Effect of mortality from COVID-19 on inpatient outcomes.

When hospitals first encountered coronavirus disease 2019 (COVID-19), there was a dearth of therapeutic options and nearly 1 in 3 patients died from the disease. By the summer of 2020, as deaths from the disease declined nationally, multiple single-center studies began to report declining mortality of patients with COVID-19. To evaluate the effect of COVID-19 on hospital-based mortality, we searched the Vizient Clinical Data Base for outcomes data from approximately 600 participating hospitals, including 130 academic medical centers, from January 2017 through December 2020. More than 32 million hospital admissions were included in the analysis. After an initial spike, mortality from COVID-19 declined in all regions of the country to under 10% by June 2020 and remained constant for the remainder of the year. Despite this, inpatient, all-cause mortality has increased since the beginning of the pandemic, even those without respiratory failure. Inpatient mortality has particularly increased in elderly patients and in those requiring intubation for respiratory failure. Since June 2020, COVID-19 kills one in every 10 patients admitted to the hospital with this diagnosis. The addition of this new disease has raised overall hospital mortality especially those who require intubation for respiratory failure.

Association between Hyperglycemia at Hospital Presentation and Hospital Outcomes in COVID-19 Patients with and without Type 2 Diabetes: A Retrospective Cohort Study of Hospitalized Inner-City COVID-19 Patients.

This study aimed to determine the relationships among hyperglycemia (HG), the presence of type 2 diabetes (T2D), and the outcomes of COVID-19. Demographic data, blood glucose levels (BG) measured on admission, and hospital outcomes of COVID-19 patients hospitalized at Boston University Medical Center from 1 March to 4 August 2020 were extracted from the hospital database. HG was defined as BG > 200 mg/dL. Patients with type 1 diabetes or BG < 70 mg/dL were excluded. A total of 458 patients with T2D and 976 patients without T2D were included in the study. The mean ± SD age was 56 ± 17 years and 642 (45%) were female. HG occurred in 193 (42%) and 42 (4%) of patients with and without T2D, respectively. Overall, the in-hospital mortality rate was 9%. Among patients without T2D, HG was statistically significantly associated with mortality, ICU admission, intubation, acute kidney injury, and severe sepsis/septic shock, after adjusting for potential confounders (p < 0.05). However, only ICU admission and acute kidney injury were associated with HG among patients with T2D (p < 0.05). Among the 235 patients with HG, the presence of T2D was associated with decreased odds of mortality, ICU admission, intubation, and severe sepsis/septic shock, after adjusting for potential confounders, including BG (p < 0.05). In conclusion, HG in the subset of patients without T2D could be a strong indicator of high inflammatory burden, leading to a higher risk of severe COVID-19.

Noninvasive respiratory support outside the intensive care unit for acute respiratory failure related to coronavirus-19 disease: a systematic review and meta-analysis.

BACKGROUND: Noninvasive respiratory support (NIRS) has been diffusely employed outside the intensive care unit (ICU) to face the high request of ventilatory support due to the massive influx of patients with acute respiratory failure (ARF) caused by coronavirus-19 disease (COVID-19). We sought to summarize the evidence on clinically relevant outcomes in COVID-19 patients supported by NIV outside the ICU. METHODS: We searched PUBMED®, EMBASE®, and the Cochrane Controlled Clinical trials register, along with medRxiv and bioRxiv repositories for pre-prints, for observational studies and randomized controlled trials, from inception to the end of February 2021. Two authors independently selected the investigations according to the following criteria: (1) observational study or randomized clinical trials enrolling ≥ 50 hospitalized patients undergoing NIRS outside the ICU, (2) laboratory-confirmed COVID-19, and (3) at least the intra-hospital mortality reported. Preferred Reporting Items for Systematic reviews and Meta-analysis guidelines were followed. Data extraction was independently performed by two authors to assess: investigation features, demographics and clinical characteristics, treatments employed, NIRS regulations, and clinical outcomes. Methodological index for nonrandomized studies tool was applied to determine the quality of the enrolled studies. The primary outcome was to assess the overall intra-hospital mortality of patients under NIRS outside the ICU. The secondary outcomes included the proportions intra-hospital mortalities of patients who underwent invasive mechanical ventilation following NIRS failure and of those with 'do-not-intubate' (DNI) orders. RESULTS: Seventeen investigations (14 peer-reviewed and 3 pre-prints) were included with a low risk of bias and a high heterogeneity, for a total of 3377 patients. The overall intra-hospital mortality of patients receiving NIRS outside the ICU was 36% [30-41%]. 26% [21-30%] of the patients failed NIRS and required intubation, with an intra-hospital mortality rising to 45% [36-54%]. 23% [15-32%] of the patients received DNI orders with an intra-hospital mortality of 72% [65-78%]. Oxygenation on admission was the main source of between-study heterogeneity. CONCLUSIONS: During COVID-19 outbreak, delivering NIRS outside the ICU revealed as a feasible strategy to cope with the massive demand of ventilatory assistance. REGISTRATION: PROSPERO, https://www.crd.york.ac.uk/prospero/ , CRD42020224788, December 11, 2020.

