the mortality for WDT and WET were 52% and 52% (p=0.98), respectively. The unadjusted hazard ratio for WET is 1.00 (p=0.89; 95% CI 0.97-1.03) and the adjusted hazard ratio for WET is 1.00 (p=0.93; 95% CI 0.97-1.03). The breakdown of cardiovascular and non-cardiovascular mortality were similar between both groups: WDT (15.8%, 36.2%, respectively) and WET (15.8%, 36.2%, respectively). Furthermore, there was no significant difference in cause of death between WDT vs WET, looking specifically at graft failure, rejection, infection, cardiovascular, malignancy, multi-organ failure, and other. Conclusion Based on this retrospective, cohort analysis of the UNOS Organ Registry there was no mortality “weekend effect” observed for cardiac transplantation surgeries.

Post-ASCT Outcomes in Multiple Myeloma Patients Who Underwent ASCT with G-CSF+Plerixafor Versus G-CSF Mobilized Graft

BACKGROUND: Impact of Plerixafor (P) mobilized stem cells on immune reconstitution of autologous stem cell transplant (ASCT) patients has not been established. Early lymphocyte recovery (Absolute lymphocyte count of > 1 K/uL at day 30 after transplant) has been established to predict outcomes in multiple myeloma (MM) patients. The purpose of this study was to evaluate lymphocyte recovery in MM patients who underwent ASCT with stem cells mobilized with G-CSF vs G-CSF+P. Secondary objective was to evaluate the survival outcomes.METHODS: This is a retrospective analysis of MM patients who underwent first ASCT between 2008 and 2016 with either G-CSF or G-CSF+P mobilization at Karmanos Cancer Institute in Detroit, Michigan. Plerixafor was used per institutional guidelines when the peripheral CD-34+ve cell-count was < 20/ uL on day 5 of G-CSF mobilization. 610 total patients were identified. Mobilization agents used were G-CSF alone (n= 469) or G-CSF+P (n= 141). All patients underwent transplant after Melphalan (M) conditioning and dose of M was at treating physician's discretion (140 vs 200 mg/m2). The primary endpoint was the Absolute Lymphocyte Count at day 30 (ALC30). Secondary endpoints were PFS and OS Univariable and multivariable Cox proportional hazards regression models were fit to assess associations between ten pre chosen predictors( age, race, stage at diagnosis, doublet vs. triplet therapy, lines of treatment, disease status, mobilization agents, melphalan dose, ALC at day 30, post- transplant maintenance) and survival benefit (PFS and OS).RESULTS: Median age of patients was older in G-CSF+P group (62 vs 60 years, p=. 006) and they were more likely to receive triplet therapy (82 vs 72%, p=. 015) for induction compared to G-CSF group (Table 1). Patients in G-CSF group were more likely to receive greater than one line of treatment before transplant (p=. 006). Disease status at transplant was similar between the two groups. G-CSF patients received higher dose of M (at 200mg/ m2) more frequently (69 vs. 58%, p = 0.010) and median cell dose infused was higher in G-CSF group (3.19 vs 2.88 x106 CD 34+ve-cells/Kg, p= 0.001).Primary endpoint, ALC30, was 1.3 K/uL(.1-4.5) and 1.2 K/uL(.1-5.1) for G-CSF and G-CSF+P, respectively (p=. 608). Median day to neutrophil recovery were similar in both groups (ANC of 500 at Day 12). Post-transplant maintenance use was similar between the two groups. The median PFS was 2.46 years (95% CI, 2.14 to 3.15) and 2.77 years (95% CI, 1.99 to 3.27) for G-CSF and G-CSF+P, respectively (HR: 1.128; 95% CI, (.843-1.509); p=. 417) (Figure 1). The median OS was 6.09 years (95% CI, 4.55 to NR) and 3.73 years (95% CI, 3.20 to NR) for G-CSF and G-CSF+P, respectively (HR: 1.638; 95% CI, (1.118-2.399); p=. 011) (Figure 2) .In MVA, higher stage at diagnosis, less than PR before ASCT, and no post-transplant maintenance therapy were associated with worse PFS and OS. More lines of treatment adversely impacted PFS. Use of G-CSF+P for mobilization and Melphalan dose ≤ 200-mg/ m2 adversely impacted OS. ALC30 did not impact PFS or OS in MVA. There were no significant differences in causes of death among the 2 groups.CONCLUSIONS: In this large, retrospective analysis of MM patients mobilized with G-CSF vs G-CSF + P, there was no significant difference in lymphocyte recovery. Higher Melphalan dose resulted in improved OS in the MVA. There was an overall survival difference favoring the G-CSF group, however, differences in baseline characteristics not accounted for in the MVA may be responsible for this observation. A Prospective study comparing these mobilization regimens including patients with similar baseline characteristics is necessary to confirm this finding. [Display omitted] DisclosuresDeol:Kite Pharmaceuticals: Consultancy; Novartis: Consultancy.

