Evaluation of the effect of sleeve gastrectomy versus Roux-en-Y gastric bypass in patients with morbid obesity: multicenter comparative study

INTRODUCTION

Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are the two most performed techniques in bariatric surgery. The aim of this study is to compare two surgical procedures in terms of weight loss and the development of comorbidities such as type II diabetes mellitus T2D, arterial hypertension, sleep apnea (OSAS), and gastroesophageal reflux disease (GERD).

METHODS

Data from the German Bariatric Surgery Registry (GBSR) from 2005 to 2021 were used. 1,392 RYGB and 1,132 SG primary surgery patients were included. Minimum age 18 years; five-year follow-up data available. Tests were performed with a 5% significance level.

RESULTS

Loss of follow-up 95.41% within five years. Five years after surgery, the RYGB showed significant advantages in terms of excess weight loss (%EWL 64.2% vs. 56.9%) and remission rates of the studied comorbidities: hypertension (54.4% vs. 47.8%), OSAS (64.5% vs. 50.1%), and GERD (86.1% vs. 66.9%). Compared to the pre-test, individuals diagnosed with insulin-dependent T2D showed significant improvements with RYGB over a five-year period (remission rate: 75% vs. 63%). In contrast, non-insulin-dependent T2D showed no significant difference between the two approaches (p = 0.125).

CONCLUSION

Both surgical procedures resulted in significant weight loss and improved comorbidities. However, the improvement in comorbidities was significantly greater in patients who underwent RYGB than in those who underwent SG, suggesting that the RYGB technique is preferable. Nevertheless, RYGB requires a high degree of surgical skill. Therefore, acquiring expertise in the technical facets of the surgery is essential to achieving favorable outcomes.

Randomized investigation of the MitraClip device in heart failure: Design and rationale of the RESHAPE-HF2 trial design

AIMS

The safety and effectiveness of the MitraClip device to treat functional mitral regurgitation (FMR) has been tested in previous clinical trials yielding somewhat heterogeneous results in heart failure (HF) patients. Over time, the MitraClip device system has been modified and clinical practice evolved to consider also less severely diseased HF patients with FMR for this therapeutic option. The RESHAPE-HF2 trial aims to assess the safety and effectiveness of the MitraClip device system on top of medical therapy considered optimal in the treatment of clinically significant FMR in symptomatic patients with chronic HF.

METHODS

The RESHAPE-HF2 is an investigator-initiated, prospective, randomized, parallel-controlled, multicentre trial designed to evaluate the use of the MitraClip device (used in the most up-to-date version as available at sites) plus optimal standard of care therapy (device group) compared to optimal standard of care therapy alone (control group). Eligible subjects have signs and symptoms of HF (New York Heart Association [NYHA] class II-IV despite optimal therapy), and have moderate-to-severe or severe FMR, as confirmed by a central echocardiography core laboratory; have an ejection fraction between ≥20% and ≤50% (initially 15-35% for NYHA class II patients, and 15-45% for NYHA class III/IV patients); have been adequately treated per applicable standards, and have received appropriate revascularization and cardiac resynchronization therapy, if eligible; had a HF hospitalization or elevated natriuretic peptides (B-type natriuretic peptide [BNP] ≥300 pg/ml or N-terminal proBNP ≥1000 pg/ml) in the last 90 days; and in whom isolated mitral valve surgery is not a recommended treatment option. The trial has three primary endpoints, which are these: (i) the composite rate of total (first and recurrent) HF hospitalizations and cardiovascular death during 24 months of follow-up, (ii) the rate of total (i.e. first and recurrent) HF hospitalizations within 24 months, and (iii) the change from baseline to 12 months in the Kansas City Cardiomyopathy Questionnaire overall score. The three primary endpoints will be analysed using the Hochberg procedure to control the familywise type I error rate across the three hypotheses.

CONCLUSIONS

The RESHAPE-HF2 trial will provide sound evidence on the MitraClip device and its effects in HF patients with FMR. The recruitment was recently completed with 506 randomized patients.

Prevalence and Risk Factors of Poststroke Dysphagia: A Meta-Analysis

INTRODUCTION

In patients with stroke, poststroke dysphagia (PSD) is a common complication that plays an important role in morbidity and mortality. The aim of this paper was to assess the prevalence and risk factors of PSD using a systemic review and meta-analysis.

METHODS

PubMed, Embase, Cochrane Library, and Web of Science databases were systematically searched for potentially eligible studies published until September 2023. Further, the pooled incidence and risk factors for PSD were determined using a random-effects model. Overall, 58 studies involving 37,404 patients with acute stroke were selected for the meta-analysis.

RESULTS

The pooled incidence of PSD in patients with acute stroke was 42% (95% confidence interval [CI]: 36-48%), which is the highest in South America (47%) and lowest in Asia (37%). Notably, older age (odds ratio [OR]: 2.13; 95% CI: 1.53-2.97; p < 0.001), hypertension (OR: 1.23; 95% CI: 1.06-1.44; p = 0.007), diabetes mellitus (OR: 1.22; 95% CI: 1.04-1.44; p = 0.014), stroke history (OR: 1.26; 95% CI: 1.04-1.53; p = 0.019), and atrial fibrillation (OR: 1.58; 95% CI: 1.02-2.44; p = 0.039) were found to be associated with an increased risk of PSD. Conversely, sex differences, smoking, alcoholism, obesity, hyperlipidemia, ischemic heart disease, stroke type, and the hemisphere affected were not associated with the risk of PSD.

CONCLUSION

The abstract reports the prevalence of PSD in patients with acute stroke and identified potential risk factors for PSD, including older age, hypertension, diabetes mellitus, stroke history, and atrial fibrillation.

Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Anemia tolerance

Anemia is a pathological condition in which the hemoglobin and red blood cell mass decrease; it is mainly defined by the concentration of hemoglobin in the blood. The World Health Organization guidelines establish specific values to define anemia in different population groups. Early detection of anemia can also be a valuable indicator of underlying medical conditions. Clinical studies have explored the relationship between perioperative anemia and morbidity, highlighting the need for more judicious therapeutic strategies, such as the use of Patient Blood Management, which aims to prevent and treat anemia in a personalized and effective way. Patient Blood Management emerges as a promising approach to dealing with anemia, recognizing that its correction through transfusion always carries risks and that personalized prevention and treatment can offer better outcomes for patients.

Revascularization for claudication: Changing the natural history of a benign disease!

OBJECTIVE

The benign natural history of intermittent claudication was first documented in 1960 and has been reconfirmed in several subsequent studies. Excellent outcomes in patients with intermittent claudication can be achieved with exercise therapy and optimal medical management. Professional society guidelines have clearly stated that revascularization procedures should be performed only in patients with incapacitating claudication who have failed conservative therapy. Despite these guidelines, revascularization procedures, primarily percutaneous interventions, have been increasingly utilized in patients with claudication. Many of these patients are not even offered an attempt at medical therapy, and those who are often do not undergo a full course of treatment. Many studies document significant reintervention rates following revascularization, which are associated with increased rates of acute and chronic limb ischemia that may result in significant rates of amputation. The objectives of this study were to compare outcomes of conservative therapy to those seen in patients undergoing revascularization procedures and to determine the impact of revascularization on the natural history of claudication.

METHODS

Google Scholar and PubMed were searched for manuscripts on the conservative management of claudication and for those reporting outcomes following revascularization for claudication.

RESULTS

Despite early improvement in claudication symptoms following revascularization, multiple studies have demonstrated that long-term outcomes following revascularization are often no better than those obtained with conservative therapy. High reintervention rates (up to 43% for tibial atherectomies) result in high rates of both acute and chronic limb ischemia as compared with those patients undergoing medical therapy. In addition, amputation rates as high as 11% on long-term follow-up are seen in patients undergoing early revascularization. These patients also have a higher incidence of adverse cardiovascular events such as myocardial infarctions compared with patients treated medically.

CONCLUSIONS

Revascularization procedures negatively impact the natural history of claudication often resulting in multiple interventions, an increase in the incidence of acute and chronic limb ischemia, and an increased risk of amputation. Accordingly, informed consent requires that all patients undergoing early revascularization must be appraised of the potential negative impact of revascularization on the natural history of claudication.

Evaluation of different scoring systems in the prediction of complications, morbidity, and mortality after laparoscopic radical gastrectomy

BACKGROUND

This retrospective study aimed to assess the suitability of POSSUM and its modified versions, E-PASS and its modified score, SRS, and SORT scores for predicting postoperative complications and mortality in patients undergoing laparoscopic radical gastrectomy for gastric cancer.

MATERIALS AND METHODS

Data analysis was performed on 349 patients who underwent laparoscopic radical gastrectomy at Tianjin Medical University General Hospital between January 2016 and December 2021. The discriminative ability of the scoring systems was evaluated using the area under the receiver operating characteristic curve (AUC). The primary endpoint focused on the prediction of postoperative complications, while the secondary endpoint assessed the prediction of postoperative mortality.