Progression and Resolution of COVID-19 Pneumonia on Chest Radiograph.

OBJECTIVE: To evaluate the temporal changes on serial chest radiographs (CXRs)of hospitalised COVID-19 positive patients till their outcome(discharge/death); to determine the severity of CXR score and its correlation with clinical outcome (hospital stay, chest intubation and mortality). STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Shifa International Hospital (SIH), Islamabad from March to June 2020. METHODOLOGY: After IRB approval, 112 patients were consecutively enrolled, having laboratory-confirmed SARS-CoV-2 and hospitalised in SIH. Patients' demographics and clinical data were retrieved from Radiology Information System (RIS). Chest radiographs (CXR) were retrieved from picture archive and communication system (PACS). CXR severity scoring was determined by three radiologists, and results were analysed. RESULTS: Lung opacities (98.2%), involvement of both lungs (96.4%), both peripheral and central region involvement (62.5%) and upper/mid/lower zone distribution (61.6%) were the most frequent findings. Males affected more than females with a mean age of 58.9 ± 13.1 years. Zonal involvement, density and extent of opacities peaked on 10-13th day of illness. In the last CXR, opacities showed decrease in extent as well as density, reduction in zonal involvement, and few having mixed interstitial thickening/fibrosis. One hundred and five out of 112 (93.8%) patients had residual radiographic abnormalities on discharge. CONCLUSION: Serial chest radiography can be used to monitor disease progression and temporal changes after initial HRCT. Patients who have CXR severity score of 4 or more at the time of admission, is a red flag for prolonged hospital stay and possible intubation. Severity of CXR findings peaked at 10-13 days. It is recommended to repeat CXRs every 3-4th day during hospital stay. Majority of the patients has residual radiographic abnormality on discharge. Key Words: COVID-19, Radiography, Thoracic, Pandemic, Chest X-ray.

Epidemiology of Surgical Procedures, Anesthesia, and Imaging Studies by Gestational Age during the First Year of Life in Medicaid-Insured Infants.

OBJECTIVES: To evaluate the rate of surgical procedures, anesthetic use, and imaging studies by prematurity status for the first year of life we analyzed data for Texas Medicaid-insured newborns. STUDY DESIGN: We developed a retrospective population-based live birth cohort of newborn infants insured by Texas Medicaid in 2010-2014 with 4 subcohorts: extremely premature, very premature, moderate/late premature, and term. RESULTS: In 1 102 958 infants, surgical procedures per 100 infants were 135.9 for extremely premature, 35.4 for very premature, 15.5 for moderate/late premature, and 6.5 for term. Anesthetic use was 62.0 for extremely premature, 20.8 for very premature, 11.1 for moderate/late premature, and 5.6 for the term subcohort. The most common procedures in the extremely premature were neurosurgery, intubations, and procedures that facilitated caloric intake (gastrostomy tubes and fundoplications). The annual rates for the first year of life for chest radiograph ranged from 15.0 per year for the extremely premature cohort to 0.6 for term infants and for magnetic resonance imaging (MRI) from 0.3 to 0.01. MRI was the most common imaging study with anesthesia support in all maturity levels. MRIs were done in extremely premature without anesthesia in over 90% and in term infants in 57.2%. CONCLUSIONS: Surgical procedures, anesthetic use, and imaging studies in infants are common and more frequent with higher a degree of prematurity while the use of anesthesia is lower in more premature newborns. These findings can provide direction for outcome studies of surgery and anesthesia exposure.

Efficacy of Tocilizumab in Patients Hospitalized with Covid-19.

