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Tolosa JE, Boelig RC, Bell J, Martínez-Baladejo M, Stoltzfus J, Mateus J, Quiñones JN, Galeano-Herrera S, Pereira L, Burwick R, López-Torres L, Valencia C, Berghella V. Concurrent progestogen and cerclage to reduce preterm birth: a multicenter international retrospective cohort. Am J Obstet Gynecol MFM 2024:101351. [PMID: 38513806 DOI: 10.1016/j.ajogmf.2024.101351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 02/21/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Both progestogens and cerclage are individually effective in preterm birth prevention in high risk pregnancies. However, national and international guidelines cite a lack of data available to comment on the potential benefit of concurrent progestogen therapy after cerclage has been placed. Studies to date have been small with mixed results regarding benefit of concurrent progestogen with cerclage leaving uncertainty regarding best clinical practice. OBJECTIVE This study aimed to evaluate whether cerclage with progestogen therapy was superior to cerclage alone in the prevention of spontaneous preterm birth in singleton pregnancies. METHODS This is an international retrospective cohort study of singleton pregnancies, without major anomaly or aneuploidy, and with cerclage placed at 10 different institutions in the United States and Colombia from June 2016 to June 2020. Exclusion criteria were lack of documentation regarding whether progestogen was prescribed, unavailable delivery outcome, and pregnancy termination (spontaneous or induced) before 16 weeks' gestation. The exposure of interest was progestogen use with cerclage placement, which included those who continued to use progestogen or who started progestogen after cerclage. The comparison group consisted of those without progestogen use after cerclage placement, which included those who had no progestogen use during the entire pregnancy or who initiated progestogen and then stopped it after cerclage placement. Progestogen type, cerclage indication, maternal baseline characteristics, and maternal/neonatal outcomes were collected. The primary outcome was spontaneous preterm birth at <37 weeks. The secondary outcomes were spontaneous preterm birth at <34 weeks, gestational age at delivery, and a composite neonatal outcome including ≥1 of the following: perinatal mortality, confirmed sepsis, grade III or IV intraventricular hemorrhage, retinopathy of prematurity, respiratory distress syndrome, and bronchopulmonary dysplasia. There were planned subgroup analyses by cerclage indication, progestogen type (vaginal progesterone vs 17-hydroxyprogesterone caproate), preterm birth history, and site. Continuous variables were compared in adjusted analyses with analysis of covariance, and categorical variables were compared with multivariable logistic regression, adjusting for potential confounders with adjusted odds ratio. A Cox regression survival curve was generated to compare latency to spontaneous delivery, censored after 37 weeks. RESULTS During the study period, a total of 699 singletons met the inclusion criteria: 561 in the progestogen with cerclage group and 138 with cerclage alone. Baseline characteristics were similar, except the higher likelihood of previous spontaneous preterm birth in the progestogen group (61% vs 41%; P<.001). Within the progestogen group, 52% were on 17-hydroxyprogesterone caproate weekly, 44% on vaginal progesterone daily, and 3% on oral progesterone daily. Progestogen with cerclage was associated with a significantly lower frequency of spontaneous preterm birth <37 weeks (31% vs 39%; adjusted odds ratio, 0.59 [0.39-0.89]; P=.01) and <34 weeks (19% vs 27%; adjusted odds ratio, 0.55 [0.35-0.87]; P=.01), increased latency to spontaneous delivery (hazard ratio for spontaneous preterm birth <37 weeks, 0.66 [0.49-0.90]; P=.009), and lower frequency of perinatal death (7% vs 16%; adjusted odds ratio, 0.37 [0.20-0.67]; P=.001). In planned subgroup analyses, association with reduced odds of preterm birth <37 weeks persisted in those on vaginal progesterone, those without a previous preterm birth, those with ultrasound- or examination-indicated cerclage, those who started progestogen therapy before cerclage, and in sites restricted to the United States. CONCLUSION Use of progestogen with cerclage was associated with reduced rates of spontaneous preterm birth and early spontaneous preterm birth compared with cerclage alone. Although this study was not sufficiently powered for subgroup analysis, the strength of evidence for benefit appeared greatest for those with ultrasound- or examination-indicated cerclage, and with vaginal progesterone.
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Affiliation(s)
- Jorge E Tolosa
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, St. Luke's University Health Network, Bethlehem, PA (Drs Tolosa and Bell); Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR (Drs Tolosa and Pereira); FUNDARED-MATERNA, Bogotá, Colombia (Drs Tolosa, Burwick, and Valencia)
| | - Rupsa C Boelig
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Philadelphia, PA (Drs Boelig and Berghella).
| | - Joseph Bell
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, St. Luke's University Health Network, Bethlehem, PA (Drs Tolosa and Bell)
| | - María Martínez-Baladejo
- Departments of Research and Innovation and Obstetrics and Gynecology, St. Luke's University Health Network, Bethlehem, PA (Dr Martínez-Baladejo)
| | - Jill Stoltzfus
- Graduate Medical Education Data Measurement and Outcomes Assessment, Lewis Katz School of Medicine at Temple University/St. Luke's University Health Network, Bethlehem, PA (Dr Stoltzfus)
| | - Julio Mateus
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Atrium Health, Wake Forest University School of Medicine, Charlotte, NC (Dr Mateus)
| | - Joanne N Quiñones
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Lehigh Valley Health Network, Allentown, PA (Dr Quiñones)
| | - Santiago Galeano-Herrera
- Departamento de Ginecología y Obstetricia, Clínica del Prado, Universidad Remington, Medellín, Colombia (Dr Galeano-Herrera)
| | - Leonardo Pereira
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR (Drs Tolosa and Pereira)
| | - Richard Burwick
- Division of Maternal Fetal Medicine, San Gabriel Valley Perinatal Medical Group, Pomona Valley Hospital Medical Center, Pomona, CA (Dr Burwick); FUNDARED-MATERNA, Bogotá, Colombia (Drs Tolosa, Burwick, and Valencia)
| | - Luisa López-Torres
- Departamento de Ginecología y Obstetricia, Medicina Materno-Fetal, Universidad Pontificia Bolivariana, Medellín, Colombia (Dr López-Torres)
| | - Catalina Valencia
- Universidad CES, Clínica del Prado, Medellín, Colombia (Dr Valencia); FUNDARED-MATERNA, Bogotá, Colombia (Drs Tolosa, Burwick, and Valencia)
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Philadelphia, PA (Drs Boelig and Berghella)
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Bauerle WB, Reese V, Stoltzfus J, Benton A, Knipe J, Wilde-Onia R, Castillo R, Thomas P, Cipolla J, Braverman MA. Effect of Standardized Reminder Calls on Trauma Patient No-Show Rate. J Am Coll Surg 2024; 238:236-241. [PMID: 37861231 DOI: 10.1097/xcs.0000000000000898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
BACKGROUND Most patients who sustain a traumatic injury require outpatient follow-up. A common barrier to outpatient postadmission care is patient failure to follow-up. One of the most significant factors resulting in failure to follow-up is age more than 35 years. Recent work has shown that follow-up telephone calls reduce readmission rates. Our aim was to decrease no-show appointments by 10% in 12 months. STUDY DESIGN The electronic medical records at our level I and II trauma centers were queried for all outpatient appointments for trauma between July 1, 2020, and June 9, 2021, and whether the patient attended their follow-up appointment. Patients with visits scheduled after August 1, 2021, received 24- and 48-hour previsit reminder calls. Patients with visits scheduled between July 1, 2020, and August 1, 2021, did not receive previsit calls. Both groups were compared using multivariable direct logistic regression models. RESULTS A total of 1,822 follow-up opportunities were included in the study. During the pre-implementation phase, there was a no-show rate of 30.9% (329 of 1,064 visits). Postintervention, a 12.2% reduction in overall no-show rate occurred. A statistically significant 11.2% decrease (p < 0.001) was seen in elderly patients. Multivariate analysis showed standardized calls resulted in significantly decreased odds of failing to keep an appointment (adjusted odds ratio = 0.610, p < 0.001). CONCLUSIONS Reminder calls led to a 12.2% reduction in no-show rate and were an independent predictor of a patient's likelihood of attending their appointment. Other predictors of attendance included insurance status and abdominal injury.
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Affiliation(s)
- Wayne B Bauerle
- From the Department of Surgery (Bauerle), St. Luke's University Health Network, Bethlehem, PA
| | - Vanessa Reese
- Department of Research and Innovation (Reese), St. Luke's University Health Network, Bethlehem, PA
| | - Jill Stoltzfus
- Department of Graduate Medical Education (Stoltzfus), St. Luke's University Health Network, Bethlehem, PA
| | - Adam Benton
- Department of Surgery, Division of Trauma and Acute Care Surgery (Benton, Knipe, Wilde-Onia, Castilllo, Thomas, Cipolla, Braverman), St. Luke's University Health Network, Bethlehem, PA
| | - Joshua Knipe
- Department of Surgery, Division of Trauma and Acute Care Surgery (Benton, Knipe, Wilde-Onia, Castilllo, Thomas, Cipolla, Braverman), St. Luke's University Health Network, Bethlehem, PA
- Department of Trauma Surgery (Knipe, Wilde-Onia, Castillo, Thomas, Cipolla, Braverman), St. Luke's University Health Network, Bethlehem, PA
| | - Rebecca Wilde-Onia
- Department of Surgery, Division of Trauma and Acute Care Surgery (Benton, Knipe, Wilde-Onia, Castilllo, Thomas, Cipolla, Braverman), St. Luke's University Health Network, Bethlehem, PA
- Department of Trauma Surgery (Knipe, Wilde-Onia, Castillo, Thomas, Cipolla, Braverman), St. Luke's University Health Network, Bethlehem, PA
| | - Roberto Castillo
- Department of Surgery, Division of Trauma and Acute Care Surgery (Benton, Knipe, Wilde-Onia, Castilllo, Thomas, Cipolla, Braverman), St. Luke's University Health Network, Bethlehem, PA
- Department of Trauma Surgery (Knipe, Wilde-Onia, Castillo, Thomas, Cipolla, Braverman), St. Luke's University Health Network, Bethlehem, PA
| | - Peter Thomas
- Department of Surgery, Division of Trauma and Acute Care Surgery (Benton, Knipe, Wilde-Onia, Castilllo, Thomas, Cipolla, Braverman), St. Luke's University Health Network, Bethlehem, PA
- Department of Trauma Surgery (Knipe, Wilde-Onia, Castillo, Thomas, Cipolla, Braverman), St. Luke's University Health Network, Bethlehem, PA
| | - James Cipolla
- Department of Surgery, Division of Trauma and Acute Care Surgery (Benton, Knipe, Wilde-Onia, Castilllo, Thomas, Cipolla, Braverman), St. Luke's University Health Network, Bethlehem, PA
- Department of Trauma Surgery (Knipe, Wilde-Onia, Castillo, Thomas, Cipolla, Braverman), St. Luke's University Health Network, Bethlehem, PA
| | - Maxwell A Braverman
- Department of Surgery, Division of Trauma and Acute Care Surgery (Benton, Knipe, Wilde-Onia, Castilllo, Thomas, Cipolla, Braverman), St. Luke's University Health Network, Bethlehem, PA
- Department of Trauma Surgery (Knipe, Wilde-Onia, Castillo, Thomas, Cipolla, Braverman), St. Luke's University Health Network, Bethlehem, PA
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Liaquat H, Harmouch F, Patel N, Prenatt Z, Stoltzfus J, Geme B, Martins N, Chaput K. Association of Metabolic Syndrome Components and Colonic Diverticulosis in the Very Elderly: A Tertiary Health Network Study. Cureus 2024; 16:e51610. [PMID: 38313910 PMCID: PMC10837053 DOI: 10.7759/cureus.51610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2023] [Indexed: 02/06/2024] Open
Abstract
Introduction There is scarce data about the association of metabolic syndrome (MetS) or its components with the development of colonic diverticulosis (CD) in the elderly. We aim to determine the association of MetS and its components with CD in the elderly aged ≥75 years. Methods We conducted a retrospective chart review at St. Luke's University Health Network to identify patients who underwent a colonoscopy between 2011 and 2020. We collected data on patient demographics, comorbidities, and colonoscopy findings. Statistical analyses were conducted to compute means and frequencies of patient characteristics and rates of CD, as well as to test for associations between potential risk factors and the presence of CD. Results A total of 1239 patients were included with a median age of 80 years, 57.6% females, 89.5% Caucasians, 72.9% with CD, and 66.7% having a left-sided disease. On bivariate analysis, the older age group (p=0.02), Caucasian ethnicity (p=0.01), and hypertension (p=0.04) were found to be significant risk factors for developing CD. Multivariate regression analysis showed older age group and hypertension (OR=1.47, 95% CI: 1.66-2.02, p=0.02) were major risk factors. A significant proportion of patients with left-sided disease had Caucasian ethnicity (p<0.001), while female gender, obesity, and iron deficiency anemia were also seen more frequently, although without statistical significance. Conclusion In the elderly (>75 years old), our study found hypertension to be associated with an increased risk of CD, while impaired fasting glucose (IFG) was protective. Most patients exhibited isolated left-sided diverticulosis, with pan-diverticulosis associated with higher proportions of adverse health indicators, including American Society of Anesthesiologists (ASA) score ≥3, IFG, hypertriglyceridemia, hypertension, and hypothyroidism. Further research with larger sample sizes in similar age groups is needed to expand upon these findings.