RESULTS

Among the scoring systems evaluated, the modified E-PASS (mE-PASS) score exhibited the highest AUC (0.846) and demonstrated the highest sensitivity (81%) and specificity (79%) for predicting postoperative complications. All other scores, except for POSSUM, showed moderate discriminative ability in predicting complications. In terms of predicting postoperative mortality, the E-PASS score had the highest AUC (0.978), while the mE-PASS score displayed the highest sensitivity (76%) and specificity (90%). Notably, both E-PASS and mE-PASS scores exhibited excellent discriminative ability.

CONCLUSIONS

The P-POSSUM, O-POSSUM, E-PASS, mE-PASS, SRS, and SORT scoring systems are useful tools for predicting postoperative outcomes in laparoscopic radical gastrectomy. Among them, the mE-PASS score demonstrated the best predictive power. However, the POSSUM system could only be applicable to predict postoperative mortality.

Political stability as a major determinant of the Covid-19 pandemic outcomes

This paper explores the role of political stability in explaining the cross-country variation of Covid-19 pandemic outcomes. Based on the international evidence, we find that lower pre-Covid-19 levels of political stability are associated with worse Covid-19 pandemic outcomes. Politically unstable countries are more likely to suffered significantly higher morbidity and mortality. Further analysis shows that political stability only matters in countries prepared with requisite medical capacity to deal with health emergencies. We also find that political stability is more crucial in countries with higher poverty rates. Overall, to combat Covid-19 and the subsequential collective threats successfully, the national authorities should pay more attention to maintain political stability.

Laparoscopic cholecystectomy in super elderly (> 90 years of age): safety and outcomes

BACKGROUND

Nonagenarian patients are an age group in progressive growth. In this age group, indications for surgical procedures, including cholecystectomy, will be increasingly frequent, as biliary pathology and its complications are frequent in this population group. The main objective of this study was to analyze the safety and outcomes of laparoscopic cholecystectomy in patients older than 90 years.

METHODS

A retrospective observational cohort study was designed. This study involved 600 patients that were classified in 4 age groups for analysis (under 50 years, 50-69 years, 70-89 years, and over 90 years). Demographic, clinical, paraclinics, surgical, and outcome variables were compared according to age group. A multivariate analysis, which included variables considered clinically relevant, was performed to identify factors associated with mortality and complications classified with the Clavien-Dindo scale.

RESULTS

The patients evaluated had a median age of 65.0 (IQR 34.0) years and there was a female predominance (61.8%). A higher complication rate, conversion rate, subtotal cholecystectomy rate, and prolonged hospital stay were found in nonagenarians. The overall mortality rate was 1.6%. Mortality in the age group over 90 years was 6.8%. Regression models showed that age over 90 years (RR 4.6 CI95% 1.07-20.13), presence of cholecystitis (RR 8.2 CI95% 1.29-51.81), and time from admission to cholecystectomy (RR 1.2 CI95% 1.10-1.40) were the variables that presented statistically significant differences as risk factors for mortality.

CONCLUSION

Cholecystectomy in nonagenarian patients has a higher rate of complications, conversion rate, subtotal cholecystectomy rate, and mortality. Therefore, an adequate perioperative assessment is necessary to optimize comorbidities and improve outcomes. Also, it is important to know the greatest risk for informed consent and choose the surgical equipment and schedule of the procedure.

[COSA 80: Oncologic surgery in the elderly patients]

INTRODUCTION

Due to longer life expectancy, an increasing number of older people are at risk of developing cancer. Surgical resection of a non-metastatic and resectable digestive tumor remains the main therapeutic weapon. The objective of our study is to assess the possibility of curative oncological surgery in patients over 80years of age, to study its impact in terms of morbidity and mortality, and to look for risk factors for the occurrence of complications.

PATIENTS AND METHODS

The study-included patients aged 80 and over operated on for digestive cancer in a curative situation. This was a multicenter prospective cohort study. A total of 230 patients were included in the study. In addition to demographic and medical data, the patients all benefited from an onco-geriatric assessment with the performance of various tests: WHO score, G8 score, IADL score, ADL score, mobility score, nutritional assessment, clock, thymic evaluation (Mini-GDS). Data collection of geriatric scores was repeated 3months postoperatively.

RESULTS

Of a total of 230 patients, 51% were male and 49% female. The average age was 84.7years. Tumor localization was mainly colorectal (65.81%). Age had no influence on the mortality rate, with a mean age with no significant difference in the event of an unfavorable outcome or not (84.6 vs. 85years). The results at the different scores were then analyzed in search of a significant difference between preoperative and at 3months. The only significant difference found was in the number of patients with a WHO status of 0 (P=0.021).

CONCLUSION

Our study shows that curative oncological surgery is possible in elderly patients without any adverse effect on their quality of life and level of postoperative autonomy. The multidisciplinary geriatric approach to the patient must make it possible to distinguish the patients who will benefit from a curative treatment and those in whom the benefit-risk balance is unfavorable.

Adverse events in neurosurgery: a comprehensive single-center analysis of a prospectively compiled database

PURPOSE

To prospectively identify and quantify neurosurgical adverse events (AEs) in a tertiary care hospital.

METHODS

From January 2021 to December 2021, all patients treated in our department received a peer-reviewed AE-evaluation form at discharge. An AE was defined as any event after surgery that resulted in an undesirable clinical outcome, which is not caused by the underlying disease, that prolonged patient stay, resulted in readmission, caused a new neurological deficit, required revision surgery or life-saving intervention, or contributed to death. We considered AEs occurring within 30 days after discharge. AEs were categorized in wound event, cerebrospinal fluid (CSF) event, CSF shunt malfunction, post-operative infection, malpositioning of implanted material, new neurological deficit, rebleeding, and surgical goal not achieved and non-neurosurgical AEs.

RESULTS

2874 patients were included. Most procedures were cranial (45.1%), followed by spinal (33.9%), subdural (7.7%), CSF (7.0%), neuromodulation (4.0%), and other (2.3%). In total, there were 621 AEs shared by 532 patients (18.5%). 80 (2.8%) patients had multiple AEs. Most AEs were non-neurosurgical (222; 8.1%). There were 172 (6%) revision surgeries. Patients receiving cranial interventions had the most AEs (19.1%) although revision surgery was only necessary in 3.1% of patients. Subdural interventions had the highest revision rate (12.6%). The majority of fatalities was admitted as an emergency (81/91 patients, 89%). Ten elective patients had lethal complications, six of them related to surgery (0.2%).

CONCLUSION

This study presents the one-year results of a prospectively compiled AE database. Neurosurgical AEs arose in one in five patients. Although the need for revision surgery was low, the rate of AEs highlights the importance of a systematic AE database to deliver continued high-quality in a high-volume center.

[Clinical and echocardiographic parameters associated with the alteration of global longitudinal strain in secondary mitral regurgitation]

INTRODUCTION

Left ventricular systolic function may be overestimated in patients with secondary mitral regurgitation when using left ventricle ejection fraction. The Global longitudinal strain is a measure less dependent on left ventricle load. However, the clinical and echocardiographic parameters associated with the alteration of Global longitudinal strain in secondary mitral regurgitation have not been evaluated.

MATERIAL AND METHODS

A total of 96 patients (mean age 62.3 ± 12.1 years, 59.3% male) with secondary mitral regurgitation and low left ventricle ejection fraction < 50% were included. The study population was subdivided according to the Global longitudinal strain value with which an increased risk of all-cause mortality was associated (Global longitudinal strain < 7.0%, left ventricle systolic function impaired compared to Global longitudinal strain ≥ 7.0%, in absolute value). The clinical and echocardiographic endpoints are analysed in both groups of patients.

RESULTS

The strong and clear correlation between Global longitudinal strain (mean ± standard deviation: 7,2 ± 2,7) and parameters of systolic function (left ventricle ejection fraction mean ± standard deviation: 32,4 ± 8,0%) and contractility (dp/dt mean ± standard deviation: 682,5 ± 204,7 mmHg/s). the mean of left ventricle ejection fraction = 26.4 ± 5.3% in the Global longitudinal strain < 7 group, and the bivariate study using the 30% threshold shows that the Global longitudinal strain < 7 group presents a more altered left ventricle ejection fraction with odds ratio = 12, 5 (CI: 4.7-33.0) p < 0.001. In multivariate analysis of ultrasound parameters and linear regression shows a significant correlation between Global longitudinal strain and left ventricle ejection fraction (p < 0.001). The dp/dt analysis found a mean of 509.3 ± 99.1 mmHg/s in the Global longitudinal strain < 7 group and of 822.9 ± 154.1 in the Global longitudinal strain ≥ 7 group with significant difference (p < 0.001). In bivariate and multivariate analysis, the alteration of Global longitudinal strain is associated with a significantly lower dp / dt p < 0.001.

CONCLUSION

A Global longitudinal strain < 7 (in absolute value) reflects a severe impairment of left ventricle function. In addition, several parameters were associated with this severe alteration of the Global longitudinal strain, namely a lower left ventricle ejection fraction, a lower dp/dt and more severe symptoms permitting to characterized this group of patients in addition to an integration in a multiparametric evaluation of the secondary mitral regurgitation.

Effects and duration of exercise-based prehabilitation in surgical therapy of colon and rectal cancer: a systematic review and meta-analysis

Purpose

Functional capacity is an independent indicator of morbidity in colon and rectal cancer surgery. This systematic review describes the evaluated and synthesized effects of exercise prehabilitation depending on the duration of interventions on functional and postoperative outcomes in colon and rectal cancer surgery.

