Standard preoperative use of nonopioid multi-modal medications for patients undergoing mastectomy with immediate reconstruction and the effect on postoperative opioid needs.

Standardized nonopioid preoperative protocol effects perioperative opioids. Combined use of acetaminophen, pregabalin, celecoxib, and transdermal scopolamine (APCS), in mastectomy with immediate subpectoral reconstruction procedures. Retrospective (2014-2017) cohort study (n = 305) examined treatment groups; APCS, no treatment (NONE), and partial combination APCS (OTHER), employing multivariable gamma regression models controlling preoperative and perioperative variables, examining postoperative opioid use (oral morphine equivalents, OME) and hospital stay (hours, LOS). APCS group had a 25% statistical reduction in OME total vs OTHER, a 12% statistical reduction in LOS vs OTHER, and 11% statistical reduction in LOS vs NONE. Standardized nonopioid preoperative protocol provides insight into perioperative opioid use.

Acid Suppression to Prevent Gastrointestinal Bleeding in Patients With Ventricular Assist Devices.

BACKGROUND: The high incidence of gastrointestinal bleeding (GIB) in patients with ventricular assist devices (VAD) is well known, but there is limited evidence to support the use of proton pump inhibitors (PPIs) or histamine receptor antagonists (H2RA) for preventing GIB in patients with VAD. MATERIALS AND METHODS: The surgical ICU and VAD databases within a large regional academic cardiac mechanical support and transplant center were queried for patients who underwent VAD implantation between 2010 and 2014. An observational cohort study was conducted to identify which acid suppressing drug regimen was associated with the fewest number of GIB events within 30 d after VAD implantation: PPI, H2RA, or neither. Secondary outcomes included timing, etiology, and location of GIB. Multivariable logistic regression was used to compare treatment cohorts to GIB. Odds ratios, 95% confidence intervals, and P-values were reported from the model. RESULTS: One hundred thirty-eight patients were included for final analysis, 19 of which had a GIB within 30 days of VAD implantation. Both H2RA and PPI use were associated with reduced GIB compared with the cohort with no acid suppressive therapy. In the multivariate analysis, the PPI cohort showed a statistically significant reduction in GIB (Odds ratio 0.18 [95% confidence interval 0.04-0.79] P = 0.026). CONCLUSIONS: Using PPI postoperatively in patients with new VAD was associated with a reduced incidence of GIB. Given that GIB is a known complication after VAD placement, clinicians should consider the use of acid suppressive therapy for primary prevention.

Surgical Outcomes for Mastectomy Patients Receiving Neoadjuvant Chemotherapy: A Propensity-Matched Analysis.

OBJECTIVE: To evaluate the risk of neoadjuvant chemotherapy for surgical morbidity after mastectomy with or without reconstruction using 1:1 matching. BACKGROUND: Postoperative surgical complications remain a potentially preventable event for breast cancer patients undergoing mastectomy. Neoadjuvant chemotherapy is among variables identified as contributory to risk, but it has not been rigorously evaluated as a principal causal influence. METHODS: Data from American College of Surgeons National Surgical Quality Improvement Program (2006-2012) were used to identify females with invasive breast cancer undergoing planned mastectomy. Surgical cases categorized as clean and undergoing no secondary procedures unrelated to mastectomy were included. A 1:1 matched propensity analysis was performed using neoadjuvant chemotherapy within 30 days of surgery as treatment. A total of 12 preoperative variables were used with additional procedure matching: bilateral mastectomy, nodal surgery, tissue, and/or implant. Outcomes examined were 4 wound occurrences, sepsis, and unplanned return to the operating room. RESULTS: We identified 31,130 patient procedures with 2488 (7.5%) receiving chemotherapy. We matched 2411 cases, with probability of treatment being 0.005 to 0.470 in both cohorts. Superficial wound complication was the most common wound event, 2.24% in neoadjuvant-treated versus 2.45% in those that were not (P = 0.627). The rate of return to the operating room was 5.7% in the neoadjuvant group versus 5.2% in those that were not (P = 0.445). The rate of sepsis was 0.37% in the neoadjuvant group versus 0.46% in those that were not (P = 0.654). CONCLUSIONS: This large, matched cohort study, controlled for preoperative risk factors and most importantly for the surgical procedure performed, demonstrates that breast cancer patients receiving neoadjuvant chemotherapy have no increased risk for surgical morbidity.