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Affiliation(s)
- Hammad Liaquat
- Gastroenterology, St. Luke's University Health Network, Bethlehem, USA
| | - Farah Harmouch
- Internal Medicine, St. Luke's University Health Network, Bethlehem, USA
| | - Nishit Patel
- Gastroenterology, St. Luke's University Health Network, Bethlehem, USA
| | - Zarian Prenatt
- Internal Medicine, St. Luke's University Health Network, Bethlehem, USA
| | - Jill Stoltzfus
- Research Institute, St. Luke's University Health Network, Bethlehem, USA
| | - Berhanu Geme
- Gastroenterology, St. Luke's University Health Network, Bethlehem, USA
| | - Noel Martins
- Gastroenterology, St. Luke's University Health Network, Bethlehem, USA
| | - Kimberly Chaput
- Gastroenterology, St. Luke's University Health Network, Bethlehem, USA
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El Chaar M, Michaud A, Stoltzfus J, Alvarado LA. Improving Operating Room Efficiency of Robotic-Assisted Metabolic and Bariatric Surgery Through Standardization. Obes Surg 2023; 33:3411-3421. [PMID: 37804468 DOI: 10.1007/s11695-023-06850-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 09/14/2023] [Accepted: 09/24/2023] [Indexed: 10/09/2023]
Abstract
INTRODUCTION The use of robotic-assisted (RA) surgery in the field of metabolic and bariatric surgery (MBS) is controversial because of cost concerns and issues related to efficiency. The objective of this study is to evaluate the operating room efficiency in performing RA-MBS prior and after the implementation of a standardized surgical approach. MATERIALS AND METHODS All MBS cases entered into our database between October 2017 and October 2022 were collected and analyzed before and after the introduction of the standardized approach (SA). The outcome variables consisted of operation time (OT), turnover time (TT), wheels in-wheels out (WW), and console time (CT). Procedures were divided into Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and revisional bariatric surgery (RBS). RESULTS For RYGB (n = 185), we found a significant reduction in OT, TT, and WW after SA (129 min vs 139 min; 37 min vs 73 min; 165 min vs 175 min, respectively, p < 0.05). For SG (n = 253), we found a significant reduction in turnover time (TT) after SA. For RBS (n = 201), we also found a significant reduction in OT, TT, WW, and CT after SA ( 157 min vs 177 min; 36 min vs 72 min; 194 min vs 216 min; 119 min vs 134 min, respectively, p < 0.05). CONCLUSION Using a standardized surgical approach, we were able to demonstrate improved operation room efficiency as demonstrated by a reduction in operation length, turnover time, and the overall time of the procedure for primary RYGB and revisional procedures and turnover time for primary sleeve procedures.
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Affiliation(s)
- Maher El Chaar
- Department of Surgery, St. Luke's University Hospital and Health Network, 1736 Hamilton Street, Allentown, PA, 18104, USA.
| | - Allincia Michaud
- St. Luke's University Hospital and Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA
| | - Jill Stoltzfus
- St. Luke's University Hospital and Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA
| | - Luis A Alvarado
- St. Luke's University Hospital and Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA
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Hoerster V, Tang D, Milkis M, Litzenberger S, Stoltzfus J, Stankewicz H. Opioid Use and Disposal Patterns of Emergency Department Patients. J Emerg Trauma Shock 2023; 16:177-181. [PMID: 38292287 PMCID: PMC10824224 DOI: 10.4103/jets.jets_55_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 10/24/2021] [Accepted: 01/20/2023] [Indexed: 02/01/2024] Open
Abstract
Introduction To date, there is limited literature to guide emergency providers (EPs) on the proper dosing of prescription opioids. Our study aims to assess the self-reported opioid use, storage, and disposal practices of patients presenting to the emergency department (ED) with acute pain. Methods This prospective cohort study employed a validated, cross-sectional survey of subjects identified using electronic medical records. The survey link was e-mailed to a continuous sample of eligible participants 3-4 weeks following ED discharge. Nonrespondents were surveyed through telephone after 1 week. We used descriptive and nonparametric statistics to report survey results. Results Of 500 eligible subjects, 97 completed the questionnaire. Only 28% of respondents reported that they took all of the prescribed pills. Of the remaining responses, 20% stated that they did not take any pills, 33% took about one-fourth, 7.2% took about half, and 12.4% took about three-fourths of the pills. Among those who did not take any pills, 42% filled the prescription. Most (71.2%) reported storing their leftover pills; among those who stored their pills, less than one-fourth (23.8%) used a locked storage location. Conclusions Our findings suggest that less than one-third of patients who receive prescriptions in the ED for acute pain use all of their prescribed pills, suggesting that many patients are unnecessarily prescribed opioids for acute conditions. The findings of this study also suggest that many patients with unused prescription opioids do not practice safe storage or proper disposal of leftover pills. This represents a potential opportunity for EPs to improve medication safety by educating patients on proper storage and disposal practices. Limitations include low response rate and the use of self-reporting.
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Affiliation(s)
- Valerie Hoerster
- Department of Emergency Medicine, Sibley Memorial Hospital, Washington, DC, USA
| | - Derek Tang
- Department of Internal Medicine, GME Data Measurement and Outcomes Assessment, St. Luke’s University Health Network, Bethlehem, USA
| | - Marlee Milkis
- Department of Family Medicine, UPMC St. Margaret, Pittsburgh, PA, USA
| | | | - Jill Stoltzfus
- Department of St. Luke's University Health Network, GME Data Measurement and Outcomes Assessment, St. Luke’s University Health Network, Bethlehem, USA
| | - Holly Stankewicz
- Department of Emergency Medicine, St. Luke’s University Health Network, Bethlehem, USA
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Faugno-Fusci D, Perrone J, Michaud A, Stoltzfus J, Alvarado LA, El Chaar M. Outcomes of Staple Line Reinforcement Following Robotic Assisted Sleeve Gastrectomy Based on MBSAQIP Database. Obes Surg 2023; 33:2662-2670. [PMID: 37515695 DOI: 10.1007/s11695-023-06740-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 07/31/2023]
Abstract
INTRODUCTION The objective of this study is to evaluate the outcomes for Staple Line Reinforcement (SLR) in RA-SG based on the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for 2019. MATERIALS AND METHODS We selected patients who underwent RA-SG in the MBSAQIP PUF (Public Utility File) for the year 2019 and grouped them based on their SLR status: Oversewing (OS), Buttressing (BR), both OS and BR and neither. Our primary outcomes were bleeding, organ space infection (OSI), and adverse events (AEs), and our secondary outcomes were operation length, hospital length of stay, readmissions, and conversion to open rates. We conducted separate chi square or one-way analysis of variance (ANOVA) as appropriate and multivariable direct logistic regression models for the categorical outcomes. RESULTS We found 115,621 patients with complete data of which there were 16,494 who underwent RA-SG. Our results did not show a statistically significant decrease in incidence of postoperative bleeding for BR and OS (Adjusted OR = 0.782, p = 0.2291 and Adjusted OR of 0.482, p = 0.054 for BR and OS respectively). There was a statistically significant effect for SLR status on operation length, with OS patients having the highest operative times (log-transformed mean = 2.03), followed by both BR + OS patients (log-transformed mean = 1.99). BR patients had the shortest operation length. CONCLUSION SLR did not result in any significant differences related to bleeding, OSI or AEs following RA-SG according to MBSAQIP for the year 2019. However, OS resulted in significantly longer operative time compared to BR alone.
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Affiliation(s)
- David Faugno-Fusci
- Department of Surgery, St Luke's University Hospital and Health Network, 1736 Hamilton Street, Allentown, PA, 18104, USA
| | - John Perrone
- Department of Surgery, St Luke's University Hospital and Health Network, 1736 Hamilton Street, Allentown, PA, 18104, USA
| | - Allincia Michaud
- St Luke's University Hospital and Health Network-Research Institute, 801 Ostrum Street, Bethlehem, PA, 18015, USA
| | - Jill Stoltzfus
- St Luke's University Hospital and Health Network-Research Institute, 801 Ostrum Street, Bethlehem, PA, 18015, USA
| | - Luis A Alvarado
- St Luke's University Hospital and Health Network-Research Institute, 801 Ostrum Street, Bethlehem, PA, 18015, USA
| | - Maher El Chaar
- Department of Surgery, St Luke's University Hospital and Health Network, 1736 Hamilton Street, Allentown, PA, 18104, USA.
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Ackert KE, Bauerle W, Pellegrino AN, Stoltzfus J, Pateman S, Graves D, Graul A, Taylor N, Zighelboim I. Implementation of an enhanced recovery after surgery (ERAS) protocol for total abdominal hysterectomies in the division of gynecologic oncology: a network-wide quality improvement initiative. J Osteopath Med 2023; 123:493-498. [PMID: 37318833 DOI: 10.1515/jom-2022-0204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 05/23/2023] [Indexed: 06/17/2023]
Abstract
CONTEXT Enhanced Recovery After Surgery (ERAS) protocols have been shown to decrease length of stay and postoperative opioid usage in colorectal and bariatric surgeries performed at large academic centers. Hysterectomies are the second most common surgical procedure among women in the United States. Hysterectomies performed in an open fashion, or total abdominal hysterectomies (TAHs), account for a large portion of procedures performed by gynecologic oncologists secondary to current oncology guidelines and surgical complexity. Implementation of an ERAS protocol for gynecologic oncology TAHs is one way in which patient outcomes may be improved. OBJECTIVES An ERAS protocol for gynecologic oncology surgeries performed in a community hospital was instituted with the goal to optimize patient outcomes preoperatively. The primary outcome of interest was to reduce patient opioid usage. Secondary outcomes included compliance with the ERAS protocol, length of stay, and cost. Thirdly, this study aimed to demonstrate the unique challenges of implementing a large-scale protocol across a community network. METHODS An ERAS protocol was implemented in 2018, with multidisciplinary input from the Departments of Gynecologic Oncology, Anesthesia, Pharmacy, Nursing, Information Technology, and Quality Improvement to develop a comprehensive ERAS order set. This was implemented across a 12-site hospital system network that consisted of both urban and rural hospital settings. A retrospective review of patient charts was performed to assess measured outcomes. Parametric and nonparametric tests were utilized for statistical analysis with p<0.05 denoting statistical significance. If the p value was >0.05 and <0.09, this was considered a trend toward significant. RESULTS A total of 124 patients underwent a TAH utilizing the ERAS protocol during 2018 and 2019. The control arm consisted of 59 patients who underwent a TAH prior to the ERAS protocol intervention, which was the standard of care in 2017. After 2 years of implementation of the ERAS protocol intervention, we found that 48 % of the ERAS patients had minimal opioid requirements after surgery (oral morphine equivalent [OME] range 0-40) with decreased postoperative opioid requirements in the ERAS group (p=0.03). Although not statistically significant, utilization of the ERAS protocol for gynecologic oncology TAHs trended toward shorter hospital length of stay from 5.18 to 4.17 days (p=0.07). The median total hospital costs per patient also showed a nonsignificant decrease in cost from $13,342.00 in the non-ERAS cohort and $13,703.00 in the ERAS cohort (p=0.8). CONCLUSIONS A large-scale quality improvement (QI) initiative is feasible utilizing a multidisciplinary team to implement an ERAS protocol for TAHs in the division of Gynecologic Oncology with promising results. This large-scale QI result was comparable to studies that conducted quality-improvement ERAS initiatives at single academic institutions and should be considered within community networks.