Methods

Three electronic databases (MEDLINE Pubmed, Web of Sciences, and Cochrane Registry) were systematically searched (January 2022) for controlled trials that investigated the effects of prehabilitation prior to colo-rectal cancer resection.

Results

Twenty-three studies were included in this systematic review and 14 in our meta-analyses assessing these outcomes: the 6 min walk distance (6MWD), postoperative overall complications, and length of stay (LOS). We observed a significant improvement in preoperative functional capacity as measured with 6MWD (mean difference: 30.8 m; 95% CI 13.3, 48.3; p = 0.0005) due to prehabilitation. No reductions in LOS (mean difference: – 0.27 days; 95% CI – 0.93, 0.40; p = 0.5) or postoperative overall complications (Odds ratio: 0.84; 95% CI 0.53, 1.31; p = 0.44) were observed. Prehabilitation lasting more than 3 weeks tended to lower overall complications (Odds ratio: 0.66; 95% CI 0.4, 1.1; p = 0.11). However, the prehabilitation time periods differed between colon and rectal carcinoma resections.

Conclusion

Prehabilitation while the patient is preparing to undergo surgery for colorectal carcinoma improves functional capacity; and might reduce postoperative overall complications, but does not shorten the LOS. The studies we reviewed differ in target variables, design, and the intervention’s time period. Multicenter studies with sufficient statistical power and differentiating between colon and rectal carcinoma are needed to develop implementation strategies in the health care system.

Registration

PROSPERO CRD42022310532

Cephalic pancreaticoduodenectomy for ductal adenocarcinoma in the elderly. Can we do it safely?

INTRODUCTION

Surgery and chemotherapy have increased the survival of pancreatic cancer. The decrease in postoperative morbidity and mortality and increase in life expectancy, has expanded the indications por cephalic pancreaticoduodenectomy (PDC), although it remains controversial in the geriatric population.

METHODS

Retrospective study on a prospective database of patients with ductal adenocarcinoma of pancreas who underwent PDC between 2007-2018. The main objective was to analyse the morbidity-mortality and survival associated with PDC in patients ≥75 years (elderly).

RESULTS

79 patients were included, 21 of them older than 75 years (27%); within this group, 23'9% were over 80 years old. The ASA of both groups was similar. Patients ≥75 years required more transfusions. No differences in operating time were observed, although more vascular resection were performed in the elderly (26 vs. 8.7%; P = .037). Morbidity was higher in the elderly (61.9% vs. 46.6%), although without differences. Patients aged ≥75 years had more non-surgical complications (33.3%, P = .050), being pneumonia the most frequent. Postoperative mortality was higher in the ≥75 years (9 vs. 0%; P = .017). The overall survival and disease-free survival did not show significant differences in both groups.

CONCLUSIONS

Elderly patients had higher postoperative mortality and more non-surgical complications. Survival did not show differences, so with an adequate selection of patients, age should not be considered itself as a contraindication for PDC.

Beyond tobacco - the secondary impact of substance misuse in chronic obstructive lung disease

BackgroundChronic obstructive lung disease, specifically chronic asthma and COPD, impacts more than 500 million adults worldwide, and is associated with high healthcare spending and significant disease-related morbidity. While the direct impact of substance use disorder is well documented, little is known about the indirect impact of substance misuse within this patient population. The healthcare cost and indirect morbidity secondary to substance misuse in obstructive lung disease has yet to be quantified.ObjectiveTo determine the indirect impact of substance misuse on disease severity, healthcare utilization and healthcare costs in patients with chronic obstructive lung disease across the United States.MethodsUtilizing data from the 2012-2015 National Readmissions Database (NRD) patients with a diagnosis of COPD or asthma were identified. Documented substance misuse, rates of hospitalization, frequency of hospital readmission, markers of admission severity and cost were assessed utilizing weighted regression analysis.ResultsA total of 1,087,226 patients with an index admission for asthma or COPD were identified. Substance misuse was documented in 4.0% of patients. Substance misuse was associated with a 30% increase in odds of readmission and a higher cost per index admission. The additional index admission costs totaled $24 million for our cohort.Conclusion Substance misuse is associated with an increase in healthcare utilization and healthcare cost in patients with chronic obstructive lung disease. Targeting substance misuse in this patient population has the potential for significant cost savings to the healthcare system.

Morbidity and mortality in patients managed with high compared with low blood pressure targets during on-pump cardiac surgery: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

Many believe that blood pressure management during cardiac surgery is associated with postoperative outcomes. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine the impact of high compared with low intraoperative blood pressure targets on postoperative morbidity and mortality in adults undergoing cardiac surgery on cardiopulmonary bypass (CPB). Our primary objective was to inform the design of a future large RCT.

SOURCE

We searched MEDLINE, EMBASE, Web of Science, CINAHL, and CENTRAL for RCTs comparing high with low intraoperative blood pressure targets in adult patients undergoing any cardiac surgical procedure on CPB. We screened reference lists, grey literature, and conference proceedings.

PRINCIPAL FINDINGS

We included eight RCTs (N =1,116 participants); all examined the effect of blood pressure management only during the CPB. Trial definitions of high compared with low blood pressure varied and, in some, there was a discrepancy between the target and achieved mean arterial pressure. We observed no difference in delirium, cognitive decline, stroke, acute kidney injury, or mortality between high and low blood pressure targets (very-low to low quality evidence). Higher blood pressure targets may have increased the risk of requiring a blood transfusion (three trials; n = 456 participants; relative risk, 1.4; 95% confidence interval, 1.1 to 1.9; P = 0.01; moderate quality evidence) but this finding was based on a small number of trials.

CONCLUSION

Individual trial definitions of high and low blood pressure targets varied, limiting inferences. The effect of high (compared with low) blood pressure targets on other morbidity and mortality after cardiac surgery remains unclear because of limitations with the body of existing evidence. Research to determine the optimal management of blood pressure during cardiac surgery is required.

STUDY REGISTRATION

PROSPERO (CRD42020177376); registered: 5 July 2020.

Access to Surgery and Quality of Care for Acute Cholecystitis During the COVID-19 Pandemic in 2020 and 2021 - an Analysis of 12,545 Patients from a German-Wide Hospital Network

PURPOSE

To determine effects on admission, treatment, and outcome for acute cholecystitis during the course of the COVID-19 pandemic in 2020 and 2021.

METHODS

Retrospective analysis of claims data from 74 German hospitals. Study periods were defined from March 5, 2020 (start of first wave) to June 20, 2021 (end of third wave) and compared to corresponding control periods (March 2018 to February 2020). All in-patients with acute cholecystitis were included. Distribution of cases, type of surgery, comorbidities, surgical outcome, and length of stay of all cases with acute cholecystitis and cholecystectomy were compared. In addition, we analyzed the type of treatment (non-surgical, cholecystostomy, or cholecystectomy) for all cases with main diagnosis of acute cholecystitis.

RESULTS

We could not demonstrate differences in daily admissions over the course of the pandemic (11.2-12.7 patients vs. 11.9-12.6 patients for control periods). Proportion of patients with non-surgical treatment was low and not increased (11.7-17.3% vs. 14.5-18.4%). Cholecystostomy was rare throughout all periods (0-0.5% of all patients). We did not observe an increase in open surgery (proportion of open cholecystectomies 3.4-5.5%). Mortality was generally low (1.5-1.9%) with no differences between periods. Median length of stay was 4 days throughout all periods.

CONCLUSION

The numerous restrictions during the COVID-19 pandemic did not result in an increase of admissions or surgery for acute cholecystitis. Laparoscopic cholecystectomy has been safely applied during the pandemic. Our results may assure the ability to maintain high quality of surgical care even in times of disruptions to the health care system.

Propensity Score Matching Sleeve Gastrectomy vs. Gastric Bypass with 5 Years of Follow-Up

PURPOSE

Beginning January 1, 2005, bariatric surgery cases were examined with the help of the quality assurance study for operative medicine. All data were registered and analyzed prospectively in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University Magdeburg, Germany. The comparative study focuses on perioperative morbidity, complications, and remission of obesity-associated diseases after gastric bypass (RYGB) and sleeve gastrectomy (SG) at 5-year follow-up.

MATERIALS AND METHODS

Data collection includes patients of full age who underwent SG or RYGB surgery between 2005 and 2017. The bougie is limited to 33-40 French for SG. The Roux-en-Y length for RYGB is set to 120-180 cm, and the biliodigestive length is set to 40-60 cm. Outcome criteria are perioperative morbidity, postoperative and intraoperative complications, and remission on comorbidities.

RESULTS

Between 2005 and 2017, 64,349 patients were enrolled in German Bariatric Surgery Registry (GBSR). Primary operations that were performed were 56.328. Out of 24,146 RYGB and 24,085 SG procedures, 922 patients had a complete 5-year follow-up. These are 342 SG patients and 580 patients with RYGB. A matching was realized for n = 285 (83.3%) patient pairs based on age, BMI, gender, ASA, and comorbidities. A significant disadvantage was identified for the SG procedure regarding reflux disease compared with RYGB (36.3% vs. 8.10%; p < 0.001). There were no significant disadvantages in terms of BMI reduction [14.92 in the RYGB and 14.50 in the SG (p = 0.437)] and %EWL [60.32 in the RYGB and 58.98 in the SG (p = 0.504)]. This also applies to the remission of NIDDM, IDDM, hypertension, and sleep apnea; no significant differences were found.