Charge Awareness Affects Treatment Choice: Prospective Randomized Trial in Pediatric Appendectomy.

OBJECTIVE: To determine whether charge awareness affects patient decisions. BACKGROUND: Pediatric uncomplicated appendicitis can be treated with open or laparoscopic techniques. These 2 operations are considered to have clinical equipoise. METHODS: In a prospective, randomized clinical trial, nonobese children admitted to a children's hospital with uncomplicated appendicitis were randomized to view 1 of 2 videos discussing open and laparoscopic appendectomy. Videos were identical except that only one presented the difference in surgical materials charges. Patients and parents then choose which operation they desired. Videos were available in English and Spanish. A postoperative survey was conducted to examine factors that influenced choice. The trial was registered at ClinicalTrials.gov (NCT 01738750). RESULTS: Of 275 consecutive cases, 100 met enrollment criteria. In the group exposed to charge data (n = 49), 63% chose open technique versus 35% not presented charge data (P = 0.005). Patients were 1.8 times more likely to choose the less expensive option when charge estimate was given (95% confidence interval, 1.17-2.75). The median total hospital charges were $1554 less for those who had open technique (P < 0.001) and $528 less for the group exposed to charge information (P = 0.033). Survey found that 90% of families valued having input in this decision and 31% of patients exposed to charge listed it as their primary reason for their choice in technique. CONCLUSIONS: Patients and parents tended to choose the less expensive but equally effective technique when given the opportunity. A discussion of treatment options, which includes charge information, may represent an unrealized opportunity to affect change in health care spending.

Propofol is associated with favorable outcomes compared with benzodiazepines in ventilated intensive care unit patients.

RATIONALE: Mechanically ventilated intensive care unit (ICU) patients are frequently managed using a continuous-infusion sedative. Although recent guidelines suggest avoiding benzodiazepines for sedation, this class of drugs is still widely used. There are limited data comparing sedative agents in terms of clinical outcomes in an ICU setting. OBJECTIVES: Comparison of propofol to midazolam and lorazepam in adult ICU patients. METHODS: Data were obtained from a multicenter ICU database (2003-2009). Patient selection criteria included age greater than or equal to 18 years, single ICU admission with single ventilation event (>48 h), and treatment with continuously infused sedation (propofol, midazolam, or lorazepam). Propensity score analysis (1:1) was used and mortality measured. Cumulative incidence and competing risk methodology were used to examine time to ICU discharge and ventilator removal. MEASUREMENTS AND MAIN RESULTS: There were 2,250 propofol-midazolam and 1,054 propofol-lorazepam matched patients. Hospital mortality was statistically lower in propofol-treated patients as compared with midazolam- or lorazepam-treated patients (risk ratio, 0.76; 95% confidence interval [CI], 0.69-0.82 and risk ratio, 0.78; 95% CI, 0.68-0.89, respectively). Competing risk analysis for 28-day ICU time period showed that propofol-treated patients had a statistically higher probability for ICU discharge (78.9% vs. 69.5%; 79.2% vs. 71.9%; P < 0.001) and earlier removal from the ventilator (84.4% vs. 75.1%; 84.3% vs. 78.8%; P < 0.001) when compared with midazolam- and lorazepam-treated patients, respectively. CONCLUSIONS: In this large, propensity-matched ICU population, patients treated with propofol had a reduced risk of mortality and had both an increased likelihood of earlier ICU discharge and earlier discontinuation of mechanical ventilation.

The importance of extended postoperative venous thromboembolism prophylaxis in IBD: a National Surgical Quality Improvement Program analysis.