Propensity-score-matched evaluation of under-recognition of acute kidney injury and short-term outcomes

Acute kidney injury (AKI) is a common disease, but diagnosis is usually delayed or missed in hospitalized patients. The aim of this study was to investigate the impact of under-recognition of AKI (beyond 3 days after AKI onset) on short-time prognosis. Of 785 patients with under-recognition of AKI and 616 patients with timely-recognition of AKI were propensity matched in a 1:1 ratio. The two groups, with a total of 482 matched patients (241:241), were comparable in baseline covariates. Under-recognition of AKI was not associated with 30-day all-cause mortality in the logistic regression model with covariate adjustment (OR = 1.01, 95% CI = 0.62–1.64, p = 0.967). Sensitivity analyses and subgroup analyses also proved the association. There were also no significant differences in causes of 30-day mortality, in-hospital mortality, recovery of renal function at discharge, length of hospital stay, length of intensive care unit stay or hospitalization costs between the two groups, although timely-recognition group had more chance of renal consult and a little more interventions for AKI. In conclusion, under-recognition of AKI may not be associated with poor short-term outcomes of adult hospitalized patients via these propensity-score-matched analyses.

Mortality after traumatic brain injury and the effect of posttraumatic epilepsy.

To assess the effect of posttraumatic epilepsy (PTE) on mortality and causes of death after traumatic brain injury (TBI). Medical reports were collected retrospectively of patients who sustained TBI between 1996 and 2013. After defining patients with PTE and picking up 2 non-PTE matched TBI controls for every patient with PTE, the database included 714 patients. Demographic data, cause and mechanism of injury, nature of injury (focal injury, intracranial bleeding), time from accident to first seizure, remission rates, neurosurgical operations undertaken, and mortality data were collected. Of the 714 patients, 555 (77.7%) were men and 159 (22.3%) were women. There was an obvious increase in long-term mortality in patients with PTE compared to control TBI patients. This increase became evident after about 1 year from the injury, when approximately 95% of both non-PTE and PTE patients were alive; after that, the difference in mortality increased. The difference remained significant at least up to 15 years from the injury, when around 65% of non-PTE patients with TBI were alive compared to only 45% of patients with PTE. In patients with PTE, the mortality was 1.75 times higher (p = 0.0001). There was no significant difference in causes of death. This study shows that long-term mortality is higher in patients with PTE than other patients with TBI, although the reasons for this difference remain unclear.

A National Registry Analysis of Aortic versus Dual in Situ Perfusion for Retrieval of the DBD Liver