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Affiliation(s)
- Kathleen E Ackert
- Department Obstetrics and Gynecology, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Wayne Bauerle
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Anna Ng Pellegrino
- Department of Anesthesia, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Jill Stoltzfus
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Shaun Pateman
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Dan Graves
- Department of Anesthesia, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Ashley Graul
- Department Obstetrics and Gynecology, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Nicholas Taylor
- Department Obstetrics and Gynecology, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Israel Zighelboim
- Department Obstetrics and Gynecology, St. Luke's University Health Network, Bethlehem, PA, USA
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El Chaar M, Petrick A, Clapp B, Stoltzfus J, Alvarado LA. Outcomes of Robotic-Assisted Bariatric Surgery Compared to Standard Laparoscopic Approach Using a Standardized Definition: First Look at the 2020 Metabolic and Bariatric Surgery Accreditation Quality Improvement Project (MBSAQIP) Data. Obes Surg 2023; 33:2025-2039. [PMID: 37184827 DOI: 10.1007/s11695-023-06585-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/04/2023] [Accepted: 04/05/2023] [Indexed: 05/16/2023]
Abstract
PURPOSE The primary objective of this study is to evaluate the outcomes of robotic-assisted (RA-) approach compared to the standard laparoscopic (L-) approach using the 2020 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry Public Use File (PUF). Our secondary objective is to establish standards for the reporting of outcomes using PUF. MATERIALS AND METHODS Using the PUF database (n = 168,568), patients were divided into sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), revisions, and conversions and then analyzed separately. We created balanced covariate through propensity score matching and inverse probability treatment weighting (IPTW). We also conducted multivariable relative risk regression to confirm our results. RESULTS For RYGB, the incidence of "transfusion" was significantly lower in the RA-RYGB compared to the L-RYGB. There was no significant difference in the rate of Serious Event Occurrences (SEOs) or rate of intervention at 30 days. For SG, there was a higher rate of "transfusion" in the RA group. Incidence of SEOs was also significantly higher in the RA-group. There was no significant difference in SEOs for conversions; however, revisions had a trend toward a lower rate of SEOs favoring the robotic approach. Operative times were significantly higher for all RA-groups. CONCLUSION RA- approach in metabolic and bariatric surgery (MBS) remains controversial because of differences in outcomes. The use of SEOs as reported by MBSAQIP in its semi-annual report can be used as a composite score to assess outcomes while using PUF. Further studies are needed to compare RA- to L- MBS.
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Affiliation(s)
- Maher El Chaar
- Department of Surgery, St Luke's University Hospital and Health Network, 1736 Hamilton Street, Allentown, PA, 18104, USA.
| | - Anthony Petrick
- Geisinger Clinic, 100 N Academy Ave, Danville, PA, 17821, USA
| | - Benjamin Clapp
- Texas Tech Health Sciences Cente School of Medicine, 4801 Alberta Ave, El Paso, TX, 79905, USA
| | - Jill Stoltzfus
- St Luke's University Hospital and Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA
| | - Luis A Alvarado
- Texas Tech University Health Sciences Center, 4801 Alberta Ave, El Paso, TX, 79905, USA
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9
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Antoine MR, Salen P, Stoltzfus J, Shoemaker M, Puleo PR. CRT-100.49 Diaphoresis, but Not Dyspnea, Nausea, or Dizziness, Is Associated With Finding a Culprit Lesion in Patients With Suspected ST Elevation Infarction. JACC Cardiovasc Interv 2023. [DOI: 10.1016/j.jcin.2023.01.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
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10
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Bauerle WB, Mody P, Estep A, Stoltzfus J, El Chaar M. Current Trends in the Utilization of a Robotic Approach in the Field of Bariatric Surgery. Obes Surg 2023; 33:482-491. [PMID: 36572836 PMCID: PMC9792156 DOI: 10.1007/s11695-022-06378-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 11/21/2022] [Accepted: 11/27/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE The utilization rate of robotic surgery for bariatric procedures is not well-described. Our study identified the proportion of metabolic and bariatric surgery (MBS) procedures in the United States between 2015 and 2020 performed using a robotic (R-) or laparoscopic (L-) approach. MATERIALS AND METHODS A descriptive analysis of the 2015-2020 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant User Data File (PUF) datasets was performed. The primary outcome was (1) surgical cases performed annually and (2) proportion of cases performed using a R- or L- approach. Analysis was done separately for sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch (BPD-DS), and revisional bariatric surgery (RBS). Statistical analysis consisted of means and proportions, fold difference, annual slope, and Student's t tests or chi-square tests as appropriate, with statistical significance set to p < .05. RESULTS A total of 1,135, 214 procedures were captured between 2015 and 2020. R-RYGB increased from 2554 to 6198 (6.8% to 16.7%), R-SG increased from 5229 to 17,063 (6.0% to 17.2%), R-RBS increased from 993 to 3386 (4.7% to 17.4%), and R-BPD-DS increased from 221 to 393 (22.0% to 28.4%). The greatest annual increase was observed among R-RBS and R-SG (3.70-fold difference; slope 2.4% per year and 2.87-fold difference; slope 2.2% per year, respectively). CONCLUSION There is a nationwide increase in the utilization of a R- approach in bariatric surgery. There are concerns related to the potential increase in healthcare expenditures related to robotics. Further studies are needed to establish key performance indicators along with guidelines for training, adoption and utilization of a R- approach.
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Affiliation(s)
- Wayne B Bauerle
- Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Pooja Mody
- Division of Bariatric Surgery, Department of Surgery, St. Luke's University Hospital and Network, Bethlehem, PA, USA
| | - Allison Estep
- Division of Bariatric Surgery, Department of Surgery, St. Luke's University Hospital and Network, Bethlehem, PA, USA
| | - Jill Stoltzfus
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Maher El Chaar
- Division of Bariatric Surgery, Department of Surgery, St. Luke's University Hospital and Network, Bethlehem, PA, USA.
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11
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Munshower E, Ren E, Bauerle WB, Ruland J, Stoltzfus J, McDonald M, Baillie DR, Chaar ME. Cost analysis of robotic assisted general surgery cases in a single academic institution. J Robot Surg 2022; 17:557-564. [PMID: 35939166 DOI: 10.1007/s11701-022-01434-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 06/06/2022] [Indexed: 11/29/2022]
Abstract
Laparoscopy is currently the standard approach for minimally invasive general surgery procedures. However, robotic surgery is now increasingly being used in general surgery. Robotic surgery provides several advantages such as 3D-visualization, articulated instruments, improved ergonomics, and increased dexterity, but is also associated with an increased overall cost which limits its widespread use. In our institution, the robotic assisted approach is frequently used for the performance of general surgery cases including inguinal hernias, cholecystectomies and paraesophageal hernia (PEH) repairs. The primary aim of the study was to evaluate the differences in cost between a robotic and laparoscopic approach for the above-mentioned cases. With IRB approval, we conducted a retrospective cost analysis of patients undergoing inguinal hernia repairs, cholecystectomies and PEH repairs between June 2018 and November 2020. Patients who had a concomitant procedure, a revisional surgery, or bilateral inguinal hernia repair were excluded from the study. Cost analysis was performed using a micro-costing approach. Statistical significance was denoted by p < 0.05. There were no differences among the different groups in relation to age, gender, ethnicity, and BMI. The overall cost of the robotic (R-) approach compared to a laparoscopic (L-) approach was significantly lower for cholecystectomy ($3,199.96 vs $4019.89, p < 0.05). For inguinal hernia repairs and PEH repairs without mesh, we found no significant difference in overall costs between the R- and L- approach (R- $3835.06 vs L- $3783.50, p = 0.69) and (R- $6852.41 vs L- $6819.69, p = 0.97), respectively. However, the overall cost of PEH with mesh was significantly higher for the R- group compared to the L- group (R- $7,511.09 vs L- $6,443.32, p < 0.05). Based on our institutional cost data, use of a robotic approach when performing certain general surgery cases does not seem to be cost prohibitive.
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Affiliation(s)
- Eva Munshower
- Temple/St. Luke's School of Medicine, Bethlehem, PA, USA
| | - Emily Ren
- Temple/St. Luke's School of Medicine, Bethlehem, PA, USA
| | - Wayne B Bauerle
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Janice Ruland
- Cost Accounting Department, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Jill Stoltzfus
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Marian McDonald
- Department of Surgery, Division of Minimally Invasive Surgery, St. Luke's University Hospital and Health Network, Allentown, PA, USA
| | - Daniel R Baillie
- Department of Surgery, Division of Minimally Invasive Surgery, St. Luke's University Hospital and Health Network, Allentown, PA, USA
| | - Maher El Chaar
- Department of Surgery, Division of Bariatric Surgery, St. Luke's University Hospital and Health Network, Allentown, PA, USA.
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12
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Aiad M, Tahir A, Fresco K, Prenatt Z, Ramos-Feliciano K, Walia J, Stoltzfus J, Albandar HJ. Does the Combined Use of Aspirin and Immunotherapy Result in Better Outcomes in Non-Small Cell Lung Cancer Than Immunotherapy Alone? Cureus 2022; 14:e25891. [PMID: 35720783 PMCID: PMC9190187 DOI: 10.7759/cureus.25891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2022] [Indexed: 11/09/2022] Open
Abstract
Introduction: Immunotherapy works by stimulating the immune system against cancer cells. Resistance to immunotherapy represents a significant challenge in the field of medical oncology. The mechanisms by which cancer cells evade immunotherapy are not well understood. Prior research suggested overexpression of prostaglandin E-2 (PGE-2) by cancer cells, which bind to EP-2 and EP-4 receptors on the tumor-specific cytotoxic T-lymphocytes (CTLs) and suppress their anticancer role. This immunosuppressive effect is involved in evading the programmed cell death-1 (PD-1)/programmed death-ligand 1 (PD-L1) blockade of immunotherapy, which fuels cancer cell growth and recurrence. Studies found that combining PGE-2 blockade and a PD-1 signaling inhibitor helped promote the anticancer immunity cells. If confirmed in a clinical setting, the above in vitro findings could be of great clinical significance. Methods: Given that aspirin (ASA) blocks PGE-2 production, this work aimed to evaluate whether ASA use with immunotherapy results in better outcomes than immunotherapy alone. We performed a retrospective chart review of 500 non-small cell lung cancer (NSCLC) patients aged 21 years or older treated with PD-1 and/or PD-L1 directed immunotherapy at St. Luke’s University Health Network between July 2015 and July 2021. Relevant patient, disease, and treatment-related variables were collected, including ASA use (≥ 81 mg daily) and the type of immunotherapy. Bivariate analyses were conducted to determine which variables to include in a multivariable model. The four primary outcomes included survival at 18-months, both after diagnosis and starting immunotherapy, achieving complete remission (CR), and having a progressive disease (PD), as defined by RECIST (Response Evaluation Criteria in Solid Tumors) criteria. Secondary outcomes included therapy-related toxicities and complications in the different treatment groups. Results: After bivariate analysis, no statistical significance was found for a difference in 18-month survival between ASA and non-ASA groups (50.3% vs 49.7%, p-value = 0.79). ASA with PD-L1 inhibitor showed a trend towards a higher likelihood of achieving CR [adjusted odds ratio (AOR) 1.85] with a p-value close to statistical significance (0.06). However, ASA with PD-L1 showed high statistical significance as an independent variable associated with a decreased likelihood of having PD (AOR 0.44, p < 0.001). These findings suggest that NSCLC patients receiving PD-L1 inhibitors could benefit more from daily ASA than patients treated with PD-1 inhibitors. Our study emphasizes using the Eastern Cooperative Oncology Group (ECOG) scoring of the performance status (PS) in NSCLC patients. Poorer PS was associated with lower survival, decreased likelihood of CR, and more PD. Other variables associated with worse outcomes were advanced cancer stage at diagnosis and male gender. Low-PD-L1 expression in NSCLC was associated with an increased likelihood of survival; this could be of clinical significance, especially with previous studies suggesting better outcomes of using ASA in PD-L1 low tumors. Conclusion: These findings suggest that daily ASA use with PD-L1 inhibitors is associated with more favorable outcomes in NSCLC. More studies are needed to investigate further the potential benefits vs. risks of using ASA with different immunotherapies and the other possible variables affecting treatment outcomes.
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13
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Aiad M, Fresco K, Prenatt Z, Tahir A, Ramos-Feliciano K, Stoltzfus J, Harmouch F, Wilson M. Comparison of Pneumonitis Rates and Severity in Patients With Lung Cancer Treated by Immunotherapy, Radiotherapy, and Immunoradiotherapy. Cureus 2022; 14:e25665. [PMID: 35677739 PMCID: PMC9167438 DOI: 10.7759/cureus.25665] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction Radiation pneumonitis (RP) is a common dose-limiting toxicity of radiotherapy to the chest in lung cancer patients. Similarly, the revolutionary use of immune checkpoint inhibitors (ICIs) to treat lung cancer can be complicated by immune-related adverse events (irAEs), particularly checkpoint inhibitor pneumonitis (CIP). Our study aimed to assess the effect of immunotherapy, with and without radiotherapy, on pneumonitis and other outcomes. Methods We performed a retrospective chart review of 680 lung cancer patients treated with either radiotherapy, immunotherapy, or both at St. Luke's University Health Network to determine the incidence rates of pneumonitis. Then, a more extensive review of 346 patients was completed, 181 of whom had pneumonitis, to investigate risk factors and outcomes. Results All-grade pneumonitis incidence was 26.6% while more severe pneumonitis (grade 3 or higher) was 13%. Receiving programmed cell death-1 (PD-1) or ligand-1 (PD-L1) inhibitors, having squamous cell carcinoma (SCC), and having poorer performance status were independently and significantly associated with increased risk of pneumonitis, with AOR (adjusted odds ratios) of 8.32, 4.10, 2.91, and 1.71, respectively. Among those who had pneumonitis, more severe cases (grade 3 or higher) were related to immunotherapy, either alone (58.32%) or with radiation (55.7%), compared to radiation therapy alone (36.2%). Poorer performance status (defined as a higher Eastern Cooperative Oncology Group (ECOG) score) was the only covariate we found to be significantly and independently associated with reduced odds of 18-months survival. More of the patients treated with both lung radiation and immunotherapy had progressive disease (53.8%) compared to those treated with only radiation (30.4%) or immunotherapy (36.7). Progressive disease occurred more in patients with pneumonitis grade 3 or higher (48.3%) than those with no or low-grade pneumonitis (27.2%). Conclusion Receiving PD-L1 and PD-1 inhibitors, either with or without radiotherapy, was associated with a higher risk of more severe pneumonitis (PD-L1 > PD-1) than radiotherapy alone. Given its high incidence and complications, more about therapy-induced pneumonitis is yet to be studied. Learning more about pneumonitis' risk factors and complications is of great clinical importance, as it may result in better treatment planning and improved outcomes. Future studies are needed to investigate the suggested association between symptomatic pneumonitis and poorer response to treatment and whether SCC increases the risk of higher-grade pneumonitis.