BACKGROUND: The National Comprehensive Cancer Network recommends that patients who have colorectal cancer receive up to 4 weeks of postoperative out-of-hospital venous thromboembolism prophylaxis. Patients with IBD are at high risk for venous thromboembolism, but there are no recommendations for routine postdischarge prophylaxis. OBJECTIVE: The purpose of this study was to compare the postoperative venous thromboembolism rate in IBD patients versus patients who have colorectal cancer to determine if IBD patients warrant postdischarge thromboembolism prophylaxis. DESIGN: This study is a retrospective review of IBD patients and patients who had colorectal cancer who underwent major abdominal and pelvic surgery. PATIENTS: Data were collected from the American College of Surgeons National Surgical Quality Improvement Program (2005-2010). MAIN OUTCOME MEASURES: The primary outcome was 30-day postoperative venous thromboembolism in IBD patients and patients who had colorectal cancer. Risk factors for venous thromboembolism were analyzed with the use of univariate testing and stepwise logistic regression. RESULTS: A total of 45,964 patients were identified with IBD (8888) and colorectal cancer (37,076). The 30-day postoperative rate of venous thromboembolism in IBD patients was significantly higher than in patients who had colorectal cancer (2.7% vs 2.1%, p < 0.001). In a model with 15 significant covariates, the OR for venous thromboembolism was 1.26 (95% CI, 1.021-1.56; p = 0.03) for the IBD patients in comparison with the patients who have colorectal cancer. LIMITATIONS: This study was limited by the retrospective design and the limitations of the data included in the database. CONCLUSIONS: Patients with IBD had a significantly increased risk for postoperative venous thromboembolism in comparison with patients who had colorectal cancer. Therefore, postdischarge venous thromboembolism prophylaxis recommendations for IBD patients should mirror that for patients who have colorectal cancer. This would suggest a change in clinical practice to extend out-of-hospital prophylaxis for 4 weeks in postoperative IBD patients.

Does travel distance influence length of stay in elective pancreatic surgery?

BACKGROUND: Length of stay (LoS) following elective surgery is being reported as an outcomes quality measure. Regional referral centres may care for patients travelling significant distances. The effect of travel distance on LoS in pancreatic surgery patients was examined. METHODS: National Surgical Quality Improvement Program data on pancreatic surgery patients, operated during the period from 2005 to 2011, were reviewed. Demographics, surgical variables and distance travelled were analysed relative to LoS. The LoS was log-transformed in general linear models to achieve normality. RESULTS: Of the 243 patients, 53% were male. The mean ± standard deviation (SD) age of the total patient sample was 60.6 ± 14 years. The mean ± SD distance travelled was 203 ± 319 miles (326.7 ± 513.4 km) [median: 132 miles (212.4 km); range: 3-3006 miles (4.8-4837.7 km)], and the mean ± SD LoS was 10.5 ± 7 days (range: 1-46 days). Univariate analysis showed a near significant increase in LoS with increased distance travelled (P = 0.05). Significant variables related to LoS were: age (P = 0.002); relative value units (P < 0.001), and preoperative American Society of Anesthesiologists class (P = 0.005). In a general linear model, for every 100 miles (160.9 km) travelled there is an associated 2% increase in LoS (P = 0.031). When the distance travelled is increased by 500 miles (804.7 km), LoS increases by 10.5%. CONCLUSIONS: Increased travel distance from a patient's home to the hospital was independently associated with an increase in LoS. If LoS is a reportable quality measure in pancreatic surgery, travel distance should be considered in risk adjustments.

Comparison of intraoperative versus delayed enteral feeding tube placement in patients undergoing a Whipple procedure.

BACKGROUND: The intraoperative placement of an enteral feeding tube (FT) during pancreaticoduodenectomy (PD) is based on the surgeon's perception of need for postoperative nutrition. Published preoperative risk factors predicting postoperative morbidity may be used to predict FT need and associated intraoperative placement. METHODS: A retrospective review of patients who underwent PD during 2005-2011 was performed by querying the National Surgical Quality Improvement Program (NSQIP) database with specific procedure codes. Patients were categorized based on how many of 10 possible preoperative risk factors they demonstrated. Groups of patients with scores of ≤ 1 (low) and ≥ 2 (high), respectively, were compared for FT need, length of stay (LoS) and organ space surgical site infections (SSIs). RESULTS: Of 138 PD patients, 82 did not have an FT placed intraoperatively, and, of those, 16 (19.5%) required delayed FT placement. High-risk patients were more likely to require a delayed FT (29.3%) compared with low-risk patients (9.8%) (P = 0.026). The 16 patients who required a delayed FT had a median LoS of 15.5 days, whereas the 66 patients who did not require an FT had a median LoS of 8 days (P < 0.001). CONCLUSIONS: In this analysis, subjects considered as high-risk patients were more likely to require an FT than low-risk patients. Assessment of preoperative risk factors may improve decision making for selective intraoperative FT placement.