CONCLUSION

The results of the study show significant findings for gastroesophageal reflux. In terms of complications and obesity-associated diseases, no significant disadvantages between both treatments were found. RYGB and SG had comparable postoperative morbidity rates. The two surgical methods are legitimate bariatric procedures. However, there is a need for further evaluation to optimize patient selection in the coming years.

Breast Radiation and the Heart: Cardiac Toxicity and Cardiac Avoidance

The purpose of this invited review is to discuss the most recent and relevant outcome studies assessing the risk of late cardiac toxicity in women treated with radiotherapy for breast cancer and to describe the evidence-based technical factors associated with late cardiac toxicity. This review will also discuss the common radiation techniques for reducing radiation dose to the heart, which will lead to better outcomes and lower rates of late toxicity that can cause morbidity and mortality in women who have been cured of their breast cancer.

The Status of Quality Improvement Programs for Pediatric Traumatic Brain Injury Care in Argentina

INTRODUCTION

Trauma quality improvement (QI) programs improve care and outcomes for injured patients. Information about QI programs for pediatric traumatic brain injury (TBI) is sparse in Latin America.

METHODS

We gathered data on the status of QI programs and activities that encompass pediatric TBI at 15 Argentine hospitals. Data were gathered during 2019 and included hospital characteristics, QI practices, presence of a queryable registry, and use of protocols for TBI care. Level of QI activities was compared between hospital types using Fisher's exact test.

RESULTS

Most hospitals had guidelines for pediatric TBI care, including management and/or prevention of intracranial pressure (100%) and central-line-associated infections (87%). Morbidity and mortality meetings or other types of case discussions in which quality of pediatric TBI care was discussed were held by all hospitals, with most (53%) having weekly-monthly meetings, but 27% having rare or annual meetings. Sixty percent of hospitals had adequate data for case reviews (fewer than 25% of cases with essential information missing). Fifty-three percent documented discussions that occurred at these meetings and 53% utilized computerized trauma registries. Larger hospitals (> 200 beds) more frequently had adequate data (88%) for case reviews than smaller hospitals (29%, P = 0.046). Hospital size did not affect other QI activities.

CONCLUSIONS

Most hospitals had guidelines for pediatric TBI care. Adequacy of care was discussed at reasonably frequent case conferences. Opportunities for improvement include increasing documentation of case reviews and improving adequacy of data for case reviews, especially at smaller hospitals. Greater use of computerized trauma registries could provide such data.

Development and implementation of a perioperative management guide for patients with hip fracture: Health management and clinical impact

INTRODUCTION

Hip fracture (HF) in the elderly has a high prevalence and risk of morbidity and mortality in the short and long term. It can reduce life expectancy by almost 2 years, and require permanent socio-sanitary assistance in one in 5 patients. Its management as a process where the patient takes priority over the activities of the organisation can bring new perspectives, optimisation tools and redesign of the workflow to make it more efficient.

OBJECTIVE

to develop an in-hospital clinical guide for the management of patients with HR adapted to the environment, clear and concise, to be able to intervene in the best possible conditions and favour their adequate recovery.

MATERIAL AND METHODS

407 patients divided into 3 groups: pre-implementation (knowing the scope of the problem and areas for improvement); implementation (after the development of the management guide) and post-implementation (valued its implementation).

RESULTS

The clinical results obtained with this guide allowed improving surgical programming and reducing delay times (increasing the proportion of patients operated in the first 48h and reducing the average hospital stay in 3 days), raising awareness of the problem at all Services involved, improve the management of drugs that altered hemostasia, optimise transfusion therapy and reduce hospital stay and perioperative complications.

CONCLUSION

The implementation of this guide, with integrated global criteria, has improved the results of this process, and achieved a more efficient management, reducing the consumption of resources and as a consequence, health expenditure.

The effect of using the minimized cardio-pulmonary bypass Systems for Coronary Artery Bypass Grafting in diabetic patients

Introduction

Multiple studies have shown a decrease in the inflammatory response with minimized bypass circuits leading to less complications and mortality rate. On the other hand, some other studies showed that there is no difference in post-operative outcomes. So, the aim of this study is to investigate the clinical benefits of using the Minimized cardiopulmonary Bypass system in Coronary Artery Bypass Grafting and its effect on postoperative morbidity and mortality in diabetic patients as one of the high-risk groups that may benefit from these systems.

Methods

This is a retrospective study that included 114 diabetic patients who underwent Coronary artery bypass grafting (67 patients with conventional cardiopulmonary bypass system and 47 with Minimized cardiopulmonary bypass system). The patients’ demographics, intra-operative characteristics and postoperative complications were compared between the two groups.

Results

Coronary artery bypass grafting was done on a beating heart less commonly in the conventional cardiopulmonary bypass group (44.78% vs. 63.83%, p = 0.045). There was no difference between the two groups in blood loss or transfusion requirements. Four patients in the conventional cardiopulmonary bypass group suffered perioperative myocardial infarction while no one had perioperative myocardial infarction in the Minimized cardiopulmonary bypass group. On the other hand, less patients in the conventional group had postoperative Atrial Fibrillation (4.55% vs. 27.5%, p = 0.001). The requirements for Adrenaline and Nor-Adrenaline infusions were more common the conventional group than the Minimized group.

Conclusion

The use of conventional cardiopulmonary bypass for Coronary Artery Bypass Grafting in diabetic patients was associated with higher use of postoperative vasogenic and inotropic support. However, that did not translate into higher complications rate or mortality.

Occupational health risk among healthcare workers during COVID-19 pandemic: actions to limit the risk

The World Health Organization declared coronavirus infection 2019 (COVID-19) as a pandemic in March 2020. The infection with coronavirus started in Wuhan city, China, in December 2019. As of October 2020, the disease was reported in 235 countries. The coronavirus infection 2019 (COVID-19) is a disease with high morbidity and mortality. As of February 2021, the number of confirmed cases of COVID-19 globally is 102,942,987 and 2,232,233 deaths according to WHO report. This infection is caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), which is a ribonucleic acid (RNA) β-coronavirus. The infection is mainly transmitted through respiratory droplets.

Healthcare workers (HCWs) play an essential role at the front lines, providing care for patients infected with this highly transmittable disease. They are exposed to very high occupational health risk as they frequently contact the infective persons. In order to limit the number of infected cases and deaths among healthcare workers, it is crucial to have better awareness, optimistic attitude, efficient PPE, and adequate health practices about COVID-19.

A brief, highly selective history of acute phase proteins as indicators of infection, inflammation and injury

There is an array of plasma protein alterations that occur in a wide variety of species, including humans in response to trauma, inflammation and infections, seemingly irrespective of etiologic agent. In numerous species, these plasma proteins are part of the innate immune response. In addition, it appears that a number of the plasma proteins in this array can be predictive of morbidity and/or mortality. We propose that based on historic use, selected acute phase proteins should be included in ongoing and future non-clinical and clinical studies to help us better understand disease progression in chronic, as well as acute diseases. In addition to assess if there is a relationship between vaccine-induced inflammation and degree of protection from live, attenuated or synthetic vaccines.

CIRSE Standards of Practice on Conducting Meetings on Morbidity and Mortality

This CIRSE Standards of Practice document is developed by an expert writing group under the guidance of the CIRSE Standards of Practice Committee. It aims to assist Interventional Radiologists in their daily practice by providing best practices for conducting meetings on morbidity and mortality.

The Status of Quality Improvement Programs for Pediatric Traumatic Brain Injury Care in Argentina

INTRODUCTION

Trauma quality improvement (QI) programs improve care and outcomes for injured patients. Information about QI programs for pediatric traumatic brain injury (TBI) is sparse in Latin America.

METHODS

We gathered data on the status of QI programs and activities that encompass pediatric TBI at 15 Argentine hospitals. Data were gathered during 2019 and included hospital characteristics, QI practices, presence of a queryable registry, and use of protocols for TBI care. Level of QI activities was compared between hospital types using Fisher's exact test.

RESULTS

Most hospitals had guidelines for pediatric TBI care, including management and/or prevention of intracranial pressure (100%) and central-line-associated infections (87%). Morbidity and mortality meetings or other types of case discussions in which quality of pediatric TBI care was discussed were held by all hospitals, with most (53%) having weekly-monthly meetings, but 27% having rare or annual meetings. Sixty percent of hospitals had adequate data for case reviews (fewer than 25% of cases with essential information missing). Fifty-three percent documented discussions that occurred at these meetings and 53% utilized computerized trauma registries. Larger hospitals (> 200 beds) more frequently had adequate data (88%) for case reviews than smaller hospitals (29%, P = 0.046). Hospital size did not affect other QI activities.

CONCLUSIONS

Most hospitals had guidelines for pediatric TBI care. Adequacy of care was discussed at reasonably frequent case conferences. Opportunities for improvement include increasing documentation of case reviews and improving adequacy of data for case reviews, especially at smaller hospitals. Greater use of computerized trauma registries could provide such data.