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14
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Shupp B, Mehta SV, Chirayath S, Patel N, Aiad M, Sapin J, Stoltzfus J, Schneider Y. Proton pump inhibitor therapy usage and associated hospitalization rates and critical care outcomes of COVID-19 patients. Sci Rep 2022; 12:7596. [PMID: 35534666 PMCID: PMC9084256 DOI: 10.1038/s41598-022-11680-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 04/12/2022] [Indexed: 11/17/2022] Open
Abstract
Proton Pump Inhibitors (PPI) are one of the most prescribed medications in the United States. However, PPIs have been shown to increase the risk of enteric infections. Our study aims to evaluate the correlation between PPI and COVID-19 severity. We performed a retrospective cohort study on patients who tested positive for SARS-CoV-2 from March to August 2020. Patients were categorized based on PPI user status. Primary outcomes included need for hospital or ICU admission and 30-day mortality. Secondary outcomes looked to determine the severity of COVID-19 infection and effect of comorbid conditions. 2,594 patients were reviewed. The primary outcomes of our study found that neither active nor past PPI use was associated with increased hospital admission or 30-day mortality following completion of multivariate analysis. Additionally, there was no association between COVID-19 infection and the strength of PPI dosing (low, standard, high). However, the following covariates were independently and significantly associated with increased admission: age, male gender, diabetes, COPD, composite cardiovascular disease, kidney disease, and obesity. The following covariates were associated with increased mortality: age, male gender, COPD, and kidney disease. In conclusion, the high risk features and comorbidities of PPI users were found to have a stronger correlation to severe COVID-19 infection and poor outcomes as opposed to the use of PPI therapy.
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Affiliation(s)
- Brittney Shupp
- Internal Medicine Resident, St. Luke's University Health Network, Bethlehem, PA, USA. .,Division of Internal Medicine, St. Luke's University Health Network, 801 Ostrum St., Suite 201, Bethlehem, 18015, PA, USA.
| | - Sagar V Mehta
- Department of Gastroenterology, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Subin Chirayath
- Internal Medicine Resident, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Nishit Patel
- Internal Medicine Resident, St. Luke's University Health Network, Easton, PA, USA
| | - Mina Aiad
- Internal Medicine Resident, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Jared Sapin
- Lewis Katz School of Medicine at Temple University - St. Luke's Campus, Bethlehem, PA, USA
| | - Jill Stoltzfus
- St. Luke's University Health Network, Bethlehem, PA, USA
| | - Yecheskel Schneider
- Department of Gastroenterology, St. Luke's University Health Network, Bethlehem, PA, USA
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15
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Chaar ME, King K, Salem JF, Arishi A, Galvez A, Stoltzfus J. Retraction notice to “Robotic surgery results in better outcomes following Roux-en-Y gastric bypass: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program analysis for the years 2015–2018” [SOARD 17/4 (2021) 694-700]. Surg Obes Relat Dis 2022; 18:299. [DOI: 10.1016/j.soard.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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McKay B, Meyers M, Rivard L, Stoltzfus J, Rammohan G, Stankewicz H. Predicting 30 - Day outcomes in emergency department patients discharged with COVID-19. Am J Emerg Med 2021; 50:513-517. [PMID: 34537576 PMCID: PMC8410217 DOI: 10.1016/j.ajem.2021.08.077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/26/2021] [Accepted: 08/29/2021] [Indexed: 12/17/2022] Open
Abstract
Introduction Determining disposition for COVID-19 patients can be difficult for emergency medicine clinicians. Previous studies have demonstrated risk factors which predict severe infection and mortality however little is known about which risk factors are associated with failure of outpatient management and subsequent admission for COVID-19 patients. Methods We conducted a retrospective observational chart review of patients who had a confirmed positive COVID-19 test collected during an ED visit between March 1, 2020 and October 11, 2020. Patients were divided into two groups based on presence or absence of a subsequent 30-day hospitalization. Clinical and demographic information were collected including chief complaint, triage vital signs and comorbid medical conditions. Results 1038 patients were seen and discharged from a network ED with a positive SARS-CoV-2 PCR test. 94 patients (9.1%) were admitted to a hospital within 30 days of the index ED visit while 944 (90.9%) were not admitted to a network hospital within 30 days. Patients that were admitted were more likely to be older (aOR = 1.04 (95% CI 1.03–1.06)), hypoxic (aOR = 2.16 (95% CI 1.14–4.10)) and tachycardic (aOR = 2.13 (95% CI 1.34–3.38)) on initial ED presentation. Preexisting hypertension, diabetes mellitus, coronary artery disease, chronic kidney disease and malignancy were all highly significant risk factors for 30-day hospital admission following initial ED discharge (p < 0.0001). Conclusion Emergency Department providers should consider age, chief complaint, vital signs and comorbid medical conditions when determining disposition for patients diagnosed with COVID-19.
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Affiliation(s)
- Benjamin McKay
- Temple/St. Luke's Medical School, 801 Ostrum Street, Bethlehem, PA 18015, United States.
| | - Matthew Meyers
- St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA 18015, United States.
| | - Leah Rivard
- St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA 18015, United States.
| | - Jill Stoltzfus
- St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA 18015, United States.
| | - Guhan Rammohan
- St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA 18015, United States.
| | - Holly Stankewicz
- St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA 18015, United States.
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17
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Coppersmith V, Hudgins S, Stoltzfus J, Stankewicz H. The use of N-acetylcysteine in the prevention of hangover: a randomized trial. Sci Rep 2021; 11:13397. [PMID: 34183702 PMCID: PMC8238992 DOI: 10.1038/s41598-021-92676-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 06/11/2021] [Indexed: 01/15/2023] Open
Abstract
Hangovers resulting from alcohol intoxication can lead to adverse effects ranging from generalized discomfort and work-related absenteeism to emergency department visits from patients seeking symptomatic care. The purpose of this study was to evaluate the efficacy of a low dose (600–1800 mg) of N-Acetylcysteine (NAC) vs placebo on mitigating hangover symptoms. This was a randomized, double-blinded, placebo controlled crossover study involving 49 volunteers who consumed beer to obtain a breath alcohol content (BrAC) of 0.1 g/210L. The participants met on two separate occasions at which time they were given either NAC or placebo capsules. Opposing treatments were administered during the second encounter. The morning after the participant’s intoxication and treatment, a Hangover Symptom Scale Questionnaire was administered to determine subjective changes in hangover symptoms. Data was analyzed by self-control, comparing the participant’s hangover symptom severity when using NAC compared to placebo. No significant difference was found in the general distribution of total hangover scores (P = .45) (NAC = 10; Placebo = 13). There was also no significant difference found in the general distribution of specific hangover symptoms. However, a significant difference was found in the general distribution of total hangover difference scores based on gender (P = .04) (Female − 3.5; Male 2), specifically for nausea (P = .05) and weakness (P = .03). Although no difference was found in the general hangover scale scores, the study was suggestive of gender specific susceptibility with female participants having improved hangover symptoms after NAC use.
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Affiliation(s)
- Veronica Coppersmith
- St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA
| | - Sarah Hudgins
- St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA
| | - Jill Stoltzfus
- St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA
| | - Holly Stankewicz
- St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA.
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18
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Corwin DS, Ender PT, Sahu N, Durgham RA, McGorry DM, Rahman A, Stoltzfus J, Jahre JA. The Efficacy of Bamlanivimab in Reducing Emergency Department Visits and Hospitalizations in a Real-world Setting. Open Forum Infect Dis 2021; 8:ofab305. [PMID: 34258324 PMCID: PMC8272954 DOI: 10.1093/ofid/ofab305] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/09/2021] [Indexed: 11/12/2022] Open
Abstract
Bamlanivimab, a monoclonal antibody targeting the spike protein of severe acute respiratory syndrome coronavirus 2, is available for ambulatory treatment of coronavirus disease 2019 (COVID-19). This real-world study confirms the efficacy of bamlanivimab in reducing hospital admissions and emergency department visits among high-risk outpatients with mild to moderate COVID-19 illness and reveals a trend toward improved mortality.
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Affiliation(s)
- Douglas S Corwin
- Section of Pulmonary and Critical Care, Department of Medicine, St Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Peter T Ender
- Section of Infectious Diseases, Department of Medicine, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Nitasa Sahu
- Section of Pulmonary and Critical Care, Department of Medicine, St Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Ryan A Durgham
- Temple/St. Luke's School of Medicine, Bethlehem, Pennsylvania, USA
| | - Dennis M McGorry
- Department of Family Medicine, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Awan Rahman
- Section of Pulmonary and Critical Care, Department of Medicine, St Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Jill Stoltzfus
- Graduate Medical Education, Data Management and Outcomes Assessment, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Jeffrey A Jahre
- Section of Infectious Diseases, Department of Medicine, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
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19
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Puleo P, Salen P, Manda Y, Vefali H, Agrawal S, Quddus A, Branch K, Shoemaker M, Stoltzfus J. Likelihood of myocardial infarction, revascularization and death following catheterization laboratory activation in patients with vs. without both chest pain and ST elevation. Coron Artery Dis 2021; 32:197-204. [PMID: 32541211 PMCID: PMC8032215 DOI: 10.1097/mca.0000000000000920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 05/26/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Emergent cardiac catheterization laboratory activation (CCLA) for patients with suspected ST-elevation myocardial infarction (STEMI) is employed to expedite acute revascularization (AR). The incidence of false-positive CCLA, in which AR is not performed, remains high. The combination of chest pain (CP) and electrocardiographic ST elevation (STE) are the hallmarks of STEMI. However, CCLA is sometimes initiated for patients lacking this combination. The study objective was to quantify the difference in likelihood of AR and mortality in patients with vs. without both CP and STE. METHODS Retrospective analysis of 1621 consecutive patients for whom CCLA was initiated in a six-hospital network. We assessed the likelihood of acute myocardial infarction (AMI), presence of a culprit lesion (CL), performance of AR, and hospital mortality among patients with both CP and STE (+CP/+STE) compared with patients lacking one or both [non(CP/STE)]. RESULTS 87.0% of patients presented with CP, 82.4% with STE, and 73.7% with both. Among +CP/+STE patients, AMI was confirmed in 90.4%, a CL in 88.9%, and AR performed in 83.1%. The corresponding values among non(CP/STE) patients were 35.8, 31.9, and 28.1%, respectively (P < 0.0001 for each). Nevertheless, mortality among non(CP/STE) patients was three-fold higher than in +CP/+STE patients (13.3% vs. 4.5%; P < 0.0001), with non-coronary deaths 24-fold more likely. CONCLUSION Patients lacking the combination of CP and STE have a markedly lower likelihood of AMI and AR than +CP/+STE patients, but significantly higher mortality. Protocols aimed at rapid, focused evaluation of non(CP/STE) patients prior to CCLA are needed.