Does travel distance influence length of stay in elective colorectal surgery?

BACKGROUND: Length of stay following elective colorectal surgery is being reported as a quality measure in surgical outcome registries, such as the National Surgical Quality Improvement Program. Regional referral centers with large geographic catchment areas attract patients from significant distances. OBJECTIVE: The aim of this study was to examine the effect of patient distance traveled, from primary residence to a tertiary care hospital, on length of stay in elective colorectal surgery patients. DESIGN: Retrospective population-based cohort study uses data obtained from the National Surgical Quality Improvement Program database. SETTINGS: This study was conducted at a tertiary referral hospital. PATIENTS: Data on 866 patients undergoing elective colorectal surgery from May 2003 to April 2011 were reviewed. MAIN OUTCOME MEASURES: Demographics, surgery-related variables, and distance traveled were analyzed relative to the length of stay. RESULTS: Of the 866 patients, 54% were men, mean age was 57 years, mean distance traveled was 145 miles (range, 2-2984 miles), and mean length of stay was 8.8 days. Univariate analysis showed a significant increase in length of stay with increased distance traveled (p = 0.02). Linear regression analysis revealed a significant association between increased length of stay and male sex (p = 0.006), increasing ASA score (p = 0.000), living alone (p = 0.009), and increased distance traveled (p = 0.028). For each incremental increase in log distance traveled, the length of stay increases by 2.5%. LIMITATIONS: This is a retrospective review that uses National Surgical Quality Improvement Program data. It is not known how many patients left the hospital and did not return to their primary residence. CONCLUSIONS: In a model that controlled for variables, increased travel distance from a patient's residence to the surgical hospital was associated with an increase in length of stay. If length of stay is a reportable quality measure in patients undergoing colorectal surgery, significant travel distance should be accounted for in the risk adjustment model calculations.

Preoperative multimodal protocol reduced postoperative nausea and vomiting in patients undergoing mastectomy with reconstruction.

BACKGROUND: Mastectomy with immediate reconstruction is a high-risk cohort for postoperative nausea and vomiting (PONV). Known risk factors for PONV include female gender, prior PONV history, nonsmoker, age < 50, and postoperative opioid exposure. The objective of this observational, cohort analysis was to determine whether a standardized preoperative protocol with nonopioid and anti-nausea multimodal medications would reduce the odds of PONV. METHODS: After IRB approval, retrospective data were collected for patients undergoing mastectomy with or without a nodal resection, and immediate subpectoral tissue expander or implant reconstruction. Patients were grouped based on treatment: those receiving the protocol - oral acetaminophen, pregabalin, celecoxib, and transdermal scopolamine (APCS); those receiving none (NONE), and those receiving partial protocol (OTHER). Logistic regression models were used to compare PONV among treatment groups, adjusting for patient and procedural variables. MAIN FINDINGS: Among 305 cases, the mean age was 47 years (21-74), with 64% undergoing a bilateral procedure and 85% having had a concomitant nodal procedure. A total of 44.6% received APCS, 30.8% received OTHER, and 24.6% received NONE. The APCS group had the lowest rate of PONV (40%), followed by OTHER (47%), and NONE (59%). Adjusting for known preoperative variables, the odds of PONV were significantly lower in the APCS group versus the NONE group (OR=0.42, 95% CI: 0.20, 0.88 p = 0.016). CONCLUSIONS: Premedication with a relatively inexpensive combination of oral non-opioids and an anti-nausea medication was associated with a significant reduction in PONV in a high-risk cohort. Use of a standardized protocol can lead to improved care while optimizing the patient experience.

Implementation of an enoxaparin protocol for venous thromboembolism prophylaxis in obese surgical intensive care unit patients.

