Simplified risk-prediction for benchmarking and quality improvement in emergency general surgery. Prospective, multicenter, observational cohort study

BACKGROUND AND AIMS

Emergency General Surgery (EGS) conditions account for millions of deaths worldwide, yet it is practiced without benchmarking-based quality improvement programs. The aim of this observational, prospective, multicenter, nationwide study was to determine the best benchmark cutoff points in EGS, as a reference to guide improvement measures.

METHODS

Over a 6-month period, 38 centers (5% of all public hospitals) attending EGS patients on a 24-h, 7-days a week basis, enrolled consecutive patients requiring an emergent/urgent surgical procedure. Patients were stratified into cohorts of low (i.e., expected morbidity risk <33%), middle and high risk using the novel m-LUCENTUM calculator.

RESULTS

A total of 7258 patients were included; age (mean ± SD) was 51.1 ± 21.5 years, 43.2% were female. Benchmark cutoffs in the low-risk cohort (5639 patients, 77.7% of total) were: use of laparoscopy ≥40.9%, length of hospital stays ≤3 days, any complication within 30 days ≤ 17.7%, and 30-day mortality ≤1.1%. The variables with the greatest impact were septicemia on length of hospital stay (21 days; adjusted beta coefficient 16.8; 95% CI: 15.3 to 18.3; P < .001), and respiratory failure on mortality (risk-adjusted population attributable fraction 44.6%, 95% CI 29.6 to 59.6, P < .001). Use of laparoscopy (odds ratio 0.764, 95% CI 0.678 to 0.861; P < .001), and intraoperative blood loss (101-500 mL: odds ratio 2.699, 95% CI 2.152 to 3.380; P < .001; and 500-1000 mL: odds ratio 2.875, 95% CI 1.403 to 5.858; P = .013) were associated with increased morbidity.

CONCLUSIONS

This study offers, for the first time, clinically-based benchmark values in EGS and identifies measures for improvement.

HIV infection is associated with lower risk of hepatocellular carcinoma after sustained virological response to direct-acting antivirals in hepatitis C infected-patients with advanced fibrosis

BACKGROUND

The aim of this study was to assess the impact of HIV infection on the risk of developing hepatocellular carcinoma (HCC) in HCV-infected patients who achieve sustained virological response (SVR) with direct-acting antiviral (DAA).

METHODS

Multisite prospective cohort study, where HCV-monoinfected patients and HIV/HCV-coinfected individuals were included if they met: 1) SVR with DAA-based combination; 2) Liver stiffness (LS) ≥9.5 kPa previous to treatment; 3) LS measurement at the SVR time-point. The main endpoint was the occurrence of HCC. Propensity score (PS) was calculated to address potential confounders due to unbalanced distribution of baseline characteristics of HIV/HCV-coinfected and HCV-monoinfected patients.

RESULTS

1035 HCV-infected patients were included, 667 (64%) coinfected with HIV. After a median (Q1-Q3) follow-up time of 43 (31-49) months, 19 (1.8%) patients developed HCC [11 (3.0%) HCV-monoinfected, 8(1.2%) HIV/HCV-coinfected individuals; p=0.013]. In the multivariable analysis, HIV co-infection was associated with a lower adjusted risk of developing HCC [sHR=0.27, 95% IC (0.08-0.90); p=0.034]. Predictors of HCC emergence were: HCV genotype 3 [sHR=7.9 (2.5-24.9); p<0.001], MELD score at SVR>10 [sHR=1.37 (1.01-1.86); p=0.043] and LS value at SVR [sHR=1.03 (1.01-1.06) for 1 kPa increase; p=0.011]. Using inverse probability weighting method on the PS, HIV-infected patients had a lower risk of HCC [powered HR=0.33 (0.11-0.85)].

CONCLUSIONS

Among HCV-infected patients with advanced fibrosis, who achieve SVR with DAA, HIV-coinfection seems to be associated with a lower risk of HCC occurrence. The underlying causes for this finding need to be investigated.