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Affiliation(s)
- Peter Puleo
- Department of Medicine, Section of Cardiology, St. Luke’s University Hospital
| | - Philip Salen
- Department of Emergency Medicine, St. Luke’s University Hospital, Bethlehem, Pennsylvania
| | - Yugandhar Manda
- Department of Medicine, Section of Cardiology, St. Luke’s University Hospital
- Department of Medicine, Section of Cardiology, The Heart Institute of East Texas, Lufkin, Texas
| | - Huseng Vefali
- Department of Medicine, Section of Cardiology, St. Luke’s University Hospital
- Department of Medicine, Section of Cardiology, New York – Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York
| | - Sahil Agrawal
- Department of Medicine, Section of Cardiology, St. Luke’s University Hospital
- Department of Medicine, Section of Cardiology, St. Francis Hospital, Tulsa, Oklahoma
| | - Abdullah Quddus
- Department of Medicine, Section of Cardiology, St. Luke’s University Hospital
- Department of Medicine, Section of Cardiology, Franciscan Health System, Michigan City, Indiana
| | | | - Melinda Shoemaker
- Department of Medicine, Section of Cardiology, St. Luke’s University Hospital
| | - Jill Stoltzfus
- Biostatistics, St. Luke’s University Hospital, Bethlehem, Pennsylvania, USA
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Duarte-Chavez R, Stoltzfus J, Yellapu V, Martins N, Nanda S, Longo S, Geme B, Schneider Y. Colonic diverticular disease in autosomal dominant polycystic kidney disease: is there really an association? A nationwide analysis. Int J Colorectal Dis 2021; 36:83-91. [PMID: 32875377 DOI: 10.1007/s00384-020-03736-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/26/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Colonic diverticulosis, diverticulitis, and diverticular bleeding are reportedly more common in patients with autosomal dominant polycystic kidney disease (ADPKD). Other studies have questioned this association. The objectives of our study are to clarify this association using a larger patient population and to identify risk factors in general to develop diverticular disease. METHODS The Nationwide Inpatient Sample weighted discharges from 2003 to 2011 were used to assess for the prevalence of diverticular disease in the population with ADPKD compared with the general population without ADPKD. A multivariable direct logistic regression model was constructed to determine independent predictors of diverticular disease in the general population. RESULTS The prevalence of diverticulosis, diverticulitis, and diverticular bleeding were considerably increased in patients with ADPKD compared with the general population without ADPKD. The prevalence of colonic surgery was less in ADPKD patients with diverticulitis. In patients with kidney transplant, the prevalence of diverticulitis was increased in the ADPKD group, but colonic surgery was not significantly different between both groups. The prevalence of diverticular bleeding was slightly elevated in patients with ADPKD, but colonic surgery was significantly increased in patients with ADPKD. NSAID use, hypertension, constipation, and ADPKD had increased odds ratios for diverticular disease during multivariate analysis. CONCLUSION There is an increased prevalence of colonic diverticular disease in the population with ADPKD.
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Affiliation(s)
- Rodrigo Duarte-Chavez
- Department of Internal Medicine, Division of Gastroenterology, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA.
| | - Jill Stoltzfus
- Department of Research, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA
| | - Vikas Yellapu
- Department of Research, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA
| | - Noel Martins
- Department of Internal Medicine, Division of Gastroenterology, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA
| | - Sudip Nanda
- Department of Internal Medicine, Division of Cardiology, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA
| | - Santo Longo
- Department of Pathology, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA
| | - Berhanu Geme
- Department of Internal Medicine, Division of Gastroenterology, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA
| | - Yecheskel Schneider
- Department of Internal Medicine, Division of Gastroenterology, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA
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El Chaar M, King K, Salem JF, Arishi A, Galvez A, Stoltzfus J. Robotic surgery results in better outcomes following Roux-en-Y gastric bypass: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program analysis for the years 2015-2018. Surg Obes Relat Dis 2020; 17:694-700. [PMID: 33509729 DOI: 10.1016/j.soard.2020.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/15/2020] [Accepted: 12/06/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND The use of robotic surgery in bariatric patients is controversial. OBJECTIVES To evaluate the outcome of robotic surgery in Roux-en-Y gastric bypass (RYGB) patients. SETTING Tertiary-care referral hospital. METHODS A total of 149,132 patients who underwent RYGB in the 2015 to 2018 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database were included in our initial analysis. The propensity-matched analysis that was performed resulted in 21,736 patients, whose data were utilized to compare outcomes of the robotic (R) and laparoscopic (L) groups. Patients were also compared after dividing them into obese (body mass index [BMI] < 50 kg/m2) and super-obese categories (BMI ≥ 50 kg/m2). RESULTS R-RYGB patients had a significantly lower 30-day incidence of serious adverse events (SAEs) and bleeding (2.0% and .7%, respectively, for R-RYGB versus 2.4% and 1.3%, respectively, for L-RYGB; P ≤ .05) but a higher incidence of 30-day reoperation compared to L-RYGB patients (2.7% versus 2.3%, respectively; P ≤ .05). The R-RYGB group also had a shorter length of hospital stay compared to the L-RYGB group (1.98 versus 2.02 days, respectively; P ≤ .05), but higher readmission rates (7.1% versus 5.8%, respectively; P ≤ .05). The robotic approach also resulted in lower mortality rates for those in the super-obese category. In that BMI category, 30-day mortality rates were .4% versus .2% for L-RYGB and R-RYGB patients, respectively (P ≤ .05). CONCLUSION The use of robotic surgery in bariatric patients is controversial. Our analysis, based on the MBSAQIP database for the years 2015 to 2018, demonstrated lower overall SAEs and bleeding rates, in addition to a shorter hospital stay, favoring robotic RYGB compared to laparoscopic RYGB. However, readmission and reoperation rates were higher in the robotic group. Randomized controlled trials are needed to further clarify the benefit of robotic surgery in bariatric patients.
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Affiliation(s)
- Maher El Chaar
- St Luke's University Hospital and Health Network, Department of Surgery, Pennsylvania; Temple Lewis Katz School of Medicine, Allentown, Pennsylvania.
| | - Keith King
- St Luke's University Hospital and Health Network, Department of Surgery, Pennsylvania
| | - Jean F Salem
- St Luke's University Hospital and Health Network, Department of Surgery, Pennsylvania
| | - AbdulAziz Arishi
- St Luke's University Hospital and Health Network, Department of Surgery, Pennsylvania
| | - Alvaro Galvez
- St Luke's University Hospital and Health Network, Department of Surgery, Pennsylvania
| | - Jill Stoltzfus
- St Luke's University Hospital and Health Network, Department of Surgery, Pennsylvania; Temple Lewis Katz School of Medicine, Allentown, Pennsylvania
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King K, Galvez A, Stoltzfus J, Claros L, El Chaar M. Robotic-Assisted Surgery Results in a Shorter Hospital Stay Following Revisional Bariatric Surgery. Obes Surg 2020; 31:634-639. [PMID: 33078338 DOI: 10.1007/s11695-020-05022-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/28/2020] [Accepted: 10/05/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Revisional surgery is rapidly growing within the field of bariatric surgery. The use of robotic assisted surgery, considered controversial by many, may offer advantages in revisional bariatric surgery (RBS). There are few studies comparing laparoscopic and robotic-assisted RBS. The aim of this study is to compare the safety and outcome of laparoscopic and robotic RBS in a single accredited center. METHODS A retrospective analysis of data collected prospectively on patients undergoing either laparoscopic (L-RBS) or robotic (R-RBS) RBS between January 1, 2017 and December 31, 2019 was performed. The primary outcomes included length of stay (LOS), 30-day major and minor complication rates, readmission rates, and mortality rates. RESULTS A total of 167 patients were included in our analysis. Fifty-two patients underwent R-RBS (31%), and 115 underwent L-RBS (69%). Thirty-day major and minor complication rates for R-RBS and L-RBS were 1.9% and 5.8% vs 5.2% and 5.2%, respectively (p > .05). There was no difference in readmission rates (3.8% vs 8.7%, p > 0.05) or intraoperative blood loss (35.5 mL vs 37.4 mL, p > .05) between R-RBS and L-RBS. R-RBS resulted in a shorter length of stay when compared with L-RBS (40.2 h vs 62.6 h, p < .05). CONCLUSIONS R-RBS has a decreased, albeit non-significant, rate of 30-day major complications with no difference in minor complications, readmission rates, or intraoperative blood loss when compared with L-RBS. R-RBS resulted in a decreased length of stay when compared with L-RBS. Randomized clinical trials are needed to better elucidate our findings.
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Affiliation(s)
- Keith King
- St Luke's University Hospital and Health Network, Bethlehem, PA, USA
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Alvaro Galvez
- St Luke's University Hospital and Health Network, Bethlehem, PA, USA
| | - Jill Stoltzfus
- St Luke's University Hospital and Health Network, Bethlehem, PA, USA
- Lewis Katz School of Medicine-Temple University, Philadelphia, PA, USA
| | - Leonardo Claros
- St Luke's University Hospital and Health Network, Bethlehem, PA, USA
- Lewis Katz School of Medicine-Temple University, Philadelphia, PA, USA
| | - Maher El Chaar
- St Luke's University Hospital and Health Network, Bethlehem, PA, USA.
- Lewis Katz School of Medicine-Temple University, Philadelphia, PA, USA.
- St. Luke's University Health Network, 240 Cetronia Road Suite 205, North Allentown, PA, 18104, USA.
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23
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Duarte-Chavez R, Stoltzfus J, Marino D, Chaput K, El Chaar M. Correction to: "Which Factors Correlate with Marginal Ulcer After Surgery for Obesity?". Obes Surg 2020; 30:4828. [PMID: 33044688 DOI: 10.1007/s11695-020-05021-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In the original article, the author names were presented incorrectly; their family names and given names were inverted.
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Affiliation(s)
- Rodrigo Duarte-Chavez
- Department of Medicine, Division of Gastroenterology, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA.
| | - Jill Stoltzfus
- Department of Research, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA
| | - Daniel Marino
- Robert Wood Johnson Medical School, 1 Robert Wood Johnson place, New Brunswick, NJ, 08901, USA
| | - Kimberly Chaput
- Department of Medicine, Division of Gastroenterology, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA
| | - Maher El Chaar
- Department of Surgery, Division of Bariatric Surgery, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA
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Schmeitzel J, Litzenberger S, Stoltzfus J, Melanson S, Stankewicz H. 151 Analysis of Race and Sex Disparities in the Emergency Department. Ann Emerg Med 2020. [DOI: 10.1016/j.annemergmed.2020.09.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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25
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Fitzpatrick K, Patterson R, Morley K, Stoltzfus J, Stankewicz H. Physician Wellness During a Pandemic. West J Emerg Med 2020; 21:83-87. [PMID: 33052816 PMCID: PMC7673879 DOI: 10.5811/westjem.2020.7.48472] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/01/2020] [Accepted: 07/29/2020] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION We are currently in the midst of the coronavirus disease 2019 (COVID-19) pandemic. Research into previous infectious disease outbreaks has shown that healthcare workers are at increased risk for burnout during these dire times, with those on the front lines at greatest risk. The purpose of this prospective study was to determine the effect that the COVID-19 pandemic has had on the wellness of emergency physicians (EP). METHODS A survey was sent to 137 EPs in a multi-hospital network in eastern Pennsylvania. We compared 10 primary and two supplemental questions based on how the physicians had been feeling in the prior 2-3 weeks (COVID-19 period) to the same questions based on how they were feeling in the prior 4-6 months (pre-COVID-19 period). RESULTS We received 55 responses to the survey (40.1% response rate). The study found that during the pandemic, EPs felt less in control (p-value = 0.001); felt decreased happiness while at work (p-value 0.001); had more trouble falling asleep (p-value = 0.001); had an increased sense of dread when thinking of work needing to be done (p-value = 0.04); felt more stress on days not at work (p-value <0.0001); and were more concerned about their own health (p-value <0.0001) and the health of their families and loved ones (p-value <0.0001). CONCLUSION This study showed a statistically significant decrease in EP wellness during the COVID-19 pandemic when compared to the pre-pandemic period. We need to be aware of evidence-based recommendations to help mitigate the risks and prevent physician burnout.
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Affiliation(s)
- Kevin Fitzpatrick
- St. Luke's University Health Network, Department of Emergency Medicine, Bethlehem, Pennsylvania
| | - Rachel Patterson
- St. Luke's University Health Network, Department of Emergency Medicine, Bethlehem, Pennsylvania
| | - Krista Morley
- St. Luke's University Health Network, Department of Emergency Medicine, Bethlehem, Pennsylvania
| | - Jill Stoltzfus
- St. Luke's University Health Network, Department of Emergency Medicine, Bethlehem, Pennsylvania
| | - Holly Stankewicz
- St. Luke's University Health Network, Department of Emergency Medicine, Bethlehem, Pennsylvania
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King K, Galvez A, Stoltzfus J, Claros L, El Chaar M. Correction to: Cost Analysis of Robotic Roux-en-Y Gastric Bypass in a Single Academic Center: How Expensive Is Expensive? Obes Surg 2020; 31:472-473. [PMID: 32820353 DOI: 10.1007/s11695-020-04897-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Keith King
- St. Luke's University Health Network, Bethlehem, PA, USA
- St. Luke's University Health Network, Suite 205 North, 240 Cetronia Road, Allentown, PA, 18104, USA
| | - Alvaro Galvez
- St. Luke's University Health Network, Bethlehem, PA, USA
- St. Luke's University Health Network, Suite 205 North, 240 Cetronia Road, Allentown, PA, 18104, USA
| | - Jill Stoltzfus
- St. Luke's University Health Network, Bethlehem, PA, USA
- Temple Lewis Katz School of Medicine, Philadelphia, PA, USA
| | - Leonardo Claros
- St. Luke's University Health Network, Bethlehem, PA, USA
- Temple Lewis Katz School of Medicine, Philadelphia, PA, USA
| | - Maher El Chaar
- St. Luke's University Health Network, Bethlehem, PA, USA.