BACKGROUND: The efficacy of interleukin-6 receptor blockade in hospitalized patients with coronavirus disease 2019 (Covid-19) who are not receiving mechanical ventilation is unclear. METHODS: We performed a randomized, double-blind, placebo-controlled trial involving patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, hyperinflammatory states, and at least two of the following signs: fever (body temperature >38°C), pulmonary infiltrates, or the need for supplemental oxygen in order to maintain an oxygen saturation greater than 92%. Patients were randomly assigned in a 2:1 ratio to receive standard care plus a single dose of either tocilizumab (8 mg per kilogram of body weight) or placebo. The primary outcome was intubation or death, assessed in a time-to-event analysis. The secondary efficacy outcomes were clinical worsening and discontinuation of supplemental oxygen among patients who had been receiving it at baseline, both assessed in time-to-event analyses. RESULTS: We enrolled 243 patients; 141 (58%) were men, and 102 (42%) were women. The median age was 59.8 years (range, 21.7 to 85.4), and 45% of the patients were Hispanic or Latino. The hazard ratio for intubation or death in the tocilizumab group as compared with the placebo group was 0.83 (95% confidence interval [CI], 0.38 to 1.81; P = 0.64), and the hazard ratio for disease worsening was 1.11 (95% CI, 0.59 to 2.10; P = 0.73). At 14 days, 18.0% of the patients in the tocilizumab group and 14.9% of the patients in the placebo group had had worsening of disease. The median time to discontinuation of supplemental oxygen was 5.0 days (95% CI, 3.8 to 7.6) in the tocilizumab group and 4.9 days (95% CI, 3.8 to 7.8) in the placebo group (P = 0.69). At 14 days, 24.6% of the patients in the tocilizumab group and 21.2% of the patients in the placebo group were still receiving supplemental oxygen. Patients who received tocilizumab had fewer serious infections than patients who received placebo. CONCLUSIONS: Tocilizumab was not effective for preventing intubation or death in moderately ill hospitalized patients with Covid-19. Some benefit or harm cannot be ruled out, however, because the confidence intervals for efficacy comparisons were wide. (Funded by Genentech; ClinicalTrials.gov number, NCT04356937.).

Alcohol Use Disorder Is Bad for Broken Ribs: A Nationwide Analysis of 19,638 Patients With Rib Fractures.

BACKGROUND: Alcohol use disorder (AUD) has deleterious effects on many organ systems. The aim of our study was to assess the impact of AUD on outcomes in patients with rib fractures. We hypothesized that AUD is associated with increased risk adverse outcomes. METHODS: We performed a 2013-2014 retrospective analysis of all adult trauma patients diagnosed with rib fractures from the American College of Surgeons-Trauma Quality Improvement Program database. We excluded patients who were acutely intoxicated with alcohol. Patients were stratified into two groups: AUD + and AUD -. A 1:1 ratio propensity score matching for demographics, admission vitals, injury severity, smoking status, operative intervention, and number of rib fractures was performed. Outcome measures were in-hospital complications, mortality, hospital and intensive care unit length of stay, and ventilator days. RESULTS: We matched 19,638 patients (AUD +:9,819, AUD -:9819). Mean age was 53 ± 22y, and median injury severity score was 15[10-20]. Matched groups were similar in age (P = 0.18), smoking status (P = 0.82), injury severity score (P = 0.28), chest Abbreviated Injury Scale (P = 0.24), and number of rib fractures (2[1-4] versus 2[1-4], P = 0.86). Alcoholic patients had higher rates of pneumonia (18.1% versus 9.2%, P < 0.01), unplanned intubation (18.5% versus 9.7, P < 0.001), sepsis (10.8% versus 6.3%, P < 0.001), acute respiratory distress syndrome (12.2% versus 7.4%, P < 0.001), and mortality (8.0 versus 5.7%, P < 0.001). Patients with AUD spent more days in the hospital and intensive care unit . There was no difference in ventilator days between the two groups. CONCLUSIONS: Patients with AUD and rib fractures had higher rates of adverse events than patients without AUD. Early identification of patients with rib fractures with AUD may allow better resource allocation and help improve outcomes. LEVEL OF EVIDENCE: Level III prognostic.

Why do some trauma patients die while others survive? A matched-pair analysis based on data from Trauma Register DGU®.

PURPOSE: The mortality rate for severely injured patients with the injury severity score (ISS) ≥16 has decreased in Germany. There is robust evidence that mortality is influenced not only by the acute trauma itself but also by physical health, age and sex. The aim of this study was to identify other possible influences on the mortality of severely injured patients. METHODS: In a matched-pair analysis of data from Trauma Register DGU®, non-surviving patients from Germany between 2009 and 2014 with an ISS≥16 were compared with surviving matching partners. Matching was performed on the basis of age, sex, physical health, injury pattern, trauma mechanism, conscious state at the scene of the accident based on the Glasgow coma scale, and the presence of shock on arrival at the emergency room. RESULTS: We matched two homogeneous groups, each of which consisted of 657 patients (535 male, average age 37 years). There was no significant difference in the vital parameters at the scene of the accident, the length of the pre-hospital phase, the type of transport (ground or air), pre-hospital fluid management and amounts, ISS, initial care level, the length of the emergency room stay, the care received at night or from on-call personnel during the weekend, the use of abdominal sonographic imaging, the type of X-ray imaging used, and the percentage of patients who developed sepsis. We found a significant difference in the new injury severity score, the frequency of multi-organ failure, hemoglobine at admission, base excess and international normalized ratio in the emergency room, the type of accident (fall or road traffic accident), the pre-hospital intubation rate, reanimation, in-hospital fluid management, the frequency of transfusion, tomography (whole-body computed tomography), and the necessity of emergency intervention. CONCLUSION: Previously postulated factors such as the level of care and the length of the emergency room stay did not appear to have a significant influence in this study. Further studies should be conducted to analyse the identified factors with a view to optimising the treatment of severely injured patients. Our study shows that there are significant factors that can predict or influence the mortality of severely injured patients.