Liver Stiffness at the Time of Sustained Virological Response Predicts the Clinical Outcome in People Living With Human Immunodeficiency Virus and Hepatitis C Virus With Advanced Fibrosis Treated With Direct-acting Antivirals

Background

Some people living with hepatitis C virus (HCV) with sustained virological response (SVR) develop hepatic complications. Liver stiffness (LS) predicts clinical outcome in people living with human immunodeficiency virus (HIV) with active HCV coinfection, but information after SVR is lacking. We aimed to analyze the predictive ability of LS at SVR for liver complications in people living with HIV/HCV with advanced fibrosis treated with direct-acting antivirals (DAA).

Methods

In sum, 640 people living with HIV/HCV fulfilling the following criteria were included: (i) Achieved SVR with DAA-including regimen; (ii) LS ≥ 9.5 kPa before therapy; and (iii) LS measurement available at SVR. The primary endpoint was the occurrence of a liver complication—hepatic decompensation or hepatocellular carcinoma (HCC)—or requiring liver transplant after SVR.

Results

During a median (Q1–Q3) follow-up of 31.6 (22.7–36.6) months, 19 (3%) patients reached the primary endpoint. In the multivariate analysis, variables (subhazard ratio [SHR] [95% confidence interval]) associated with developing clinical outcomes were: prior hepatic decompensations (3.42 [1.28–9.12]), pretreatment CPT class B or C (62.5 [3.08–1246.42]) and MELD scores (1.37 [1.03–1.82]), CPT class B or C at SVR (10.71 [1.32–87.01]), CD4 cell counts &lt;200/µL at SVR time-point (4.42 [1.49–13.15]), FIB-4 index at SVR (1.39 [1.13–1.70]), and LS at SVR (1.05 [1.02–1.08] for 1 kPa increase). None of the 374 patients with LS &lt;14kPa at SVR time-point developed a liver complication or required hepatic transplant.

Conclusions

LS at the time of SVR after DAA therapy predicts the clinical outcome of people living with HIV/HCV with advanced fibrosis. These results suggest that LS measurement may be helpful to select candidates to be withdrawn from surveillance programs.

Prevalence and distribution of hepatitis C virus genotypes in Spain during the 2000-2015 period (the GEHEP 005 study)

We report the largest study on the prevalence and distribution of HCV genotypes in Spain (2000-2015), and we relate them with clinical, epidemiological and virological factors. Patients from 29 hospitals in 10 autonomous communities (Andalusia, Aragon, Castilla-Leon, Catalonia, Galicia, Canary Islands, Madrid Community, Valencian Community, Murcia Region and Basque Country) have been studied. Annual distribution of HCV genotypes and subtypes, as well as gender, age, transmission route, HIV and/or HBV coinfection, and treatment details were recorded. We included 48595 chronically HCV-infected patients with the following characteristics: median age 51 years (IQR, 44-58), 67.9% male, 19.1% HIV-coinfected, 23.5% HBV-coinfected. Parenteral transmission route was the most frequent (58.7%). Genotype distribution was 66.9% GT1 (24.9% subtype 1a and 37.9% subtype 1b), 2.8% GT2, 17.3% GT3, 11.4% GT4 and 0.1% GT5 and 0.02% GT6. LiPA was the most widely HCV genotyping test used (52.4%). HCV subtype 1a and genotypes 3 and 4 were closely associated with male gender, parenteral route of infection and HIV and HBV coinfection; in contrast, subtype 1b and genotype 2 were associated with female gender, nonparenteral route and mono-infection. Age was related to genotype distribution, and different patterns of distribution and biodiversity index were observed between different geographical areas. Finally, we describe how treatment and changes in transmission routes may have affected HCV genotype prevalence and distribution patterns. We present the most recent data on molecular epidemiology of hepatitis C virus in Spain. This study confirms that genotype distributions vary with age, sex, HIV and HBV coinfection and within geographical areas and epidemiological groups.

Isolation of Mycoplasma hominis from extragenital cultures

In order to document the characteristics of extragenital Mycoplasma hominis infections, the clinical features of 36 cases in which M. hominis was isolated from extragenital sites of adult patients were reviewed. In most cases, the organism was detected in conventional bacterial cultures (from specimens obtained from surgical and immunosuppressed patients) that had been incubated for at least 72 h. The results indicate that in cases in which M. hominis involvement is suspected, prolonged incubation or specialized microbiological techniques for detecting Mycoplasma spp. should be employed.