- Temple Lewis Katz School of Medicine, Philadelphia, PA, USA.
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King K, Galvez A, Stoltzfus J, Claros L, El Chaar M. Cost Analysis of Robotic Roux-en-Y Gastric Bypass in a Single Academic Center: How Expensive Is Expensive? Obes Surg 2020; 30:4860-4866. [PMID: 32720261 DOI: 10.1007/s11695-020-04881-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/22/2020] [Accepted: 07/23/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Although the use of da Vinci robotic platforms in bariatric surgery is gaining momentum, it is still controversial because of financial concerns. OBJECTIVES The objective of our study is to evaluate the cost of robotically assisted Roux-en-Y gastric bypass (R-RYGB) versus conventional laparoscopic Roux-en-Y gastric bypass (L-RYGB). METHODS We analyzed consecutive primary bariatric patients who underwent R-RYGB and compared them with patients who underwent L-RYGB during the same time period. Primary outcomes were overall cost for length of stay, operating time, and supplies. Direct cost data was generated using the StrataJazz reporting module, which is fed daily from EPIC, our electronic health record system, and contains hospital-based data only. Secondary outcomes were 30-day rates of complications, reoperations, and readmissions. RESULTS We found no difference in primary or secondary outcomes following R-RYGB and L-RYGB. The overall cost for R-RYGB and L-RYGB was not statistically different (median total cost for R-RYGB and L-RYBG was $6431.34 and $6349.09, P > 0.05, respectively). Operating time cost was significantly higher for R-RYGB compared with L-RYGB ($2248.51 versus $19,836.29, respectively, P < 0.0001, respectively). R-RYGB had lower cost of supplies as well as a shorter length of stay compared with L-RYGB (mean 1.5 versus 1.7 days, respectively). CONCLUSIONS Our study revealed no cost difference between R-RYGB and L-RYGB, with a decreased cost of supplies and trend toward lower hospital stay favoring R-RYGB. Further studies are needed to evaluate the outcomes of R-RYGB compared with L-RYGB; however, the cost of robotic surgery may not be a prohibitive factor.
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Affiliation(s)
- Keith King
- St. Luke's University Health Network, Bethlehem, PA, USA. .,St. Luke's University Health Network, Suite 205 North, 240 Cetronia Road, Allentown, PA, 18104, USA.
| | - Alvaro Galvez
- St. Luke's University Health Network, Bethlehem, PA, USA.,St. Luke's University Health Network, Suite 205 North, 240 Cetronia Road, Allentown, PA, 18104, USA
| | - Jill Stoltzfus
- St. Luke's University Health Network, Bethlehem, PA, USA.,Temple Lewis Katz School of Medicine, Philadelphia, PA, USA
| | - Leonardo Claros
- St. Luke's University Health Network, Bethlehem, PA, USA.,Temple Lewis Katz School of Medicine, Philadelphia, PA, USA
| | - Maher El Chaar
- St. Luke's University Health Network, Bethlehem, PA, USA.,Temple Lewis Katz School of Medicine, Philadelphia, PA, USA
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El Chaar M, King K, Al-Mardini A, Galvez A, Claros L, Stoltzfus J. Thirty-Day Outcomes of Bariatric Surgery in Adolescents: a First Look at the MBSAQIP Database. Obes Surg 2020; 31:194-199. [PMID: 32712784 PMCID: PMC7382644 DOI: 10.1007/s11695-020-04866-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/12/2020] [Accepted: 07/15/2020] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Bariatric surgery is the only effective treatment of severe obesity. The number of adolescents undergoing bariatric surgery is increasing. However, bariatric surgery in adolescents is controversial. OBJECTIVE The purpose of this study is to evaluate the outcomes of bariatric surgery in adolescents based on the MBSAQIP database (Metabolic and Bariatric Surgery Accreditation and Quality Improvement Project). METHODS We analyzed the 2015-2017 MBSAQIP database; patients ≤ 19 years of age were included in our analysis. Primary outcomes were 30-day serious adverse events (SAEs), organ space infection (OSI), re-intervention, and re-operation rates. Secondary outcomes included operation length, hospital stay, and re-admission rates. We conducted separate Mann-Whitney rank sums tests, chi-square, or Fisher's exact tests as appropriate, with p < .05 denoting statistical significance. RESULTS A total of 1983 adolescent patients were included in our analysis. The average age and BMI were 18.1 and 47.5, respectively. Of adolescent patients, 21.7% underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) and 78.3% underwent laparoscopic sleeve gastrectomy (LSG). The 30-day SAE and readmission rates were significantly lower for LSG compared with LRYGB (2.9% and 2.6% vs 6.5% and 5.6%, respectively; p < 0.05). The 30-day reoperation rate was also lower for LSG compared with LRYGB albeit not significant (1.1% and vs 2.3%; p = 0.05). The 30-day intervention rate for LSG was significantly lower, however, compared with LRYGB (1.2% vs 3%; p < 0.05). Compared with adult patients, > 19 years old (n = 353,726), we found no difference in our outcomes. However, adolescents had significantly shorter operation length. CONCLUSION In adolescents, LSG had fewer SAE, re-intervention, and readmission rates compared with LRYGB. There was no difference in outcomes between adolescents and adults.
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Affiliation(s)
- Maher El Chaar
- St. Luke's University Health Network (SLUHN), Bethlehem, PA, USA.,Temple Lewis Katz School of Medicine, Philadelphia, PA, USA
| | - Keith King
- St. Luke's University Health Network (SLUHN), Bethlehem, PA, USA. .,St Luke's University Health Network, 240 Cetronia Road, Suite 205 North, Allentown, PA, 18104, USA.
| | - Amin Al-Mardini
- St. Luke's University Health Network (SLUHN), Bethlehem, PA, USA
| | - Alvaro Galvez
- St. Luke's University Health Network (SLUHN), Bethlehem, PA, USA.,St Luke's University Health Network, 240 Cetronia Road, Suite 205 North, Allentown, PA, 18104, USA
| | - Leonardo Claros
- St. Luke's University Health Network (SLUHN), Bethlehem, PA, USA.,Temple Lewis Katz School of Medicine, Philadelphia, PA, USA
| | - Jill Stoltzfus
- St. Luke's University Health Network (SLUHN), Bethlehem, PA, USA.,Temple Lewis Katz School of Medicine, Philadelphia, PA, USA
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El Chaar M, King K, Pastrana M, Galvez A, Stoltzfus J. Outcomes of robotic surgery in revisional bariatric cases: a propensity score-matched analysis of the MBSAQIP registry. J Robot Surg 2020; 15:235-239. [PMID: 32474795 DOI: 10.1007/s11701-020-01098-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 05/26/2020] [Indexed: 11/29/2022]
Abstract
In recent years, there has been a significant increase in the number of Revisional Bariatric Surgery (RBS) cases performed to address complications and weight recidivism. The use of the da Vinci robotic platform, considered controversial by many, may offer advantages in RBS. The objective of our study is to compare the outcomes of Robotic RBS (R-RBS) to Laparoscopic RBS (L-RBS). Using the 2015-2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, we selected all RBS and we matched R-RBS to L-RBS using a propensity score matching system to create balanced groups. Our primary outcomes were 30-day Serious Adverse Events (SAE), 30-day Organ Specific Infection (OSI), 30-day reoperation and 30-day interventions. Our secondary outcomes included length of operation and 30-day readmission. We conducted separate Mann-Whitney rank sums tests or chi-square tests and Fisher exact test. R-RBS and L-RBS included 220 patients each. The overall incidence of 30-day SAEs, 30-day OSIs, 30-day reoperations, 30-day interventions were lower for R-RBS (6.4%, 0.9%, 2.7% and 2.3%, respectively) compared L-RBS (7.7%, 1.4%, 3.6% and 3.6%, respectively). Subgroup analysis showed that R-RBS had a lower rate of complications for the Gastric Bypass procedure but not for Sleeve gastrectomy cases. However, 30-day readmission was higher for R-RBS compared to L-RBS (9.1% vs 6.4% respectively). None of the analyses reached statistical significance. R-RBS took significantly longer compared to L-RBS (169 min vs 138 min, p < 0.05). Our study shows that R-RBS has lower complication rate albeit non-significant as compared to L-RBS.
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Affiliation(s)
- Maher El Chaar
- St. Luke's University Health Network (SLUHN), Bethlehem, PA, USA.,Temple Lewis Katz School of Medicine, Philadelphia, USA
| | - Keith King
- St. Luke's University Health Network (SLUHN), Bethlehem, PA, USA. .,St. Luke's University Health Network, 240 Cetronia Road, Suite 205 North, Allentown, PA, 18104, USA.
| | - Marlon Pastrana
- St. Luke's University Health Network (SLUHN), Bethlehem, PA, USA.,St. Luke's University Health Network, 240 Cetronia Road, Suite 205 North, Allentown, PA, 18104, USA
| | - Alvaro Galvez
- St. Luke's University Health Network (SLUHN), Bethlehem, PA, USA.,St. Luke's University Health Network, 240 Cetronia Road, Suite 205 North, Allentown, PA, 18104, USA
| | - Jill Stoltzfus
- St. Luke's University Health Network (SLUHN), Bethlehem, PA, USA.,Temple Lewis Katz School of Medicine, Philadelphia, USA
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Pastrana M, Stoltzfus J, AlMandini A, El Chaar M. Evolution of outcomes of robotic bariatric surgery: first report based on MBSAQIP database. Surg Obes Relat Dis 2020; 16:916-922. [PMID: 32340825 DOI: 10.1016/j.soard.2020.01.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 11/12/2019] [Accepted: 01/04/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Robotic surgery is increasingly being used in bariatric surgery; however, the benefits of robotic surgery in bariatrics remain controversial. OBJECTIVES The objective of this study was to compare the outcomes of robotic bariatric surgery with laparoscopic surgery over a 3-year period between 2015 and 2017 using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. SETTING University Hospital, United States. METHODS Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database for the years 2015 to 2017, we included patients who underwent primary robotic or laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass procedures. Patients were divided into either robotic or laparoscopic groups. Primary outcomes included serious adverse events, organ space infection (OSI), readmissions, reoperations, and interventions at 30 days. Secondary outcomes included operation length and hospital stay. We performed propensity score matching based on clinically relevant preoperative variables to create balanced groups before analysis. We analyzed our data using separate Cochran-Mantel-Haenszel tests with year as the stratification variable and conducted subgroup analyses for robotic patients only using separate t tests for proportions, with P < .05 denoting statistical significance. RESULTS Of the 315,647 patients available for comparison in the 2015 to 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant User Files, there were 41,364 matched in the final data set. Using the Cochran-Mantel-Haenszel test, we found a significant association between year of performance and outcomes for OSI, 30 day-readmission, and intervention. The incidence of OSI after laparoscopic and robotic cases was .3% and .4%, respectively, in 2015 versus .2% and .3%, respectively, in 2017 (P = .04, odds ratio = 1.49). Thirty-day readmission for robotic cases was 5.2% in 2015 and 4.0% in 2017 (P < .05, odds ratio = 1.16). The incidence of 30-day intervention for robotic cases also dropped from 2.2% in 2015 to 1.3% in 2017 (P < .05, odds ratio = 1.37). Using a Student's t test, there was also a statistically significant decrease in serious adverse events in the robotic group between 2015 and 2017 (incidence of serious adverse events in 2015 was 5.2% versus 3.7% in 2017, P < .05). Rate of 30-day reoperation for the robotic group did change over time but was comparable to the laparoscopic group (1.4% versus 1.3%). CONCLUSIONS Our study showed between 2015 and 2017 the outcomes of robotic bariatric surgery have improved as evidenced by the significant decrease in the rate of OSI, readmissions, and interventions at 30 days.
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Affiliation(s)
- Marlon Pastrana
- St. Luke's University Hospital and Health Network (SLUHN), Bethlehem, Pennsylvania
| | - Jill Stoltzfus
- St. Luke's University Hospital and Health Network (SLUHN), Bethlehem, Pennsylvania
| | - Amin AlMandini
- St. Luke's University Hospital and Health Network (SLUHN), Bethlehem, Pennsylvania
| | - Maher El Chaar
- St. Luke's University Hospital and Health Network (SLUHN), Bethlehem, Pennsylvania.