Introduction In situ perfusion of preservation fluid during donation after brain death (DBD) liver retrieval can be conducted via the aorta alone, or aorta and portal vein (dual perfusion). There is considerable disagreement in the literature with regards to the comparative efficacy of each perfusion route for both normal and expanded criteria liver donors, and the few existing studies are disadvantaged by low patient numbers and short periods of follow-up. Materials/Methods DBD whole liver transplants (initial) in Australia were included from 2007-2016, and stratified by aortic (n = 957) or dual (n = 425) perfusion routes. Data points were obtained from the Australia and New Zealand (ANZ) Liver Transplant Registry, the ANZ Organ Donation Registry, and a national survey of senior donor surgeons. University of Wisconsin (UW) solution was given via the aorta and/or portal vein, followed by organ transport in the same fluid. Missing data was handled by multiple imputations. Graft and patient survival were compared using Kaplan-Meier curves and Cox proportional hazards. Causes of graft loss, including primary non-function (PNF), hepatic artery (HAT) and portal vein thrombosis (HAT), biliary complications (BC) and acute rejection (AR) were compared using logistic regression. Results Baseline characteristics between study groups were similar, except for a lower mean cold ischemic time (CIT; 6.3 vs 7.0 hrs), mean secondary warm ischemic time (SWIT; 37.8 vs 45.4 mins), and median recipient MELD score (14 vs 18) in the dual-perfused patient cohort compared to the aortic-only perfusion group (p < 0.001). Actuarial 5-year graft and patient survivals in aortic and dual perfusion cohorts were 80.1% vs 84.6% (p = 0.066, univariate log-rank test), and 82.6% vs 87.8% (p = 0.026, univariate log-rank test), respectively. Multivariate Cox proportion hazards models, accounting for CIT, SWIT, MELD, and other donor/recipient factors with a p-value < 0.1 in univariate analyses, showed that graft survival after aortic vs dual perfusion was not significantly different (HR 0.81, 95% CI 0.60-1.11, p = 0.188). Similarly, overall patient survival was not different between the aortic and dual groups (HR 0.74, 95% CI 0.52-1.05, p = 0.087). There were no significant differences between aortic and dual perfusion groups with respect to causes of graft loss, including PNF, HAT, PVT, BC, and AR. Discussion After accounting for confounders, there were no significant differences in causes of graft loss, graft survival, and patient survival between liver transplants performed after aortic-only or dual in situ liver perfusion at retrieval. Subgroup analyses will need to be conducted to compare high-risk donors. Conclusion The retrieval technique employed does not impact outcomes for standard risk donors. Future RCTs should focus on the efficacy of either technique in liver donors with a high donor risk index, and also consider the impact on other organs, in particular the pancreas. Royal Australasian College of Surgeons.

Incidence, Prevalence, and Survival of Biopsy-Proven Giant Cell Arteritis in Northern Italy During a 26-Year Period.

To investigate the epidemiology and mortality in patients with biopsy-proven giant cell arteritis (GCA) in northern Italy. All patients with incident temporal-artery biopsy-positive GCA, diagnosed between 1986 and 2012 and living in the Reggio Emilia area, were identified by using a pathology register and by reviewing all histopathologic specimens. For each patient, we identified 1 comparison subject from the same geographic area, matched for age and sex. Mortality rates and specific causes of death were reported. There were 285 incident cases of biopsy-proven GCA (210 women) during the 26-year study period. The overall age- and sex-adjusted incidence per 100,000 persons ages ≥50 years was 5.8 (95% confidence interval [95% CI] 5.1, 6.5). Incidence was significantly higher in women (7.8 [95% CI 6.7, 8.9]) than in men (3.3 [95% CI 2.6, 4.1]) (P < 0.0001). Annual age- and sex-adjusted incidence rates significantly increased by 15.9% per 3 years from 1986 to 2000, then significantly fell by -4.8% per 3 years from 2001-2012. The prevalence of GCA on December 31, 2012 was 87.9 (95% CI 75.8, 101.4). No significant differences in the mortality rates were observed between GCA patients (4.9 per 100 person-years [95% CI 4.1, 5.8]) and non-GCA subjects (5.6 [95% CI 4.7, 6.6]). No significant differences in causes of death were observed comparing GCA patients to non-GCA subjects. This large population-based study of biopsy-proven GCA confirmed the lower incidence of GCA in Mediterranean countries and did not observe any increased mortality risk.

Prospective randomized study of the effect of nebivolol on the incidence of late invasive mechanical ventilation in ischemic heart disease patients with acute exacerbation of chronic obstructive pulmonary disease