[Descriptive study of delirium in the emergency department]

Objetivo

Conocer mejor las variables clínicas, funcionales y analíticas que se asocian al síndrome confusional agudo (SCA) en urgencias y la evolución de las mismas con el fin de obtener una mejora en el abordaje terapéutico del paciente anciano previniendo así la morbimortalidad en este tipo de pacientes.

Diseño

Se trata de un estudio descriptivo prospectivo de SCA en urgencias.

Emplazamiento

Hospital General Universitario de Ciudad Real.

Participantes

Se incluyó, en el intervalo de las 24 h siguientes al ingreso en el Servicio de Geriatría, a todos los pacientes procedentes del Servicio de Urgencias con diagnóstico de SCA.

Mediciones principales

Se realizó un análisis de las variables del conjunto de datos (variables sociodemográficas y clínicas), calculando tablas de frecuencias para variables de tipo cualitativo y estadísticos descriptivos para las variables cuantitativas. Posteriormente, se han empleado técnicas de inferencia estadística.

Resultados

El antecedente médico más frecuente fueron la enfermedad neurológica y la HTA, seguida de las enfermedades reumatológicas. Los motivos de consulta principales fueron el deterioro del estado general, la disnea, la disminución del nivel de consciencia y la fiebre. Se debe destacar la incidencia de la polifarmacia, especialmente de fármacos como los diuréticos, benzodiacepinas o hipnóticos. En relación con la etiología principal, destaca el papel de las infecciones de tipo urinario y respiratorio.

Conclusiones

Se destaca el papel fundamental de las enfermedades neurológicas (especialmente la demencia), la HTA, la polifarmacia (uso inadecuado de benzodiacepinas e hipnóticos) y las infecciones urinarias y respiratorias como factores tratables o prevenibles del delirium en el paciente de Atención Primaria en nuestro medio.

Effects of chronic exposure to ambient air pollutants on COVID-19 morbidity and mortality - A lesson from OECD countries

BACKGROUND

Exposure to ambient air pollution is related to 4.2 million premature deaths per year worldwide and is associated with a variety of adverse health outcomes, such as respiratory and cardiovascular morbidity. Furthermore, exposure to air pollution can increase human sensitivity to respiratory pathogens via damage to the respiratory tract or via airborne transmission on the surface of particulate matter, and might be an additional factor influencing COVID-19 morbidity and mortality rates. The aim of this study was to examine the association between populations' exposure to air pollution and the morbidity and mortality rates from COVID-19.

METHODS

We examined the association between population-weighted long-term exposure to PM_2.5 and NOx, and the morbidity and mortality over time following the detection of the first COVID-19 positive case in 36 OECD countries. Pearson and Spearman correlations between daily COVID-19 morbidity and mortality (Jan-Jun 2020) on the 10^th, 20^th, 40^th, 60^th and 80^th days since first confirmed case in the country, and demographic, health, economic, and environmental data were calculated. Multivariate linear regression were used to examine the associations between demographic, health, economic and air pollution features and the rate of confirmed cases and deaths on the 60^th and 80^th days following the first confirmed case.

RESULTS

PM_2.5 concentrations in 2015-2017 were positively correlated with COVID-19 morbidity and mortality on the 10^th, 20^th, 40^th and 60^th days since the first confirmed case in all countries. NOx concentrations in 2015-2017 and country's density (population/Km²) were positively correlated with COVID-19 morbidity and mortality on the 60^th day. All multivariate linear regressions consisting PM_2.5 concentrations models were statistically significant. Our models also emphasize the importance of the relative number of hospital beds in decreasing the morbidity and mortality of COVID-19.

CONCLUSIONS

The adverse health outcomes stemming from long-term exposure to various air pollutants has long been known to the scientific community. According to our results and previously published studies, it appears that long-term exposure to air pollutants concentrations exceeding WHO guidelines, such as PM_2.5 and NOx, might exacerbate morbidity and mortality rates from COVID-19. These results should raise a red flag globally among decision makers about the urgent need to reduce air pollution and its harmful effects.

Cephalic pancreaticoduodenectomy for ductal adenocarcinoma in the elderly. Can we do it safely?

INTRODUCTION

Surgery and chemotherapy have increased the survival of pancreatic cancer. The decrease in postoperative morbidity and mortality and increase in life expectancy, has expanded the indications por cephalic pancreaticoduodenectomy (PDC), although it remains controversial in the geriatric population.

METHODS

Retrospective study on a prospective database of patients with ductal adenocarcinoma of pancreas who underwent PDC between 2007-2018.The main objective was to analyse the morbidity-mortality and survival associated with PDC in patients≥75 years (elderly).

RESULTS

79 patients were included, 21 of them older than 75 years (27%); within this group, 23.9% were over 80 years old. The ASA of both groups was similar. Patients≥75 years required more transfusions. No differences in operating time were observed, although more vascular resection were performed in the elderly (26 vs. 8.7%; P=.037). Morbidity was higher in the elderly (61.9 vs. 46.6%), although without differences. Patients aged≥75 years had more non-surgical complications (33.3%, P=.050), being pneumonia the most frequent. Postoperative mortality was higher in the≥75 years (9 vs. 0%; P=.017). The overall survival and disease-free survival did not show significant differences in both groups.

CONCLUSIONS

Elderly patients had higher postoperative mortality and more non-surgical complications. Survival did not show differences, so with an adequate selection of patients, age should not be considered itself as a contraindication for PDC.

[Relationship between left ventricular diastolic dysfunction and coronary disease in type 2 diabetes mellitus]

INTRODUCTION

Type 2 diabetes is associated with an increased risk of coronary disease and is the leading cause of morbidity and mortality in this population. The main objective of our work is to study the correlation of diastolic function of the left ventricle with coronary disease in type 2 diabetics.

MATERIAL AND METHODS

Analytical cross-sectional, monocentric prospective-looking study of 703 type 2 diabetic patients performed at the Military Regional Hospital of Constantine over a period of 04 years (2016-2019). We excluded 338 patients who did not receive coronary angiography; thus 365 patients are ultimately analyzed. Evaluation of diastolic function was performed by two-dimensional transthoracic echocardiography with the search of coronary disease. The data was analyzed using the Epi Info 7.2.1.0 with study of the relationship of the diastolic function to coronary disease by multiple logistic regression.

RESULTS

The average age of our final cohort is 57,7±6,5 years, an average of 7.4±1.8% of glycated hemoglobin, an average of 5,8±4,1 years of diabetes, a sex ratio to 1.27. 49.3% had diastolic dysfunction. The prevalence of coronary disease is 32,9%. In multivariate analysis; diastolic dysfunction is correlated with coronary involvement significantly (OR=2.02, _95% CI [1.50 - 2.90], p=0.02).

CONCLUSION

The prevalence of diastolic dysfunction is high in type 2 diabetics and is significantly correlated with coronary heart disease.

Impact of the tetra viral vaccine introduction on varicella morbidity and mortality in the Brazilian macro regions

OBJECTIVE

To describe the impact of the introduction of the viral tetra vaccine in the National Immunization Program in 2013 for 15-month-old children in mortality rates and hospitalization associated with varicella in Brazil.

METHODS

Mortality rates and hospitalizations rates associated with varicella were evaluated between 2010 and 2016 and described according to Brazilian macro regions and age. The population was stratified into age groups: < 1year, 1-4 years, and 5-14 years. Data were collected from the Informatics Department of the Unified Health System. A percentage difference was calculated between rates of hospitalizations and mortality in the pre (2010-2012) and post-vaccination periods (2014-2016) to estimate the approximate effectiveness of the vaccine.

DATA SYNTHESIS

At the national level, vaccination significantly reduced the mortality rates and hospitalizations rates in all age groups analyzed. Among those under 5 years of age, mortality rates and hospitalizations rates decreased 57-49% and 40-47%, respectively. There was a national decrease of up to 57% in the mortality rates due to the disease, with smaller decreases seen in the North and Northeast regions and the largest in the South and Southeast regions. The hospitalizations rates for varicella reached a maximum national decline of 47%. In children aged 1-4 years, with higher vaccination coverage, the highest reduction was observed in both mortality rates and hospitalizations rates, which decreased from 2.6 to 0.4/100,000/year.

CONCLUSIONS

The tetra vaccine proved to be effective in reducing both mortality and hospitalizations of children and adolescents up to 15 years of age in the 2014-2016 triennium.

Supratentorial intracerebral hemorrhage as a complication of infratentorial tumor removal: A case report

•

Intracerebral hemorrhage (ICH) at the operative site is one of the major complications of brain surgery.

•

Imaging modalities like CT scan can easily discover and diagnose intracerebral hemorrhage.

•

When intracerebral hemorrhage occurs it may lead to deadly complications and best to be surgically evacuated.

•

Supratentorial intracerebral hemorrhage rarely complicates surgeries of infratentorial tumors.

Introduction

In this article we report a case of supratentorial intracerebral hemorrhage developed following days of posterior fossa surgical tumor removal.

Presentation of case

Nine years old female was diagnosed as a patient with posterior fossa tumor and hydrocephalus, endoscopic third ventriculostomy was done and the tumor was resected using craniectomy and trans-vermian approach. The patient was discharged home on post-operative day 10 but re-admitted on day 35 with a new insult of right temporo-parieto-occipital intracerebral hematoma which was evacuated successfully urgently and the patient had got better on day 4, but then she developed right hemispheric ischemia and died.