BACKGROUND: Venous thromboembolism (VTE) is a serious health care issue that affects a large number of people. Few standards exist for delineating the optimal dosing strategy for VTE prevention in obese patients, especially in the setting of major surgery or trauma. OBJECTIVE: To document the efficacy of a surgical intensive care unit (SICU)-specific, weight-based dosing protocol of enoxaparin 0.5 mg/kg given subcutaneously every 12 hours for VTE prophylaxis in morbidly obese (defined as body mass index [BMI] ≥35 kg/m(2) or weight ≥150 kg) SICU patients, using peak anti-factor Xa levels to determine therapeutic endpoints. METHODS: Data were collected retrospectively in an academic, university-based SICU on 23 morbidly obese patients who received weight-based enoxaparin for VTE prophylaxis from December 1, 2008, through June 30, 2010. RESULTS: A weight-based dosage range of enoxaparin 50-120 mg twice daily (median 60) was given to 23 patients. The mean BMI was 46.4 kg/m(2). The initial mean anti-factor Xa level (measured after the third dose) was 0.34 IU/mL (range 0.20-0.59). Patients received an average of 18 doses. Two cases required an increase or decrease in dosage based on anti-factor Xa levels. Morbidity related to this dosing included a single event of minor endotracheal bleeding and a single deep vein thrombosis that was likely present prior to treatment. CONCLUSIONS: Weight-based dosing with enoxaparin in morbidly obese SICU patients was effective in achieving anti-factor Xa levels within the appropriate prophylactic range. This regimen reduced the rate of VTE below expected levels and no additional adverse effects were reported.

Short-Term Clinical and Quality Outcomes Have Inconsistent Changes From a Quality Improvement Initiative to Increase Access to Physical Therapy in the Cardiovascular and Surgical ICU.

Studies of mobility during critical illness have mostly examined transitions from immobility (passive activities) or limited mobility to active "early mobility." DESIGN: Observational analysis of a quality improvement initiative. SETTING: Two ICUs (surgical ICU, cardiovascular ICU) at a tertiary academic medical center. PATIENTS: Critically ill surgical and cardiovascular patients. INTERVENTIONS: Doubling available physical therapy. MEASUREMENTS AND MAIN RESULTS: We examined the outcomes of therapy time/patient/day, ICU and hospital length of stay, disposition location, and change in functional status. We adjusted for age, sex, illness severity, and number of surgeries. Among 1,515 patients (703 baseline, 812 quality improvement), total therapy time increased from 71,994 to 115,389 minutes and from 42,985 to 93,015 minutes, respectively, in each ICU. In the cardiovascular ICU per patient therapy increased 17% (95% CI, -4.9 to 43.9; p = 0.13), and in the surgical ICU, 26% (95% CI, -1 to 59.4; p = 0.06). In the cardiovascular ICU, there was a 27.4% decrease (95% CI, -52.5 to 10.3; p = 0.13) in ICU length of stay, and a 12.4% decrease (95% CI, -37.9 to 23.3; p = 0.45) in total length of stay, whereas in the surgical ICU, the adjusted ICU length of stay increased 19.9% (95% CI, -31.6 to 108.6; p = 0.52) and total length of stay increased 52.8% (95% CI, 1.0-130.2; p = 0.04). The odds of a lower level of care discharge did not change in either ICU (cardiovascular ICU: 2.6 [95% CI, 0.6-12.2; p = 0.22]); surgical ICU: 3.6 [95% CI, 0.9-15.4; p = 0.08]). CONCLUSIONS: Among diverse cardiothoracic and surgical patients, a quality improvement initiative doubling physical therapy shifts is associated with increased total administered therapy time, but when distributed among a greater number of patients during the quality improvement period, the increase is tempered. This was not associated with consistent changes in ICU length of stay or changes in disposition location.

Predicting ICU readmission among surgical ICU patients: Development and validation of a clinical nomogram.