Background Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the USA and acute exacerbations result in more than 800 000 hospitalizations annually. The combination of COPD treatment often coexists with treatment for congestive heart failure or ischemic heart disease (IHD) and present complex therapeutic challenges. β2-Agonists, which are frequently used in the treatment of COPD, have the potential for adverse cardiovascular effects including ischemic events and arrhythmias. β-Blocker therapy improves symptoms and survival among patients with IHD and congestive heart failure, but is frequently withheld in patients with COPD. During an acute exacerbation of chronic obstructive pulmonary disease (AECOPD), patients may be particularly vulnerable to develop acute cardiac events due to increased use in β2-agonists, tachycardia, and hypoxemia. The addition of a cardioselective β-blocker, especially nebivolol, may have a cardioprotective effect in this population, blunting the cardiac toxicity of the β2-agonists. We evaluated the association of the cardioselective β-blocker nebivolol treatment with the incidence of late invasive ventilation among patients with IHD who were hospitalized for an AECOPD. Hypothesizing that the nebivolol as a highly selective β-blocker is not deleterious and is safe in the setting of AECOPD, we also compared the outcomes with patients who are not treated with nebivolol in the setting of AECOPD. Objective The aim of the paper was to study the incidence of late invasive mechanical ventilation among a group of ischemic heart disease patients with AECOPD who received oral nebivolol and compare the results with another group of patients with the same diagnosis who did not receive it. Patients and methods This study was conducted on 90 adult patients of both sexes, who were admitted to the Critical Care Medicine Department of Alexandria Main University Hospital after fulfilling the inclusion and exclusion criteria and obtaining an informed consent from patients’ relatives, and from the local ethics committee. Patients were subjected to full routine examination and categorized into two groups; each group comprised 45 patients using the sealed-envelop technique as a method for randomization of participants in both groups. Group I, patients who received oral nebivolol tablets on the first and/or second day of admission. Group II, patients who did not receive oral nebivolol tablets on the first and/or second day of admission. Results In comparing the patients in both groups, there was no statistically significant difference between them with regard to age, sex, comorbidities, and Acute Physiology and Chronic Health Evaluation II score on admission. Incidence of late invasive ventilation was the same between the case and the control groups. There was no significant difference in causes of intubation between both groups. There was no statistically significant reduction in the duration of invasive ventilation, ICU and hospital stay between both studied groups. Acute ischemic events showed no statistically significant reduction between case and control groups. Regarding in-hospital and 28-day mortality, there was no statistically significant difference between both studied groups. Conclusion Our results suggest that among the studied population of patients with AECOPD with underlying coronary artery disease, using oral nebivolol tablet seems to be safe as it does not cause worsening of the clinical condition of the patients regarding the incidence of late invasive mechanical ventilation or incidence of acute ischemic events. In addition, it does not affect the duration of ICU or hospital stay and showed no effect on in hospital or 28-day mortality.

Multicenter epidemiological investigation of hospitalized children with severe burn

Multicenter epidemiological investigation of hospitalized children with severe burn

What are the consequences of enlarging the extraction site to exteriorize a large specimen during laparoscopic surgery for Crohn's enteritis?

The implications of extraction site enlargement for the removal of large specimens during laparoscopic surgery for Crohn's disease have not been clearly described; such a description is the aim of this study. An institutional database was queried to identify patients undergoing laparoscopic resection for Crohn's disease through midline incision between 1995 and 2013. Perioperative outcomes were compared among cases completed through their initial extraction site (L), completed after increasing the length of the initial extraction site (IL) for specimen exteriorization, and cases converted to open surgery (C). Univariate and multivariate statistical analyses were performed. Out of 309 patients, 52 required IL and 36 required C. Heavier, older, male patients were more likely to require IL or C. There were no differences in disease behaviour (P=0.260), procedures performed (P=0.12) or postoperative morbidity (P=0.33). IL and L groups had a comparable initial length of hospital stay (LOS), which was shorter than in the C group. While there were no significant differences in causes of readmission (P=0.31), IL had increased readmission rates compared with L [odds ratio (OR) 2.80, P=0.021] or C (OR 13.89, P=0.015). When combining initial and readmission LOS, C and IL groups had comparable overall LOS [median ratio (MR) 1.09, P=0.57], which was significantly longer than in the L group (MR 1.27, P=0.02). Extraction site enlargement during laparoscopic surgery for enteric Crohn's disease had no impact on primary LOS. However, the shorter initial LOS was offset by increased readmission rates when compared with formal conversion. The threshold to convert in case of anticipated difficulty due to a large specimen should be low.

Causes of death in a contemporary cohort of patients with invasive aspergillosis.

Information regarding the processes leading to death in patients with invasive aspergillosis (IA) is lacking. We sought to determine the causes of death in these patients, the role that IA played in the cause, and the timing of death. The factors associated with IA-related mortality are also analyzed. We conducted a multicenter study (2008-2011) of cases of proven and probable IA. The causes of death and whether mortality was judged to be IA-related or IA-unrelated were determined by consensus using a six-member review panel. A multivariate analysis was performed to determine risk factors for IA-related death. Of 152 patients with IA, 92 (60.5%) died. Mortality was judged to be IA-related in 62 cases and IA-unrelated in 30. The most common cause of IA-related death was respiratory failure (50/62 patients), caused primarily by Aspergillus infection, although also by concomitant infections or severe comorbidities. Progression of underlying disease and bacteremic shock were the most frequent causes of IA-unrelated death. IA-related mortality accounted for 98% and 87% of deaths within the first 14 and 21 days, respectively. Liver disease (HR 4.54; 95% CI, 1.69-12.23) was independently associated with IA-related mortality, whereas voriconazole treatment was associated with reduced risk of death (HR 0.43; 95% CI, 0.20-0.93). In conclusion, better management of lung injury after IA diagnosis is the main challenge for physicians to improve IA outcomes. There are significant differences in causes and timing between IA-related and IA–unrelated mortality and these should be considered in future research to assess the quality of IA care.