Discussion

Although this complication is rare, it carries significant morbidity and mortality, literatures discussing this condition are scanty and no obvious cause was mentioned.

Conclusion

We recommend putting in mind such a complication in case of any post-operative neurological deterioration occurs to a patient with surgically excised posterior fossa lesion.

Development of a Surgical Evidence Blog at Morbidity and Mortality Conferences: Integrating Clinical Librarians to Enhance Resident Education

INTRODUCTION

Surgical morbidity and mortality (M&M) conference is a primary educational endeavor for trainees and faculty alike. Case presentations are enhanced by inclusion of clinical evidence; however, trainees are frequently limited in their ability to collect and share this type of material.

METHODS

A surgical evidence web log ("blog") was created in partnership between the Clinical Librarian Service and the Department of Surgery. A clinical librarian attended weekly departmental M&M conferences and reviewed evidence in collaboration with a surgical resident. For each case presented, the clinical librarian created an evidence-based blog post based on specific learning topics encountered in the routine discussion of the M&M conference. The goal of this surgeon-librarian partnership was to enhance M&M's educational value by reinforcing learning topics, serving as a repository of case-based evidence, and involving trainees in evidence-based surgical practice.

RESULTS

Blog posts included summaries of available evidence, critical reviews of seminal studies, and reviews of evidence-based guidelines framed in the context of the case. New blog posts were promoted via direct links in an existing weekly newsletter sent to all trainees and faculty in the department. Within the first year, surgical residents reported increased interaction with the literature, and 100% reported gaining knowledge that they would otherwise not receive through their standard readings, with 73% of residents using this to influence clinical practice and 87% applying knowledge in test preparation. This surgeon-librarian partnership enforces interdisciplinary collaboration through existing resources, and is highly generalizable to both surgical and medical training programs.

CONCLUSIONS

In this study, the development of a surgical evidence blog represents an effective resource for promoting evidence-based practices within a case-based learning curriculum. This intervention is the first report in the literature to integrate the expertise and resources of a Clinical Librarian Service with an evidence-based resident educational curriculum in a surgical residency program.

Developing standardized titles to classify the adverse events in 7,418 cranial and spinal neurosurgical procedures

BACKGROUND

Neurosurgical procedures are life- and function-saving but carry a risk of adverse events (AE) which can cause permanent neurologic deficits. Unfortunately, there is lack of clearly defined AEs associated with given procedures, and their reporting is non-uniform and often arbitrary. However, with an increasing number of neurosurgical procedures performed, there is a need for standardization of AEs for systematic tracking. Such a system would establish a baseline for future quality improvement strategies.

OBJECTIVE

To review our institutional AEs and devise standardized titles specific to the spine, tumor, functional, and vascular neurosurgery divisions.

METHODS

A review of prospective monthly-reported morbidity and mortality (M&M) conference data within the Department of Neurological Surgery was conducted from January 2017 to December 2019. An AE was defined as any mortality, an "unintended and undesirable diagnostic or therapeutic event", "an event that prolongs the patient's hospital stay", or an outcome with permanent or transient neurologic deficit.

RESULTS

A total of 1096 AEs from 7418 total procedures (14.8 %) were identified. Of those, 418 (5.6 %) were in cerebrovascular, 249 (3.4 %) were in neuro-oncology and 429 (5.8 %) were in the spine & functional divisions. The most common AEs across all divisions were infection (17 %), hemorrhage (11 %) and cerebrospinal fluid (CSF) leak (7.8 %). Other AEs were indirectly related to the neurosurgical procedure, such as deep vein thrombosis or pulmonary embolism (2.7 %), or pneumothorax (0.3 %).

CONCLUSION

This work illustrates standardized AEs can be implemented universally across the spectrum of neurological surgery. Standardization can help identify recurring AE patterns through better tracking.

Contemporary Issues in Pregnancy (and Offspring) in the Current HIV Era

PURPOSE OF REVIEW

Although antiretroviral therapy (ART) has dramatically reduced mother to child transmission of HIV, data continue to mount that infants exposed to HIV in utero but are not infected (HEU) have serious negative health consequences compared to unexposed infants. This review evaluates recent literature on contemporary issues related to complications seen in pregnant women with HIV and their offspring.

RECENT FINDINGS

Current studies show that HEU infants are at a high risk of adverse outcomes, including premature birth, poor growth, neurodevelopmental impairment, immune dysfunction, infectious morbidity, and death. Etiologies for the observed clinical events and subclinical alterations are complex and multifactorial, and the long-term consequences of many findings are yet unknown. HEU infants have an unacceptable rate of morbidity and mortality from perinatal HIV and ART exposure, even in the modern ART era. Continual monitoring and reporting is imperative to protect this vulnerable population in our everchanging landscape of HIV treatment and prevention.

Clinical Spectrum and Long-term Outcome of 183 Cases of Ebstein's Anomaly, Experience of Mexican Population

BACKGROUND

Ebstein's anomaly (EA) is a myopathy of the right ventricle that causes a variable spectrum of tricuspid valve delamination failure with diverse clinical and anatomical presentation. We reviewed our data of EA to establish an association between clinical and echocardiographic findings with mortality.

METHODS

We divided patients in infants, Children/adolescents (Ch/A), and adults, according to age of presentation. Clinical and echocardiographic parameters were compared among groups. Multivariate analysis was performed for mortality. Survival analysis was plotted using Kaplan Meier curves.

RESULTS

Cyanosis, severe forms of AE and heart failure were more frequent among infants, arrhythmias in Ch/A and stroke among adults. Surgery was performed in 71 patients; infants had higher mortality and early complications. We found that the predicted mortality at 40 years of age in the three groups was significantly different (log rank test, p <0.0001): Infants: 38%, Ch/A 16 and 4% in adults. Multivariate model in surgical group showed that progressive drop of right ventricular fractional shortening (RVFS) predicts a higher mortality risk. In the non-surgical group, low RVFS and cyanosis were significantly associated with mortality.

CONCLUSION

EA in infants is linked to higher morbidity and mortality, while arrhythmias predominate in Ch/A and stroke in adults. In general, stroke is frequent in patients with EA, some prevention alternative must be implemented. Right ventricular dysfunction is very important in EA and is associated with high mortality. It must be subject of discussion the planning of the type of surgery or even in the decision of to preclude surgical treatment.

Less guessing, more evidence in identifying patients least fit for cytoreductive surgery in advanced ovarian cancer: A triage algorithm to individualize surgical management

OBJECTIVE

We previously reported an algorithm that identifies women at high risk of postoperative morbidity & mortality (M/M) as a tool to triage between neoadjuvant chemotherapy and primary surgery for epithelial ovarian cancer (EOC). We sought to independently validate its performance using multicenter data.

METHODS

Women who underwent surgery for stage IIIC/IV EOC between 1/1/2014 and 12/31/2017 were identified from the National Surgical Quality Improvement Program database and classified as "high risk" or "triage appropriate" using our algorithm. Outcomes were compared between triage appropriate and high-risk women using the chi-square test.

RESULTS

1777 women met inclusion criteria; the mean age was 62.6 years and 81.9% had stage IIIC disease. Nationally, the surgical complexity scores were low (69.8% low, 25.2% intermediate and 5.0% high). "High risk" women had 2-fold higher rate of severe 30-day complication or death (6.2% vs 3.5%; p = 0.01), a 3-fold higher rate of 30-day mortality (1.4% vs 0.5%; p = 0.08), and a higher risk of death following a severe complication (11.1% vs. 0%, p = 0.11). A sensitivity analysis excluding women with unknown albumin who didn't meet other high risk criteria showed similar results: severe 30-day complications or death (6.2% vs 3.5%; p = 0.02) and 30-day mortality (1.4% vs 0.3%; p = 0.04) for "high risk" vs "triage appropriate" women.

CONCLUSIONS

Primary cytoreductive surgery to minimal residual disease remains the goal for EOC. We verify that our algorithm can identify women at risk of M/M using national multicenter data, despite a low complexity surgical setting and using 30-day mortality (vs. 90-day). Objective surgical risk assessment for ovarian cancer should be standard of care and can be incorporated into practice using the Mayo triage algorithm.

Two case reports of novel syndrome of bizarre performance of gastrointestinal endoscopy due to toxic encephalopathy of endoscopists among 181767 endoscopies in a 13-year-university hospital review: Endoscopists, first do no harm!

BACKGROUND

Although deficient procedures performed by impaired physicians have been reported for many specialists, such as surgeons and anesthesiologists, systematic literature review failed to reveal any reported cases of deficient endoscopies performed by gastroenterologists due to toxic encephalopathy. Yet gastroenterologists, like any individual, can rarely suffer acute-changes-in-mental-status from medical disorders, and these disorders may first manifest while performing gastrointestinal endoscopy because endoscopy comprises so much of their workday.