BACKGROUND: Unplanned intensive care unit readmission within 72 hours is an established metric of hospital care quality. However, it is unclear what factors commonly increase the risk of intensive care unit readmission in surgical patients. The objective of this study was to evaluate predictors of readmission among a diverse sample of surgical patients and develop an accurate and clinically applicable nomogram for prospective risk prediction. METHODS: We retrospectively evaluated patient demographic characteristics, comorbidities, and physiologic variables collected within 48 hours before discharge from a surgical intensive care unit at an academic center between April 2010 and July 2015. Multivariable regression models were used to assess the association between risk factors and unplanned readmission back to the intensive care unit within 72 hours. Model selection was performed using lasso methods and validated using an independent data set by receiver operating characteristic area under the curve analysis. The derived nomogram was then prospectively assessed between June and August 2017 to evaluate the correlation between perceived and calculated risk for intensive care unit readmission. RESULTS: Among 3,109 patients admitted to the intensive care unit by general surgery (34%), transplant (9%), trauma (43%), and vascular surgery (14%) services, there were 141 (5%) unplanned readmissions within 72 hours. Among 179 candidate predictor variables, a reduced model was derived that included age, blood urea nitrogen, serum chloride, serum glucose, atrial fibrillation, renal insufficiency, and respiratory rate. These variables were used to develop a clinical nomogram, which was validated using 617 independent admissions, and indicated moderate performance (area under the curve: 0.71). When prospectively assessed, intensive care unit providers' perception of respiratory risk was moderately correlated with calculated risk using the nomogram (ρ: 0.44; P < .001), although perception of electrolyte abnormalities, hyperglycemia, renal insufficiency, and risk for arrhythmias were not correlated with measured values. CONCLUSION: Intensive care unit readmission risk for surgical patients can be predicted using a simple clinical nomogram based on 7 common demographic and physiologic variables. These data underscore the potential of risk calculators to combine multiple risk factors and enable a more accurate risk assessment beyond perception alone.

Outcomes When Using Adjunct Dexmedetomidine with Propofol Sedation in Mechanically Ventilated Surgical Intensive Care Patients.

Objective: Compare the duration of mechanical ventilation between patients receiving sedation with continuous infusions of propofol alone or combination with the use of dexmedetomidine and propofol. Design: Retrospective, propensity matched (1:1) cohort study, employing eight variables chosen a priori for matching. Timing of exposure to dexmedetomidine initiation was incorporated into a matching algorithm. Setting: Level 1, university-based, 32-bed, adult, mixed trauma and surgical intensive care unit (SICU). Continuous sedation was delivered according to a protocol methodology with daily sedation vacation and spontaneous breathing trials. Choice of sedation agent was physician directed. Patients: Between 2010 and 2014, 149 SICU patients receiving mechanical ventilation for >24 h received dexmedetomidine with propofol. Propensity matching resulted in 143 pair cohorts. Interventions: Dexmedetomidine with propofol or propofol alone. Measurements and Main Results: There was no statistical difference in SICU length of stay (LOS), with a median absolute difference of 5.3 h for propofol alone group (p = 0.43). The SICU mortality was not statistically different (RR = 1.002, p = 0.88). Examining a 14-day period post-treatment with dexmedetomidine, on any given day (excluding days 1 and 14), dexmedetomidine with propofol-treated patients had a 0.5% to 22.5% greater likelihood of being delirious (CAM-ICU positive). In addition, dexmedetomidine with propofol-treated patients had a 4.5% to 18.8% higher likelihood of being above the target sedation score (more agitated) compared to propofol-alone patients. Conclusions: In this propensity matched cohort study, adjunct use of dexmedetomidine to propofol did not show a statistically significant reduction with respect to mechanical ventilation (MV) duration, SICU LOS, or SICU mortality, despite a trend toward receiving fewer hours of propofol. There was no evidence that dexmedetomidine with propofol improved sedation scores or reduced delirium.

Perioperative antibiotics should be used for placement of implanted central venous ports: A propensity analysis evaluating risk.