484 Rates of self-reported burnout amongst urologists in Ireland and the United Kingdom – a comparative cohort study

INTRODUCTION & OBJECTIVES: Burnout was first coined (1947) to describe the declining levels of performance exhibited by professionals who had expended themselves on their occupation. Burnout has been shown to affect the personal lives of doctors, and is associated with a reduced quality of life, broken relationships, substance abuse, increased levels of myocardial infarction, anxiety and suicidal ideation, as well as an Increase in medical error and litigation, decreased empathy, job withdrawal, decreased productivity and increased absenteeism. Whilst many surgeons may believe that they are less susceptible to the effects of burnout compared with other specialities, the traits that define some of their success such as commitment, drive and self-sacrifice place them in a vulnerable position. RESULTS: A total of 575 urologists responded out of a total of 1437 invites (40% response rate). All respondents were below 75 years of age (Median age: 45), with males representing 87.5% of respondents. 75% respondents worked in England, followed by the Republic of Ireland (9%), Scotland (8%), Northern Ireland (4%) and Wales (3%). 79% respondents were consultants, with 13% representing training posts. 40% respondents held a professorship/clinical lead position. Overall, the mean emotional exhaustion score was 23.5 and the mean depersonalisation score was 8.2, representing moderate levels of each. The mean personal achievement score was 17.1, which is considered high. 15% (n=86) reported self-medication with nonprescription drugs or alcohol to combat signs and symptoms of burnout. 8% (n=46) sought professional help for symptoms of burnout. 80% respondents (n=460) felt that burnout should be evaluated amongst members of BAUS/ISU, and 60% (n=345) would avail of counselling. There were significant differences in causes of burnout between non-consultant hospital doctors and consultants, however the overall most commonly given reasons were an excessive administrative workload, a high volume of work, a lack of institutional resources, a poor worklife balance, and inadequate support/communication with institutional management. CONCLUSIONS: This is the first study to address the issue of burnout across two separate health systems. This study has demonstrated high levels of burnout, with significant levels of self-medication amongst a male-predominant cohort. Burnout was attributed to administrative/institutional factors, with the majority of respondents reporting support for evaluation and the provision of counseling services. This study lends itself to the creation of risk stratification for urologists, and an opportunity to provide educational resources, and collegial and administrative support pathways. Further study is needed within to assess the link between burnout and patient safety and surgical

Regional differences in use and outcomes of left ventricular assist devices: Insights from the Interagency Registry for Mechanically Assisted Circulatory Support Registry

We examined whether characteristics, implant strategy, and outcomes in patients who receive continuous-flow left ventricular assist devices (CF-LVAD) differ across geographic regions in the United States. A total of 7,404 CF-LVAD patients enrolled in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) from 134 participating institutions were analyzed from 4 distinct regions: Northeast, 2,605 (35%); Midwest, 2,210 (30%); West, 973 (13%); and South, 1,616 (22%). At baseline, patients in the Northeast and South were more likely to have INTERMACS risk profiles 1 and 2. A bridge-to-transplant (BTT) strategy was more common in the Northeast (31.7%; West, 18.5%; South, 26.9%; Midwest, 25.5%; p < 0.0001). In contrast, destination therapy (DT) was more likely in the South (40.6%; Northeast, 32.3%; Midwest, 27.3%; West, 27.3%; p < 0.0001). Although all regions showed a high 1-year survival rate, some regional differences in long-term mortality were observed. Notably, survival beyond 1 year after LVAD implant was significantly lower in the South. However, when stratified by device strategy, no significant differences in survival for BTT or DT patients were found among the regions. Finally, with the exception of right ventricular failure, which was more common in the South, no other significant differences in causes of death were observed among the regions. Regional differences in clinical profile and LVAD strategy exist in the United States. Despite an overall high survival rate at 1 year, differences in mortality among the regions were noted. The lower survival rate in the South may be attributed to patient characteristics and higher use of LVAD as DT.