CASE SUMMARIES

Among 181767 endoscopies performed by gastroenterologists at William-Beaumont-Hospital at Royal-Oak, two endoscopies were performed by normally highly qualified endoscopists who manifested bizarre endoscopic interpretation and technique during these endoscopies due to toxic encephalopathy. Case-1-endoscopist repeatedly insisted that gastric polyps were colonic polyps, and absurdly “pressed” endoscopic steering dials to “take” endoscopic photographs; Case-2-endoscopist repeatedly insisted that had intubated duodenum when intubating antrum, and wildly turned steering dials and bumped endoscopic tip forcefully against antral wall. Endoscopy nurses recognized endoscopists as impaired and informed endoscopy-unit-nurse-manager. She called Chief-of-Gastroenterology who advised endoscopists to terminate their esophagogastroduodenoscopies (fulfilling ethical imperative of “physician, first-do-no-harm”), and go to emergency room for medical evaluation. Both endoscopists complied. In-hospital-work-up revealed toxic encephalopathy in both from: case-1-urosepsis and left-ureteral-impacted-nephrolithiasis; and case-2-dehydration and accidental ingestion of suspected illicit drug given by unidentified stranger. Endoscopists rapidly recovered with medical therapy.

CONCLUSION

This rare syndrome (0.0011% of endoscopies) may manifest abruptly as bizarre endoscopic interpretation and technique due to impairment of endoscopists by toxic encephalopathy. Recommended management (followed in both cases): 1-recognize incident as medical emergency demanding immediate action to prevent iatrogenic patient injury; 2- inform Chief-of-Gastroenterology; and 3-immediately intervene to abort endoscopy to protect patient. Syndromic features require further study.

Mortality and Morbidity in Office-Based General Anesthesia for Dentistry in Ontario

Our objective was to estimate the prevalence of mortality and serious morbidity for office-based deep sedation and general anesthesia (DS/GA) for dentistry in Ontario from 1996 to 2015. Data were collected retrospectively in 2 phases. Phase I involved the review of incidents, and phase II involved a survey of DS/GA providers. In phase I, cases involving serious injury or death for dentistry under DS/GA, sourced from the Office of the Chief Coroner of Ontario and from the Royal College of Dental Surgeons of Ontario (RCDSO), were reviewed. Phase II involved a survey of all RCDSO-registered providers of DS/GA in which they were asked to estimate the number of DS/GAs administered in 2015 and the number of years in practice since 1996. Clinician data were pooled to establish an overall number of DS/GAs administered in dental offices in Ontario from 1996 to 2015. Prevalence was calculated using phase I (numerator) and phase II (denominator) findings. The estimated prevalence of mortality in the 20-year period from 1996 to 2015 was 3 deaths in 3,742,068 cases, with an adjusted mortality rate of 0.8 deaths per 1 million cases. The estimated prevalence of serious morbidity was 1 injury in 3,742,068 cases, which adjusts to a serious morbidity rate of 0.25 per 1 million cases. The mortality rate found in this study was slightly lower than those published by earlier studies conducted in Ontario. The risk of serious morbidity was found to be low and similar to other studies investigating morbidity in office-based dental anesthesia.

Illinois Dental Anesthesia and Sedation Survey for 2016

A statewide decennial survey was sent to practicing dentists holding sedation or general anesthesia permits to identify office sedation/general anesthesia trends and practices over the last 10 years. This survey constitutes the third such survey, spanning a total of 20 years. Of the 234 respondents in the 2016 survey, 34% held an Illinois moderate sedation permit and 64% held a general anesthesia permit. Oral and maxillofacial surgeons represented the majority of respondents (143/234; 61%). The remainder of responses were from general dentists (39; 17%) pediatric dentists (32; 14%), periodontists (16; 7%), dentist anesthesiologists (3; 1.3%) and 1 periodontist/dentist anesthesiologist. Surveys over the 20 years revealed the following significant trends: an increase in practitioners current in advanced cardiac life support certification, an increase in the number of non-oral maxillofacial surgeons with a sedation permit, an increase in providers of moderate sedation, and an increase in offices equipped with end-tidal CO₂ and electrocardiogram monitoring. However, a number of providers were identified as not compliant with certain state mandates. For example, many respondents failed to meet minimum office team staffing requirements during sedation, hold semiannual office emergency drills, and establish written emergency management protocols.

Year-to-year trends in emergency medicine morbidity and mortality cases

BACKGROUND

Morbidity and Mortality (M&M) rounds are peer review conferences during which cases with adverse outcomes and difficult management decisions are presented. Their primary objective is to learn from complications and errors, modify behavior and judgment based on previous experiences, and prevent repetition of errors leading to complications. The objective of this study was to determine if M&M conferences can reduce repetitive error making demonstrated by a shift of the incidence of cases presented at M&M by chief complaint (CC) and experience of attendings.

METHODS

All M&M cases from 1/1/2014-12/31/2017 derived from an urban, tertiary referral Emergency Department were reviewed and grouped into 12 different CC categories and by attending years of experience (1-4, 5-9 and 10+). Number and percent of M&M cases by CC and years of attending experience were calculated by year and a chi-squared analysis was performed.

RESULTS

350 M&M cases were presented over the four-year study period. There was a significant difference between CC categories from year-to-year (p < 0.001). Attendings with 1-4 years of experience had the majority of cases (46.3%), while those with 5-9 years had the fewest total cases (15.1%, p < 0.001).

CONCLUSIONS

There was a persistent significant difference across CC categories of M&M cases from year-to-year, with down-trending and up-trending of specific CCs suggesting that M&M presentation may prevent repetitive errors. Newer attendings show increased rates of M&M cases relative to more experienced attendings. There may be a distinctive educational benefit of participation at M&M for attendings with fewer than five years of clinical experience.

Preventing patient harm via adverse event review: An APSA survey regarding the role of morbidity and mortality (M&M) conference

INTRODUCTION

Peer-review endeavors represent the continual learning environment critical for a culture of patient safety. Morbidity and mortality (M&M) conferences are designed to review adverse events to prevent future similar events. The extent to which pediatric surgeons participate in M&M, and believe M&M improves patient safety, is unknown.

METHODS

A cross-sectional survey of the American Pediatric Surgical Association membership was conducted to evaluate participation in and perception of M&M conferences. Closed and open-ended questions were provided to gauge participation and perceptions of M&M effectiveness. Standard frequency analyses and tests of associations between M&M program attributes and surgeons' perceptions of effectiveness were performed.

RESULTS

The response rate was 38% (353/928). Most surgeons (85%) reported that they always participate in M&M, but only 64% believe M&M is effective in changing practice or prevention of future adverse events. Effective M&Ms were more likely to emphasize loop closure, multidisciplinary participation, standardized assessment of events, and connection to quality improvement efforts.

CONCLUSIONS

Most pediatric surgeons participate in M&M, but many doubt its effectiveness. We identified attributes of M&M conferences that are perceived to be effective. Further investigation is needed to identify how to optimally utilize peer-review programs to prevent adverse events and improve patient safety.

LEVEL OF EVIDENCE

V.

[Renal transplantation on vascular prosthesis]

INTRODUCTION

In front of a very calcified aortoiliac axis, renal transplantation with implantation of the artery on vascular prosthesis can be proposed. This rare intervention is considered difficult and morbid. The main objective of this work was to evaluate the overall and specific survival of the transplant in this situation. The secondary objective was the study of the complications and the evolution of the transplant's renal function.

MATERIAL AND METHODS

From a multicenter retrospective data collection of the DIVAT cohort (6 centers) added with data from 4 other transplant centers, we studied transplants with prosthetic arterial anastomosis.

RESULTS

Thirty four patients was included. The median duration of follow-up was 2.5 years. 4 patients died in the month following transplantation, 16 were hemodialysis and 9 were transfused. The median survival of the transplant was 212 days. Functional arrests of the transplant were mostly associated with nephrological degradation and return to dialysis (about 80%) while 10% were related to a death of the recipient directly attributable to renal transplantation. The surgical complications of the transplantation were marked by one arterial stenosis, one fistula and 4 urinary stenoses.

CONCLUSION

Thus, renal transplantation with arterial anastomosis on vascular prosthesis, on selected patients, offers an alternative to dialysis. A national compendium of transplanted patients on vascular prosthesis would allow a long-term follow-up of transplant's survival and define selection criteria prior to this kind of surgery.

LEVEL OF EVIDENCE

3.

[Impact of hospital admission on centenarians admitted due to an acute illness. A description of a series of 165 cases and comparison with the literature]

INTRODUCTION

The number of centenarians is increasing with the aging of the Spanish population. This age group might present different clinical features from younger groups. This study was carried out to determine the impact hospital admission on centenarians with an acute disease.

MATERIALS AND METHODS

A retrospective observational study was conducted that included patients ≥100 years-old admitted from 1995 to 2016 to a third level university hospital and attended by the Geriatrics department in the acute ward, the Orthogeriatric ward, and by request. An analysis was made using the clinical-administrative databases containing information about the demographics, clinical, functional and cognitive features, length of hospital length, as well as discharge destination.

RESULTS

The study included 165 patients with a mean age of 101.6 ± 1.7 (range 100-109) years, of whom 140 (85%) were female. The mean hospital stay was 10.3 ± 7.4 days. Respiratory infections (41%) were the most common cause of admission to the Acute Geriatric Unit (AGU). The overall in-hospital mortality was 16%, but mortality in AGU reached up to 31%. There was an increase on moderate-severe functional disability (51% to 96%), and on the inability to walk independently (52% to 99%) from baseline to admission. There was a reduction in people living in their own home from 71% prior to admission to 29% at hospital discharge.