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Kelly B, Black J, Stoltzfus J, Stankewicz HA. Manipulation of Breath Alcohol Tests: Can Specific Techniques Alter Breath Alcohol Content? J Emerg Trauma Shock 2020; 13:54-57. [PMID: 32395051 PMCID: PMC7204959 DOI: 10.4103/jets.jets_4_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 06/04/2019] [Indexed: 11/05/2022] Open
Abstract
Objective: The most common form of measurement of breath alcohol content (BrAC) is through the use of a diode catheter. This study aims to test the accuracy of breath alcohol analysis through different manipulations. Methods: BrAC was measured after individuals consumed each standardized beer until they reached a 0.1 BrAC. Then, the individuals were breath analyzed while not providing full effort, using the side of their mouths, immediately after hyperventilating, 5 and 10 min after hyperventilation, immediately after a sip of water, and 5 min after that water. Results: There were 54 individuals. Two baselines were used as the controls. The first baseline was a mean BrAC of. 104 with standard deviation of +0.008 for poor effort, side of mouth, and hyperventilating. The second baseline used for drinking water manipulations was a BrAC of 0.099 + 0.11. Poor effort (mean + standard deviation: 0.099 ± 0.10, P < 0.0001), immediately after hyperventilating (0.086 ± 0.011, P < 0.0001), 5 min after hyperventilating (0.099 ± 0.009, P < 0.0001), and 10 min after hyperventilating (0.099 ± 0.011, P < 0.0001) were all found to be statistically significant in their ability to lower BrAC. Both immediately after water (0.084 ± 0.011, P < 0001) and 5 min after drinking water (0.096 ± 0.13, P < 0.0001) were found to have significantly altered the BrAC. Conclusion: Our research shows that manipulations can alter BrAC readings significantly. Breath analyzer operators should be cognizant of these methods that may lead to falsely lower BrAC readings.
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Affiliation(s)
- Brian Kelly
- Department of Emergency Medicine, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Jason Black
- Department of Emergency Medicine, Abrazo Healthcare System, Pheonix, AZ, USA
| | - Jill Stoltzfus
- Department of Research Institute, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Holly A Stankewicz
- Department of Emergency Medicine, St. Luke's University Health Network, Bethlehem, PA, USA
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Vallabhaneni S, Matka M, Thacker P, Carey M, Sarnoski C, Durkin R, Stoltzfus J, Shirani J. IMPACT OF PATIENT PROSTHESIS MISMATCH ON CLINICAL OUTCOMES OF PATIENTS UNDERGOING EDWARDS SAPIEN 3 TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR). J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)32801-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Pastrana M, Stoltzfus J, Claros L, El Chaar M. Outcomes of robotic bariatric surgery in super-obese patients: first report based on MBSAQIP database. Surg Obes Relat Dis 2019; 16:71-79. [PMID: 31767380 DOI: 10.1016/j.soard.2019.10.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 08/22/2019] [Accepted: 10/10/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Bariatric surgery in the super-obese (SO) patient population represents a challenge. Although the robotic platform is increasingly used for these patients, there are limited data on outcomes compared with conventional laparoscopy. OBJECTIVE Our study compared the safety and short-term outcomes of robotic and laparoscopic platforms for SO patients compared with morbidly obese patients based on the 2015 to 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. SETTING University Hospital, United States. METHODS We evaluated all primary robotic and laparoscopic cases and extracted 30-day outcomes in patients with body mass index <50 and ≤50 kg/m2. For our primary analysis, we used the Cochran-Mantel-Haenszel method with surgery type Roux-en-Y gastric bypass (RYGB) versus sleeve gastrectomy (SG) as the stratification variable to determine the association between body mass index categories and outcomes. RESULTS A total of 355,278 patients were included in our analysis. For the robotic RYGB (R-RYGB) group (n = 6645) and R-SG (n = 15,984) there were 1674 SO patients (25.2%) and 3688 SO patients (23.1%), respectively.For the laparoscopic RYGB (LRYGB) group (n = 95,374) and LSG group (n = 237,275), there were 24,991 (26.2%) and 51,524 SO patients (21.7%), respectively. The incidence of serious adverse events in SO patients for R-RYGB and LRYGB groups was 7.6% versus 7.2% (P > .05) and 4% versus 3.5% (P > .05) for R-SG and L-SG, respectively. The incidence of organ space infection in SO patients for R-RYGB and LRYGB groups was .5% versus .4% (P > .05) and .4% versus .2% (P < .05) for R-SG and LSG, respectively. CONCLUSIONS Based on 2015 to 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data, we found no difference in outcomes between robotic and laparoscopic approaches in SO patients. There was a higher incidence of serious adverse events in SO patients compared with morbidly obese patients for both approaches.
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Affiliation(s)
- Marlon Pastrana
- St Luke's University Hospital and Health Network, Lewis Katz School of Medicine at Temple University, Allentown, Pennsylvania
| | - Jill Stoltzfus
- St Luke's University Hospital and Health Network, Lewis Katz School of Medicine at Temple University, Allentown, Pennsylvania
| | - Leonardo Claros
- St Luke's University Hospital and Health Network, Lewis Katz School of Medicine at Temple University, Allentown, Pennsylvania
| | - Maher El Chaar
- St Luke's University Hospital and Health Network, Lewis Katz School of Medicine at Temple University, Allentown, Pennsylvania.
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El Chaar M, Al-Mardini A, Pastrana M, Stoltzfus J. A138 Outcomes of Bariatric Surgery in Adolescents: First Look Based on MBSAQIP. Surg Obes Relat Dis 2019. [DOI: 10.1016/j.soard.2019.08.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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El Chaar M, Pastrana M, Stoltzfus J. A148 Safety of Robotic Surgery in the Super Obese Patients: First Analysis Using MBSAQIP data 2015-2017. Surg Obes Relat Dis 2019. [DOI: 10.1016/j.soard.2019.08.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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El Chaar M, Pastrana MP, Claros L, Stoltzfus J. A142 Evolution of Robotic Outcomes in Bariatric Surgery: First look at MBSAQIP database. Surg Obes Relat Dis 2019. [DOI: 10.1016/j.soard.2019.08.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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El Chaar M, Stoltzfus J, Melitics M, Claros L, Zeido A. 30-Day Outcomes of Revisional Bariatric Stapling Procedures: First Report Based on MBSAQIP Data Registry. Obes Surg 2019; 28:2233-2240. [PMID: 29876840 DOI: 10.1007/s11695-018-3140-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The number of bariatric revisional cases has nearly doubled since 2011, and now comprises 13.6% of the total number of cases. The objective of this study is to evaluate the outcomes and safety of the two most common stapling revisional procedures, namely, sleeve and gastric bypass in comparison to primary stapling procedures using the MBSAQIP data registry. METHODS We reviewed all the sleeve and gastric bypass cases entered between January 1, 2015, and December 31, 2015, in the MBSAQIP data registry. We, then, identified sleeve and bypass patients who have had a previous bariatric procedure. Demographics and 30 day outcomes of all sleeve and gastric bypass patients were analyzed. We conducted within group comparisons comparing primary sleeve gastrectomy (PS) and primary gastric bypass (PB) patients to revisional sleeve (RS) and revisional gastric bypass (RB) patients, respectively. We, then, conducted group comparisons comparing RS to RB patients. RESULTS The total number of patients analyzed was 141,577 (98,292 or 69% sleeve patients and 43,285 or 31% gastric bypass patients). Among the sleeve patients, 92,666 (94%) had a PS and 5626 (6%) had RS. Among the bypass patients, 39,567 (91%) had a PB and 3718 patients (9%) had RB. 30-day readmission rate of RS was significantly higher as compared to PS (4.1 vs 0.4%, p < 0.05). The incidence of at least one complication requiring reoperation or reintervention within 30 days following RS was twice as high as compared to PS (1.9 and 2% for RS vs 0.9 and 1.1% for PS respectively, p < 0.05). Length of stay and 30 day mortality rates for PS and RS were the same. 30-day readmission rate of RB as compared to PB was 8.3 vs 6.3% (p < 0.05). Also, the incidence of at least one complication requiring reoperation or reintervention following RB was 3.9 and 4%, respectively vs 2.4 and 2.7% for PB (p < 0.05). In addition, readmission rates and unplanned admission rates to the ICU were significantly higher for RB compared to RS (8.3 and 2% for RB vs 4.1 and 0.9% for RS respectively, p < 0.05). The incidence of at least one reoperation or one intervention following RB were also significantly higher compared to RS (3.9 vs 1.9% and 4 vs 2% respectively, p < 0.05). CONCLUSION Revisional stapling procedures are safe but the rates of complications following RS and RB are twice as high compared to PS and PB. Also, RB are more likely to develop complications compared to RS.
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Affiliation(s)
- Maher El Chaar
- St Luke's University Hospital and Health Network, Allentown, PA, USA.
| | - Jill Stoltzfus
- St Luke's University Hospital and Health Network, Allentown, PA, USA
| | - Maureen Melitics
- St Luke's University Hospital and Health Network, Allentown, PA, USA
| | - Leonardo Claros
- St Luke's University Hospital and Health Network, Allentown, PA, USA
| | - Ahmad Zeido
- St Luke's University Hospital and Health Network, Allentown, PA, USA
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El Chaar M, Stoltzfus J, Melitics M, Claros L, Zeido A. Correction to: 30-Day Outcomes of Revisional Bariatric Stapling Procedures: First Report Based on MBSAQIP Data Registry. Obes Surg 2019; 29:2357. [DOI: 10.1007/s11695-019-03886-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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El Chaar M, Gacke J, Ringold S, Stoltzfus J. Cost analysis of robotic sleeve gastrectomy (R-SG) compared with laparoscopic sleeve gastrectomy (L-SG) in a single academic center: debunking a myth! Surg Obes Relat Dis 2019; 15:675-679. [PMID: 31043334 DOI: 10.1016/j.soard.2019.02.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/18/2019] [Accepted: 02/21/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although use of the da Vinci robotic platform in bariatric surgery is gaining momentum, there are financial concerns. OBJECTIVES Our retrospective study evaluated the cost of robotically assisted sleeve gastrectomy (R-SG) versus conventional laparoscopic sleeve gastrectomy (L-SG). SETTING Center of Excellence bariatric surgery center in Allentown, Pennsylvania. METHODS We analyzed consecutive patients who underwent primary R-SG and compared them with L-SG patients. Primary outcomes were overall cost for length of stay, operating time, and supplies. Secondary outcomes were 30-day complications, reoperations, and readmissions. RESULTS We had no adverse events in either group. The overall cost for R-SG and L-SG was not statistically different (mean total cost for R-SG and L-SG was $5308.99 and $4918.88, respectively). Operating time cost was significantly higher for R-SG compared with L-SG ($1340 versus $112 for R-SG and L-SG, respectively). R-SG had a shorter length of stay compared with L-SG (1.4 versus 1.5 d, respectively). CONCLUSIONS Our study revealed no difference in cost R-SG and L-SG, with a trend toward shorter length of stay for R-SG over time.
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Affiliation(s)
- Maher El Chaar
- St. Luke's University Health Network, Allentown, Pennsylvania; Temple University/St Luke's University Health Network, School of Medicine, Allentown, Pennsylvania.
| | - Jacob Gacke
- Temple University/St Luke's University Health Network, School of Medicine, Allentown, Pennsylvania
| | - Samuel Ringold
- University of Michigan College of Engineering, Ann Arbor, Michigan
| | - Jill Stoltzfus
- Temple University/St Luke's University Health Network, School of Medicine, Allentown, Pennsylvania; Research Institute, St. Luke's University Health Network, Allentown, Pennsylvania
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El Chaar M, Stoltzfus J, Gersin K, Thompson K. A novel risk prediction model for 30-day severe adverse events and readmissions following bariatric surgery based on the MBSAQIP database. Surg Obes Relat Dis 2019; 15:1138-1145. [PMID: 31053498 DOI: 10.1016/j.soard.2019.03.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 01/21/2019] [Accepted: 03/01/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although bariatric surgery is safe, some patients fear serious complications. OBJECTIVES This retrospective study used the 2015 Metabolic and Bariatric Surgery Accreditation Quality Improvement Project (MBSAQIP) database to evaluate patient outcomes for gastric bypass (GB) and sleeve gastrectomy and to develop a risk prediction model for serious adverse events (SAEs) and readmission rates 30 days after surgery. SETTING MBSAQIP national patient database. METHODS We created separate exploratory multivariable logistic regression models for SAEs and readmissions. We then externally validated both models using the 2016 MBSAQIP Participant Use Data File. RESULTS Significant predictors of SAEs were preoperative body mass index (adjusted odds ratio [AOR] 1.07, P < .0001); GB surgery (AOR 2.08, P < .0001); cardiovascular disease (AOR 1.43, P < .0001); smoking (AOR 1.12, P = .04); diabetes (AOR 1.15, P = .0001); hypertension (AOR 1.17, P < .0001); limited ambulation (AOR 1.48, P < .0001); sleep apnea (AOR 1.12, P = .001); history of pulmonary embolism (AOR 2.81, P < .0001); and steroid use (AOR 1.40, P = .001). Significant predictors of readmissions were GB surgery (AOR 1.81, P < .0001); female sex (AOR 1.26, P < .0001); diabetes (AOR 1.08, P = .04); hypertension (AOR 1.11, P = .004); preoperative body mass index (AOR 1.05, P < .0001); sleep apnea (AOR 1.11, P = .002); history of pulmonary embolism (AOR 2.35, P < .0001); cardiovascular disease (AOR 1.61, P < .0001); smoking (AOR 1.14, P = .01); and limited ambulation (AOR 1.55, P < .0001). External validation supported these covariates, with similar model discriminative power. CONCLUSIONS Our exploratory regression models may be used by clinicians to counsel patients about surgical risks, although future external validation should occur in non-North American populations.