Characteristics of pediatric noniatrogenic pneumomediasinum

Purpose: Pneumomediastinum is rare in children and adolescents, and its causes have not yet been clearly determined. We aimed to identify the causes, clinical manifestations and prognosis of noniatrogenic pneumomediastinum in children. Methods: From February 2007 to June 2014, we retrospectively investigated 121 patients with pneumomediastinum under 18 years of age in 2 hospitals. Eighteen patients with pneumomediastinum after thoracotomy and 35 patients with iatrogenic pneumomediastinum were excluded. Results: Sixty-eight patients were divided into 4 age groups: those under 1 year of age (n= 9, 13.2%), those 1 to 5 years of age (n= 9, 13.2%), those 6 to 10 years of age (n= 17, 25.0%) and those over 11 years of age (n= 33, 48.5%). Chest pain (n= 43, 63.2%) was the most common initial complaint and subcutaneous emphysema was identified in 18 patients (26.5%). Chest x-ray was diagnostic in all except 9 patients (13.2%). Predisposing causes of pneumomediastinum were idiopathic (n= 26, 38.2%), respiratory tract infection (n= 23, 33.8%), asthma exacerbation (n= 4, 5.9%), trauma (n= 4, 5.9%), endobronchial foreign body (n= 2, 2.9%), interstitial lung disease (n= 5, 7.4%), and neonatal respiratory disease (n= 4, 5.9%). Chest pain (P< 0.001) and idiopathic cause (P= 0.001) were shown to linearly increase with age. On the contrary, tachypnea (P< 0.001), dyspnea (P= 0.016), and interstitial lung disease (P= 0.008) were shown to have a decreasing linear association with age. The length of hospital stay was significantly increased in patients with interstitial lung disease (P= 0.042), those with pneumothorax (P= 0.044), and those without chest pain (P= 0.013). Conclusion: According to age groups, there were significant differences in causes and clinical manifestations. In particular, pneumomediastinum that developed in younger patients with interstitial lung disease showed unfavorable outcomes, such as dyspnea, pneumothorax, and increased length of hospital stay. Therefore, precise evaluation of predisposing causes and careful management are needed for children with pneumomediastinum. (Allergy Asthma Respir Dis 2015;3:145-150)

A randomised double blind controlled trial comparing rifaximin plus lactulose with lactulose alone in treatment of hepatic encephalopathy

Background and Aims: Hepatic encephalopathy (HE) is associated with poor prognosis in cirrhosis. Majority of the drugs used in the treatment of HE are primarily directed at the reduction or elimination of the blood ammonia levels. We evaluated the efficacy and safety of rifaximin plus lactulose versus lactulose alone for treatment of overt hepatic encephalopathy. Methods: In prospective double blind randomized controlled trial, 120 patients with overt HE were randomized in 2 groups, group 1- lactulose (n=57) and group 2- lactulose plus rifaximin (n=63). Primary end point was reversal of hepatic encephalopathy. Secondary end points were mortality and hospital stay. Results: One hundred and twenty patients (mean age 39.4 ± 9.6 years; M: F 89:31) were included in study. Thirty seven (30.8%) patients were in Child-Turcotte-Pugh (CTP) class B and 83 (69.2%) were in CTP Class C. Mean CTP score was 9.7 ± 2.8 and MELD score was 24.6 ± 4.2. 22 (18.3%) had grade 2, 40 (33.3%) had grade 3 and 58 (48.3%) had grade 4 HE at the time of admission. Forty eight (76%) patients in group 2 compared to 29 (50.8%) patients in group 1 had reversal of HE (P<0.004). There was significant decrease in mortality after treatment with lactulose plus rifaximin versus lactulose alone (23.8% Vs 49.1%, P <0.05). Most common cause of death was sepsis (n=43, 55.8%), followed by hepatorenal syndrome (n=11, 25.6%) and GI bleed (n=8, 18.6%). There was no significant difference in cause of death in two groups. Patients in latulose plus rifaximin group had shorter hospital stay (5.8 ± 3.4 vs. 8.2 ± 4.6 days, P =0.001). Conclusions: Combination of lactulose plus rifaximin is more effective than lactulose alone in treatment of HE.