[Simplified method for the processing of sputum in the diagnosis of tuberculosis]

OBJECTIVE

We evaluated a simplified method for processing three serial sputum samples as a single sample, and compare the results with those obtained when processing three samples individually.

MATERIAL AND METHODS

During a 32-week period, we studied 867 sputum samples from 289 patients with pulmonary tuberculosis suspicious. Samples from 148 patients (n = 444) were processed by simplified method, and samples from 141 patients (n = 423) were processed by individually method. All cultures were processed by ESP Culture System II (Difco Laboratories, USA).

RESULTS

Seven mycobacterium's strains were isolated by individually method. Simplified method detected another seven strains. In both cases, four strains were identified as Mycobacterium tuberculosis. Mean time to detection mycobacteria were 21.5 and 24 days for simplified and individually method, respectively. Cultures from 21 patients were contaminated (11 patients by simplified method and 10 patients by individually method). Mean time to detection contaminated cultures were 8 days and 7.5 days for simplified and individually method, respectively.

CONCLUSION

Simplified method may be a useful alternative in laboratories that must handle increasing numbers of samples, without decline in diagnostic performance.

Effect of the addition of vancomycin on the performance of an automated nonradioactive system for detection of mycobacteria

A recently developed automated, nonradioactive system for the detection of mycobacteria (MB/BacT; Organon Teknika, Belgium) has provided good results, but the contamination rate was found to be higher than that obtained with the radiometric Bactec 460 system (Becton Dickinson, USA). In the present study, the effects of adding vancomycin (1 microg/ml) to the antibiotic mixture of the nonradioactive system were evaluated, and the performance of the system with versus without vancomycin was compared. Three hundred sputum samples were tested, using the radiometric system as the reference method. Mycobacteria were isolated from 47 (15.7%) samples. The nonradioactive system with and without vancomycin detected 42 and 43 strains, respectively; the time to detection was 1 day shorter with the medium without vancomycin (15.7 days vs. 14.3 days). The radiometric system detected 42 strains of mycobacteria in a mean detection time of 13.6 days. Contamination rates with the nonradioactive system were 6.7% in the medium without vancomycin and 2.7% in the medium with vancomycin. The latter figure was approximately the same as the contamination rate found with the radiometric system (2.3%). Our data suggest that the addition of vancomycin considerably reduces the number of contaminants in the MB/BacT medium without affecting the performance of the system.

[Utility of bronchoalveolar lavage in the diagnosis of respiratory infection in HIV patients]

From January 1, 1992, to December 31, 1995, we studied 52 bronchoalveolar lavages in 45 HIV-infected patients. All patients with pulmonary symptoms and/or new pulmonary infiltrates underwent bronchoalveolar lavage (BAL) when the results of blood cultures and mycobacterial smears of sputum and urine were negative. Lavage fluid was investigated for the presence of P. carinii, bacteria, mycobacteria, fungi and virus. BAL was diagnostic in 39 (75%) cases. The organisms more frequently isolated were P. carinii and M. tuberculosis. Only one pathogen was identified in 28 cases (54%); two in ten (19%); and three in one patient (2%). BAL was, generally, well tolerated by the patient and had a high diagnostic yield in the evaluation of patients with HIV infection and respiratory symptoms.

Posthysterectomy wound infection. A review

We reviewed the microorganisms isolated from gynecologic surgery wounds showing signs of infection, from January to December 1990. A total of 88 samples of abdominal wall exudates from as many patients who had undergone abdominal hysterectomy were studied. In 54 women (61.3%), cultures were positive and, in 26 specimens (48.1%), mixed aerobic-anaerobic flora were isolated. In 28 cases (51.9%), a single microorganism was isolated, the most frequent being Staphylococcus aureus, followed by Mycoplasma hominis and Escherichia coli. Mycoplasma hominis was unexpectedly frequent, appearing in five women with wall abscess and fever.

[Quantification of the levels of p24 antigen and antibodies in human immunodeficiency virus infection]

BACKGROUND

Quantification and clinical evaluation of p24 antigen and anti-HIV antibody levels.