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Affiliation(s)
- Maher El Chaar
- St Luke's University Hospital and Health Network, Lewis Katz School of Medicine at Temple University, Allentown, Pennsylvania.
| | - Jill Stoltzfus
- St Luke's University Hospital and Health Network, Lewis Katz School of Medicine at Temple University, Allentown, Pennsylvania
| | - Keith Gersin
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Kyle Thompson
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
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Lee C, Strauss D, Stone L, Stoltzfus J, Puc M, Burfeind W. Preoperative CHA2DS2-VASc Score Predicts Postoperative Atrial Fibrillation after Lobectomy. Thorac Cardiovasc Surg 2019; 67:125-130. [DOI: 10.1055/s-0038-1675638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background Postoperative atrial fibrillation (POAF) affects 10 to 20% of noncardiac thoracic surgeries and increases patient morbidity and costs. The purpose of this study is to determine if preoperative CHA2DS2-VASc score can predict POAF after pulmonary lobectomy for nonsmall cell lung cancer.
Methods Patients with complete CHA2DS2-VASc data who underwent lobectomies from January 2007 to January 2016 at a single institution were analyzed in a retrospective case–control study using a prospective database. An independent samples t-test was used to compare the mean CHA2DS2-VASc scores of POAF and non-POAF groups. A multivariable logistic regression analysis (MVA) evaluated the independent contribution of variables of the CHA2DS2-VASc score in predicting POAF. Chi-square test with univariate odds ratios (ORs) was used to determine a statistically significant cutoff score for predicting POAF.
Results Of 525 total patients, 82 (15.6%) developed POAF (mean CHA2DS2-VASc score: 2.7) and 443 (84.4%) did not develop POAF (mean score: 2.3). Mean difference between these groups was significant at 0.43 (p = 0.01; 95% confidence interval [CI]: 0.09–0.76). In the MVA, significant predictors of POAF were age 65 to 74 years (adjusted OR [aOR] = 2.45; 95% CI: 1.31–4.70; p = 0.006) and age ≥75 years (aOR = 3.11; 95% CI: 1.62–5.95; p = 0.0006). Patients with CHA2DS2-VASc scores ≥5 had significantly increased OR for POAF (OR = 2.59; 95% CI: 1.22–5.50).
Conclusions Preoperatively calculated CHA2DS2-VASc score can predict POAF in patients undergoing pulmonary lobectomy. Age is the most statistically significant independent predictor, and patients with scores ≥5 have significantly increased risk. Trials for POAF prophylaxis should target this population.
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Affiliation(s)
- Charles Lee
- Department of Surgery, St. Luke's University Health Network, Bethlehem, Pennsylvania, United States
- Department of Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania, United States
| | - David Strauss
- Department of Surgery, St. Luke's University Health Network, Bethlehem, Pennsylvania, United States
- Department of Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania, United States
| | - Lauren Stone
- Department of Surgery, St. Luke's University Health Network, Bethlehem, Pennsylvania, United States
- Department of Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania, United States
| | - Jill Stoltzfus
- Department of Surgery, St. Luke's University Health Network, Bethlehem, Pennsylvania, United States
| | - Matthew Puc
- Department of Surgery, St. Luke's University Health Network, Bethlehem, Pennsylvania, United States
| | - William Burfeind
- Department of Surgery, St. Luke's University Health Network, Bethlehem, Pennsylvania, United States
- Department of Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania, United States
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Lands V, Avery D, Malige A, Stoltzfus J, Gibson B, Carolan G. Rating visualization in shoulder arthroscopy: A comparison of the visual analog scale versus a novel shoulder arthroscopy grading scaleRating visualization in shoulder arthroscopy: A comparison of the visual analog scale versus a novel shoulder arthroscopy grading scale. J Orthop Allied Sci 2019. [DOI: 10.4103/joas.joas_8_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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El Chaar M, Stoltzfus J. Assessment of Sleeve Gastrectomy Surgical Technique: First Look at 30-Day Outcomes Based on the MBSAQIP Database. J Am Coll Surg 2018; 227:564-572. [DOI: 10.1016/j.jamcollsurg.2018.09.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 09/25/2018] [Accepted: 09/25/2018] [Indexed: 12/29/2022]
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Milano A, Stankewicz H, Stoltzfus J, Salen P. The Impact of a Standardized Checklist on Transition of Care During Emergency Department Resident Physician Change of Shift. West J Emerg Med 2018; 20:29-34. [PMID: 30643598 PMCID: PMC6324700 DOI: 10.5811/westjem.2018.10.39020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 09/09/2018] [Accepted: 10/04/2018] [Indexed: 11/11/2022] Open
Abstract
Introduction Transitions of patient care during physicians' change of shift introduce the potential for critical information to be missed or distorted, resulting in possible morbidity. The Joint Commission, the Accreditation Council for Graduate Medical Education, and the Society of Hospital Medicine jointly encourage a structured format for patient care sign-out. This study's objective was to examine the impact of a standardized checklist on the quality of emergency medicine (EM) resident physicians' patient-care transition at shift change. Methods Investigators developed a standardized sign-out checklist for EM residents to complete prior to sign out. This checklist included topics of diagnoses, patient-care tasks to do, patient disposition, admission team, and patient code status. Two EM attending physicians, the incoming and departing, assessed the quality of transitions of care at this shift change using a standardized assessment form. This form also assessed overall quality of sign-out using a visual analog scale (VAS), based on a 10-centimeter scale. For two months, we collected initial, status quo data (pre-checklist [PCL] cohort) followed by two months of residents using the checklist (post-checklist [CL] cohort). Results We collected data for 77 days (July 1, 2015 - November 11, 2015), 38 days of status quo sign-out followed by 39 days of checklist utilization, comprised of 1,245 attending assessments. Global assessment of sign-out for the CL was 8 compared to 7.5 for the PCL. Aspects of transition of care that implementation of the sign-out checklist impacted included the following (reported as a frequency): "To Do" (PCL 84.3%, CL 97.8%); "Disposition" (PCL 97.2%, CL 99.4%); "Admit Team" (67.1%, CL 76.2%); and "Attending Add" (PCL 23.4%, CL 11.3%). Conclusion Implementation of a sign-out checklist enhanced EM resident physician transition of care at shift end by increasing the frequency of discussion of critical tasks remaining for patient care, disposition status, and subjective assessment of quality of sign-out.
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Affiliation(s)
- Alyssa Milano
- St. Luke's University Health Network, Department of Emergency Medicine, Bethlehem, Pennsylvania
| | - Holly Stankewicz
- St. Luke's University Health Network, Department of Emergency Medicine, Bethlehem, Pennsylvania
| | - Jill Stoltzfus
- St. Luke's University Health Network, Research Institute, Department of Emergency Medicine, Bethlehem, Pennsylvania
| | - Philip Salen
- St. Luke's University Health Network, Department of Emergency Medicine, Bethlehem, Pennsylvania
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Chaar ME, Stoltzfus J. First look at the Outcomes of the Different Sleeve Gastrectomy (SG) Surgical Techniques Reported in MBSAQIP: What Did We Learn? Surg Obes Relat Dis 2018. [DOI: 10.1016/j.soard.2018.09.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Chaar ME, Stoltzfus J, Gersin KS, Thompson KJ. A Novel Risk Prediction Model for Complications and Readmissions Following Bariatric Surgery Based on the MBSAQIP database. Surg Obes Relat Dis 2018. [DOI: 10.1016/j.soard.2018.09.475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Lundberg PW, Stoltzfus J, El Chaar M. 30-day outcomes of robot-assisted versus conventional laparoscopic sleeve gastrectomy: First analysis based on MBSAQIP. Surg Obes Relat Dis 2018; 15:1-7. [PMID: 30497847 DOI: 10.1016/j.soard.2018.10.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 08/30/2018] [Accepted: 10/20/2018] [Indexed: 01/25/2023]
Abstract
BACKGROUND Sleeve gastrectomy (SG) is the most popular bariatric procedure in the United States. Although standardized, variation exists in how the staple line is managed. Robotic approaches to SG (RSG) are increasing, though benefits compared with the conventional laparoscopic approach (LSG) remain controversial. OBJECTIVE Evaluate the safety of RSG versus LSG using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry, controlling for variation in staple-line management. SETTING University health network, United States. METHODS SG cases from January 1 to December 31, 2016, in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry were included. Demographic characteristics and 30-day outcomes were analyzed with separate Mann-Whitney rank sums tests, χ2 tests, or Fisher's exact tests, with P < .05 denoting statistical significance. Multivariate regression analysis was performed to control for method of staple-line treatment. RESULTS Of the 107,726 patients who underwent SG, 7385 were RSG. Treatment of the staple line was associated with a significantly lower rate of bleeding, with odds ratios of .69 and .58 for staple-line reinforcement alone and staple-line reinforcement plus oversewing, respectively. Multivariate analysis revealed RSG had a higher rate of organ space infection than LSG (odds ratio 2.07). Otherwise, RSG did not significantly differ from LSG save for a longer median operative time (89 versus 63 min, respectively, P < .0001). CONCLUSIONS RSG is a growing alternative to the conventional laparoscopic approach. According to the 2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, the RSG carries a higher risk of organ space infection. The reasons behind this finding require further study.
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Affiliation(s)
| | - Jill Stoltzfus
- St. Luke's University Health Network, Bethlehem, Pennsylvania
| | - Maher El Chaar
- St. Luke's University Health Network, Bethlehem, Pennsylvania.
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Lundberg PW, Wolfe S, Seaone J, Stoltzfus J, Claros L, El Chaar M. Robotic gastric bypass is getting better: first results from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Surg Obes Relat Dis 2018; 14:1240-1245. [PMID: 30580769 DOI: 10.1016/j.soard.2018.05.022] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 04/30/2018] [Accepted: 05/26/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND The use of robotic platforms in performing laparoscopic Roux-en-Y gastric bypass (LRYGB) is increasing, though their safety compared with the conventional laparoscopic approach remains unclear. OBJECTIVE The objective of this study was to evaluate perioperative data and 30-day outcomes of conventional and robot-assisted LRYGB using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry. SETTING University health network, United States. METHODS We reviewed all conventional and robot-assisted LRYGB cases entered between January 1 and December 31, 2016 in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry. Demographic characteristics and 30-day outcomes were analyzed based on separate Mann-Whitney rank sums tests, χ2, or Fisher's exact tests as appropriate, with P ≤ .05 denoting statistical significance with no adjustment for multiple testing. RESULTS Of the 39,425 patients who underwent LRYGB, 2822 were robot-assisted. The robot-assisted approach required significantly more time (138 versus 108 min, P < .0001). Rates of organ space infection, bleeding, and other significant adverse events after the conventional and robot-assisted approaches were .3% versus .5% (P = .13), 1.1% versus .8% (P = .11), and 2.3% versus 2.3% (P = .96), respectively. There were also no significant differences in the rates of mortality, length of stay, reoperation, or readmission between the 2 groups. CONCLUSIONS Robot-assisted LRYGB is an increasingly popular alternative to the conventional laparoscopic approach. According to the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, the early safety of these 2 techniques is equal, although the robotic approach requires more operative time.
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Affiliation(s)
| | - Samantha Wolfe
- St. Luke's University Health Network, Bethlehem, Pennsylvania
| | - Jacqueline Seaone
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Jill Stoltzfus
- St. Luke's University Health Network, Bethlehem, Pennsylvania
| | - Leonardo Claros
- St. Luke's University Health Network, Bethlehem, Pennsylvania
| | - Maher El Chaar
- St. Luke's University Health Network, Bethlehem, Pennsylvania
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Chaar ME, Lundberg P, Stoltzfus J. Thirty-day outcomes of sleeve gastrectomy versus Roux-en-Y gastric bypass: first report based on Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. Surg Obes Relat Dis 2018; 14:545-551. [DOI: 10.1016/j.soard.2018.01.011] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 01/05/2018] [Accepted: 01/08/2018] [Indexed: 10/18/2022]
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Qiu J, Lundberg PW, Javier Birriel T, Claros L, Stoltzfus J, El Chaar M. Revisional Bariatric Surgery for Weight Regain and Refractory Complications in a Single MBSAQIP Accredited Center: What Are We Dealing with? Obes Surg 2018; 28:2789-2795. [DOI: 10.1007/s11695-018-3245-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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