OBJECTIVE: To quantify risk for CRI based on PABX use in CVAP placement for cancer patients. SUMMARY BACKGROUND DATA: Central venous access ports (CVAP) are totally implanted devices used for chemotherapy. There is a temporal risk for catheter related infection (CRI) to insertion and perioperative prophylactic antibiotics (PABX) use is a contested issue among practitioners. METHODS: Data was collected from a single center, academic oncology center. Treatment with a perioperative PABX was compared to non-treatment, to examine the incidence of 14-day CRI. Propensity scores with matched weights controlled for confounding, using 15 demographic, procedural and clinical variables. RESULTS: From 2007 to 2012, 1,091 CVAP were placed, where 59.7 % received PABX. The 14-day CRI rate was 0.82%, with 78% of those not receiving PABX. While results did not achieve statistical significance, use of PABX was associated with a 58% reduction in the odds of a 14-day CRI (OR = 0.42, 95% CI: 0.08-2.24, p = 0.31). CONCLUSION: The findings suggest a reduction in early CRI with the use of PABX. Since CRI treatment can range from a course of oral antibiotics, port removal, to hospital admission, we suggest clinicians consider these data when considering PABX in this high-risk population.

Single intervention for a reduction in portable chest radiography (pCXR) in cardiovascular and surgical/trauma ICUs and associated outcomes.

PURPOSE: Studies suggest that "on-demand" radiography is equivalent to daily routine with regard to adverse events. In these studies, provider behavior is controlled. Pragmatic implementation has not been studied. MATERIALS AND METHODS: This was a quasi-experimental, pre-post intervention study. Medical directors of two intervention ICUs requested pCXRs be ordered on an on-demand basis at one time point, without controlling or monitoring behavior or providing follow-up. RESULTS: A total of 11,994 patient days over 18months were included. Combined characteristics: Age: 56.7, 66% male, 96% survival, APACHE II 14 (IQR: 11-19), mechanical ventilation (MV) (occurrences)/patient admission: mean 0.7 (SD: 0.6; range: 0-5), duration (hours) of MV: 21.7 (IQR: 9.8-81.4) and ICU LOS (days): 2.8 (IQR: 1.8-5.6). Average pCXR rate/patient/day before was 0.93 (95% CI: 0.89-0.96), and 0.73 (95% CI: 0.69-0.77) after. Controlling for severity, daily pCXR rate decreased by 21.7% (p<0.001), then increased by about 3%/month (p=0.044). There was no change in APACHE II, mortality, and occurrences or duration of MV, unplanned re-intubations, ICU LOS. CONCLUSIONS: In critically ill adults, pCXR reduction can be achieved in cardiothoracic and trauma/surgical patients with a pragmatic intervention, without adversely affecting patient care, outside a controlled study.

Reproducibility of bladder pressure measurements in critically ill patients.

OBJECTIVE: Intra-abdominal hypertension is an independent cause of multiorgan failure and directly effects other physiological measurements, making it an important factor in the management of critically ill patients, but no clinical studies have investigated the reproducibility of intra-abdominal pressure (IAP) measurement to ensure diagnostic accuracy. This study evaluated the intraobserver and interobserver variability of bladder pressure measurements. DESIGN AND SETTING: Prospective, observational study in a university-based adult surgical intensive care unit. PATIENTS: Critically ill patients undergoing intra-abdominal pressure readings, measured by nursing staff. MEASUREMENTS AND RESULTS: The study compared patient IAP measurements obtained by the same nurse (intraobserver variation) and between two different nurses (interobserver variation) in critical care patients with clinical indications for IAP monitoring. Data related to the nursing technique and performance were observed and collected for each IAP measurement obtained. Good correlation of bladder pressure measurements between the same and different individuals was found. Intraobserver and interobserver Pearson's correlations for measured IAP were 0.934 and 0.950, respectively. A unit protocol for IAP measurement standardization was modified based on observational data collected. CONCLUSIONS: Intra-abdominal pressure can be accurately and reliably measured in critically ill patients by utilizing a standardized measurement device combined with a standardized clinical protocol.

Hospital wide porcine mesh conversion results in cost savings with equivalent clinical outcomes.

BACKGROUND: A variety of biologic mesh is available for ventral hernia repair. Despite widely variable costs, there is no data comparing cost of material to clinical outcome. METHODS: Biologic mesh product change was examined. A prospective survey was done to determine appropriate biologic mesh utilization, followed by a retrospective chart review of those treated from Sept. 2012 to Aug. 2013 with Strattice™ and from Sept. 2013 to Aug. 2014 with Permacol™. Outcome variables included complications associated with each material, repair success, and cost difference over the two periods. RESULTS: 28 patients received Strattice™ and 41 Permacol™. There was no statistical difference in patient factors, hernia characteristics, length of stay, readmission rates or surgical site infections at 30 days. The charges were significantly higher for Strattice™ with the median cost $8940 compared to $1600 for Permacol™ (p < 0.001). Permacol™ use resulted in a savings if $181,320. CONCLUSIONS: Permacol™ use resulted in similar clinical outcomes with significant cost savings when compared to Strattice™. Biologic mesh choice should be driven by a combination of clinical outcomes and product cost.