METHODS

Follow up of 13 HIV infected patients (53 sera) by determination of p24 antigen, total anti-HIV antibodies, anti-p24 and anti-env antibodies by ELISA and their semiquantitation. IgG and IgM class antibody determination by immunoblot techniques.

RESULTS

The highest levels of p24 have been found in WR 1 and WR 6 stages. Commonly accepted serologic pattern has not been found in 100% of our cases. Western-blot is more sensitive for the detection of anti-p24 antibodies.

CONCLUSIONS

p24 antigen appearance and a decrease in anti-p24 antibody level is related to a worse clinical prognosis. p24 antigen quantification is a usefull test for monitoring AZT therapy in patients suffering from AIDS.

[Antimicrobial activity of ornidazole and 6 other antibiotics against anaerobic bacteria]

The antimicrobial susceptibility of 235 anaerobic bacterial strains to ornidazole, metronidazole, chloramphenicol, clindamycin, penicillin, cefoxitin and imipenem has been studied using agar-dilution technique. Ornidazole and metronidazole were active against 88.6% and 86% of gram-positive cocci. Overall, 99.1% of Bacteroides group fragilis, and 91.3% of non-fragilis Bacteroides were also sensitive to both drugs. We did not find any Clostridium perfringens resistant strain. Cefoxitin and penicillin showed good activity against all Clostridium perfringens strains, and also against 97.7% and 92.5% of gram-positive cocci. We found one single imipenem resistant strain among gram-positive bacteria. Bacteroides fragilis also showed sensitivity to penicillin (41.5%), cefoxitin (85.7%) and imipenem (97.1%). Clindamycin was active against Clostridium perfringens (90.9%), gram-positive cocci (86.7%) and imipenem (68.6%). Chloramphenicol showed good activity against Clostridium perfringens (100%), gram-positive cocci (95.5%) and Bacteroides spp. (99.4%). Our results showed an overall good activity of all the seven drugs tested against anaerobic gram-positive microorganisms. Of notice, we found a good activity of chloramphenicol, imipenem, metronidazole and ornidazole against Bacteroides spp.

Post-antibiotic effect of three quinolones against gram negative isolates from urine

The post-antibiotic effect (PAE) is defined as the bacterial growth suppression which persists after a limited exposure to an antimicrobial agent. The PAE and the bactericidal effect of the quinolones ciprofloxacin, norfloxacin and nalidixic acid have been studied against several urinary isolates of Gram-negative bacteria. The PAE was determined after one hour's exposure to the antimicrobial agent using an initial inoculum of 10(5) to 10(6) cfu/ml; the drug was rapidly removed by a 10(-2) dilution technique in antibiotic-free medium. When ciprofloxacin was used at four times its MIC the PAEs were 1.37 +/- 0.09; 2.45 +/- 0.63 and 2.86 +/- 0.15 h against Esch. coli, Klebs. pneumoniae and Pseudomonas aeruginosa, respectively. We found lower values for norfloxacin under the same conditions, and nalidixic acid did not induce a significative PAE. These results could support changes in dosing intervals of norfloxacin and ciprofloxacin, with possibly greater intervals between doses.

Metabolic changes induced by urethane-anesthesia in rats

1. Fasting hyperglycemia was observed in urethane-anesthetized rats. No significant changes had been observed in fed animals. The effect is dose-dependent, being ineffective doses lesser than 1.4 g/kg of body weight. 2. Urethane originates a rise in glycemia during the first 10 min of anesthesia followed by control values at 30 min, and a latter hyperglycemic phase for more than 60 min that remain at 2 hr. 3. The negative correlationship between plasma glucose, lactate and amino acid levels suggest that gluconeogenesis may be the main responsibility of the observed hyperglycemia during the first phase, but it is possible that during the second phase a decrease in the consumption of glucose may take place as a consequence of the competitive effects of ketone bodies increased during the first 30 min of anesthesia. 4. We postulate that the mechanism of the hyperglycemic response to urethane is a sympathetic response with release of catecholamines both in the liver and in the adrenal gland which enhances gluconeogenesis and lipolysis.