CONCLUSIONS

Centenarians who required hospital admission showed a high rate of mortality, a significant deterioration in their functional capacity, and a decrease in their chances of going back to their own home at discharge.

Knowledge about and preventive practices against neonatal tetanus among young Nigerian women

Objective:

The objective of this study was carried out to determine the knowledge about and preventive practices against neonatal tetanus (NNT) in young women of reproductive age.

Materials and Methods:

Descriptive cross-sectional study design of 380 randomly selected consenting young women of child-bearing age at a Nigerian tertiary educational institution. They completed a semi-structured questionnaire on knowledge about and risk factors for NNT, willingness to receive the vaccine, and uptake of tetanus toxoid vaccine.

Results:

The mean age (standard deviation) of the women was 22.4 (4.6) years ranging from 15 to 30 years. The majority (64.5%) had poor knowledge of the causes of and risk factors for NNT with only 31% knowing that immunizing women against tetanus prevents NNT. Most of the women (58%) were unwilling to receive tetanus immunization. A total of 15.5% had received tetanus toxoid, but only 0.5% had completed the required dosage. A higher proportion of respondents with good knowledge about tetanus had tetanus toxoid immunization (28.1% vs. 8.6%; P < 0.0001).

Conclusion:

Knowledge about NNT, willingness to receive the vaccine, and uptake of tetanus toxoid were unacceptably poor among respondents. There is a need for continuous education targeting young women on the link between the tetanus immunization status of women and the occurrence of NNT.

CR-Possum-Can It Be Used to Predict Morbidity? A Single-Centre Retrospective Study

Preoperative prediction of morbidity in colorectal cancer (CRC) surgery helps to optimize the surgical outcome. In this study, we aim to develop a dedicated equation for predicting operative morbidity using colorectal possum scoring system and also to validate the predictive accuracy of CR-POSSUM scoring system in prognosticating actual complications. We did a retrospective analysis of 322 patients undergoing colorectal cancer surgery from a single centre in South India from 2004 to 2016. Mortality and morbidity risk factors as defined by CR POSSUM were collected from 322 patients who underwent CRC surgery and were used to derive equations to predict morbidity, and the results were compared with the observed morbidity. Logistic regression analysis was used to derive the equation. The model fit and model discrimination were analysed using the Hosmer-Lemeshow statistical test for goodness of fit, the Nagelkerke R ² and area under the receiver operating characteristic (ROC) curve respectively. Out of 322 patients, 103 (32%) patients developed complications and 10 (3%) died due to complications. The regression equation we derived has an overall correct classification of about 70% (P < 0.01) with positive and negative predictive value of 60% and 73% respectively. The Hosmer-Lemeshow goodness of fit was 3.147 (P = 0.829), and the Nagelkerke R ² was 17% and area under ROC as model discrimination was 71.6%. Hence, CR-POSSUM scoring which was originally used for predicting mortality risk can also be extrapolated to predict morbidity.

Impact of Time Interval Between Glenn and Fontan Procedures on Fontan Operative and Long-Term Follow-up Results

OBJECTIVE

The bidirectional cavopulmonary shunt (BCPS) is an effective palliative procedure which has been widely used to boost outcome of the Fontan procedure. However, there is no standard duration time between these two procedures. Therefore, we investigated whether different time intervals between BCPS and Fontan procedure affects morbidity and mortality of Fontan patients.

METHODS

Between 2004 and 2016, 210 post-BCPS patients underwent Fontan operation at Fuwai Hospital. The median interval between BCPS and Fontan procedure was 3.7 years (range 0.55-11.86 years) and this was used to divide study cohort into Group 1 (< 3.7 years; n = 124) and Group 2 (> 3.7 years; n = 86). We analyzed these patients retrospectively in terms of their preoperative characteristics and post-operative and follow-up results.

RESULTS

Weight z-scores for age at BCPS (- 0.73 ± 1.39 vs - 1.17 ± 1.60, p < 0.05) was significantly higher in Group 2. However, saturation at room air before Fontan (76.42 ± 20.01 vs 82.85 ± 9.69, p < 0.001) was significantly higher in Group 1. The morbidity and mortality were similar between two groups. There were twelve hospital deaths (5.7%): eight (8/124, 6.5%) presented in Group 1 and four (4/86, 4.7%) in Group 2. On multi-variable analysis, risk factors for death were prolonged mechanical ventilation [hazard ratio (HR) 1.02, p = 0.004] and single right ventricle (HR 7.17, p = 0.03). After a mean follow-up of 4.95 years (range 0.74-13.62 years), one patient in Group 1 died of heart failure 13 months after Fontan procedure. The overall Fontan failure in Group 1 was similar to that in Group 2 (2.7% vs 2.6%, p = 0.985). The incidence of arrhythmias and re-intervention were not different between the two groups.

CONCLUSIONS

Fontan procedure could be performed safely in patient who stayed in long duration between Fontan procedure and BCPS without affecting the operative and long-term follow-up results. However, for post-BCPS patients with severe hypoxemia, earlier age at Fontan might be a good choice.

Impact of Enhanced Recovery after Surgery protocol on immediate surgical outcome in elderly patients undergoing pancreaticoduodenectomy

The numbers of patients undergoing pancreaticoduodenectomy are increasing and considerable percentage is elderly patients. Pancreaticoduodenectomy is a major and complicated surgery. The morbidity and mortality following pancreaticoduodenectomy have significantly reduced in recent times; it still remains unclear in elderly patients. Applications of Enhanced Recovery after Surgery protocol have contributed for this better outcome. In this retrospective study, patients who underwent pancreaticoduodenectomy with Enhanced Recovery after Surgery protocol were included and divided into two groups (< 60 years vs ≥ 60 years). The "elderly patients" (≥ 60 years) were defined based on the WHO definition for Indian subcontinent. Outcomes were analyzed in terms of postoperative morbidity, mortality and length of hospital stay. Total 103 patients underwent pancreaticoduodenectomy during the study period (January 2012-December 2017). The mean age was 56.6 ± 10.32 years. Fifty-six (54.37%) patients were aged < 60 years (young group) and 47 (45.63%) patients were aged ≥ 60 years (elderly group). There was no difference between the groups in terms of age, gender, co-morbidity, preoperative drainage and diagnosis. There was no significant difference in the morbidity and mortality (p > 0.05). Delayed gastric emptying was the most common complication which was 25.24% (21% vs 23.41%). Pancreatic fistula rate was 13.59% (8.9% vs 12.76%) and hemorrhage was 4.85% (5.4% vs 4.3%). Mortality was 4.85%. Postoperative hospital stay was comparable (14.7 days vs 15.3 days) (p = 0.164). Pancreaticoduodenectomy is a safe surgical procedure in elderly patients in comparison to young patients. Application of Enhanced Recovery after Surgery protocol can improve the outcome further.

Ultra-fast-track extubation vs. conventional extubation after cardiac surgery in a cardiovascular reference centre in Colombia. A longitudinal study

INTRODUCTION

The fast track / ultra-fast-track protocols are techniques used to optimise the patient care process and a quick recovery after cardiac surgery. They are one of the mainstays of efficient practice. With their use, the length of hospital and intensive care unit (ICU) stays are reduced, with a direct impact on costs and the quality of the health service.

OBJECTIVE

To compare the length of stay in the ICU, length of hospital stay, and post-operative mortality in ultra-fast-track extubated (uFTE) patients and those with conventional extubation (CE) after cardiac surgery.

METHODS

Longitudinal, analytical, retrospective study was conducted, with the period between the time of surgery and discharge being included as the study period.

RESULTS

A total of 396 patients older than 18 years who required cardiac surgery were included, of whom 207 patients had (uFTE) and 189 had CE. Although the groups were not comparable due to the statistical differences found, when performing the multivariate adjustment, uFTE maintained its statistical independence and was associated with lower cardiovascular morbidity, such as myocardial ischaemia (95% CI: 0.37-0.86; P = .01) and lower post-surgical vasopressor requirement (95% CI: 0.18-0.49; P < .01). No significant differences were found in the length of hospital stay, ICU stay, or post-operative mortality in the ICU.

CONCLUSION

Implementing the uFTE strategy, decreases cardiovascular morbidity and vasopressor requirement. The change to uFTE should be accompanied by changes in models and practices in patient recovery to standardised protocols. This study shows that uFTE did not reduce the length of ICU stay, hospital stay, or mortality.

Process improvement strategies: Designing and implementing quality improvement research

Quality improvement (QI) is the practice of continuously evaluating and improving the quality of health care that is delivered to patients. In this article, we will use practical examples to show how quality improvement projects have improved surgical patient care, and can be shared between institutions to accelerate the pace of improvement. We will explain the differences between quality improvement and research, and describe the methodological approach to performing and reporting quality improvement projects. Finally, we will describe ways to disseminate and widely implement changes in clinical practice using QI methodology. Even if they are not initiating and developing QI projects, all surgeons are likely to be affected by improvement initiatives going on in their hospitals, and should understand their valuable contribution to patient care.