The molecular portraits of breast tumors are conserved across microarray platforms.

BACKGROUND: Validation of a novel gene expression signature in independent data sets is a critical step in the development of a clinically useful test for cancer patient risk-stratification. However, validation is often unconvincing because the size of the test set is typically small. To overcome this problem we used publicly available breast cancer gene expression data sets and a novel approach to data fusion, in order to validate a new breast tumor intrinsic list. RESULTS: A 105-tumor training set containing 26 sample pairs was used to derive a new breast tumor intrinsic gene list. This intrinsic list contained 1300 genes and a proliferation signature that was not present in previous breast intrinsic gene sets. We tested this list as a survival predictor on a data set of 311 tumors compiled from three independent microarray studies that were fused into a single data set using Distance Weighted Discrimination. When the new intrinsic gene set was used to hierarchically cluster this combined test set, tumors were grouped into LumA, LumB, Basal-like, HER2+/ER-, and Normal Breast-like tumor subtypes that we demonstrated in previous datasets. These subtypes were associated with significant differences in Relapse-Free and Overall Survival. Multivariate Cox analysis of the combined test set showed that the intrinsic subtype classifications added significant prognostic information that was independent of standard clinical predictors. From the combined test set, we developed an objective and unchanging classifier based upon five intrinsic subtype mean expression profiles (i.e. centroids), which is designed for single sample predictions (SSP). The SSP approach was applied to two additional independent data sets and consistently predicted survival in both systemically treated and untreated patient groups. CONCLUSION: This study validates the "breast tumor intrinsic" subtype classification as an objective means of tumor classification that should be translated into a clinical assay for further retrospective and prospective validation. In addition, our method of combining existing data sets can be used to robustly validate the potential clinical value of any new gene expression profile.

Classification and risk stratification of invasive breast carcinomas using a real-time quantitative RT-PCR assay.

INTRODUCTION: Predicting the clinical course of breast cancer is often difficult because it is a diverse disease comprised of many biological subtypes. Gene expression profiling by microarray analysis has identified breast cancer signatures that are important for prognosis and treatment. In the current article, we use microarray analysis and a real-time quantitative reverse-transcription (qRT)-PCR assay to risk-stratify breast cancers based on biological 'intrinsic' subtypes and proliferation. METHODS: Gene sets were selected from microarray data to assess proliferation and to classify breast cancers into four different molecular subtypes, designated Luminal, Normal-like, HER2+/ER-, and Basal-like. One-hundred and twenty-three breast samples (117 invasive carcinomas, one fibroadenoma and five normal tissues) and three breast cancer cell lines were prospectively analyzed using a microarray (Agilent) and a qRT-PCR assay comprised of 53 genes. Biological subtypes were assigned from the microarray and qRT-PCR data by hierarchical clustering. A proliferation signature was used as a single meta-gene (log2 average of 14 genes) to predict outcome within the context of estrogen receptor status and biological 'intrinsic' subtype. RESULTS: We found that the qRT-PCR assay could determine the intrinsic subtype (93% concordance with microarray-based assignments) and that the intrinsic subtypes were predictive of outcome. The proliferation meta-gene provided additional prognostic information for patients with the Luminal subtype (P = 0.0012), and for patients with estrogen receptor-positive tumors (P = 3.4 x 10-6). High proliferation in the Luminal subtype conferred a 19-fold relative risk of relapse (confidence interval = 95%) compared with Luminal tumors with low proliferation. CONCLUSION: A real-time qRT-PCR assay can recapitulate microarray classifications of breast cancer and can risk-stratify patients using the intrinsic subtype and proliferation. The proliferation meta-gene offers an objective and quantitative measurement for grade and adds significant prognostic information to the biological subtypes.