Observational Study of Hydroxychloroquine in Hospitalized Patients with Covid-19.

BACKGROUND: Hydroxychloroquine has been widely administered to patients with Covid-19 without robust evidence supporting its use. METHODS: We examined the association between hydroxychloroquine use and intubation or death at a large medical center in New York City. Data were obtained regarding consecutive patients hospitalized with Covid-19, excluding those who were intubated, died, or discharged within 24 hours after presentation to the emergency department (study baseline). The primary end point was a composite of intubation or death in a time-to-event analysis. We compared outcomes in patients who received hydroxychloroquine with those in patients who did not, using a multivariable Cox model with inverse probability weighting according to the propensity score. RESULTS: Of 1446 consecutive patients, 70 patients were intubated, died, or discharged within 24 hours after presentation and were excluded from the analysis. Of the remaining 1376 patients, during a median follow-up of 22.5 days, 811 (58.9%) received hydroxychloroquine (600 mg twice on day 1, then 400 mg daily for a median of 5 days); 45.8% of the patients were treated within 24 hours after presentation to the emergency department, and 85.9% within 48 hours. Hydroxychloroquine-treated patients were more severely ill at baseline than those who did not receive hydroxychloroquine (median ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen, 223 vs. 360). Overall, 346 patients (25.1%) had a primary end-point event (180 patients were intubated, of whom 66 subsequently died, and 166 died without intubation). In the main analysis, there was no significant association between hydroxychloroquine use and intubation or death (hazard ratio, 1.04, 95% confidence interval, 0.82 to 1.32). Results were similar in multiple sensitivity analyses. CONCLUSIONS: In this observational study involving patients with Covid-19 who had been admitted to the hospital, hydroxychloroquine administration was not associated with either a greatly lowered or an increased risk of the composite end point of intubation or death. Randomized, controlled trials of hydroxychloroquine in patients with Covid-19 are needed. (Funded by the National Institutes of Health.).

Terminal ileum intubation is not associated with colonoscopy quality measures.

BACKGROUND AND AIM: Intubation of the terminal ileum (TI) demonstrates a complete colonoscopy, but its clinical value during screening exams is unknown. We aimed to determine whether TI intubation during screening colonoscopy is associated with colonoscopy quality measures or identifies subclinical pathology. METHODS: We performed a retrospective cohort study examining average-risk screening colonoscopies performed at an academic health system between July 2016 and October 2017. Data were extracted from an internal colonoscopy quality registry and the electronic health record. Appropriate statistical tests were used for group comparisons, to correlate TI intubation rate (TIIR) with measures of colonoscopy quality and to examine factors associated with the likelihood of TI intubation. RESULTS: There were 7799 colonoscopies performed with adequate prep quality by 28 gastroenterologists. Most patients were female (56.4%) with a median age of 58. The median TIIR was 37.0%, with significant variability among physicians (2-93%). The detection rates for all polyps, adenomas, and sessile serrated polyps were 62.1%, 45.5%, and 7.2%, respectively, and none correlated with TIIR. Intubation of the TI was associated with significantly longer withdrawal times. In a random 10% sample of cases with TI intubation, no clinically significant pathology was found. CONCLUSIONS: There is wide variability in TIIR among endoscopists. Except to provide photodocumentation of exam extent when other images may be difficult to obtain, the lack of correlation between TI intubation and meaningful clinical outcomes together with the associated time costs suggest routine TI intubation during screening colonoscopy may not be warranted.

Evaluation of two intensive care models in relation to successful extubation after cardiac surgery.

OBJECTIVE: To compare outcomes between intensivist-directed and cardiac surgeon-directed care delivery models. DESIGN: This retrospective, historical-control study was performed in a cohort of adult cardiac surgical patients at Zhongshan Hospital (Fudan University, China). During the first phase (March to August 2015), cardiac surgeons were in charge of postoperative care while intensivists were in charge during the second phase (September 2015-June 2016). Both phases were compared regarding successful extubation rate, intensive care unit (ICU) length of stay (LOS), and in-hospital mortality. SETTING: Tertiary Zhongshan Hospital (Fudan University, China). PATIENTS: Consecutive adult patients admitted to the cardiac surgical ICU (CSICU) after heart surgery. INTERVENTIONS: Phase I patients treated by cardiac surgeons, and phase II patients treated by intensivists. MAIN VARIABLES OF INTEREST: Successful extubation, ICU LOS and in-hospital mortality. RESULTS: A total of 1792 (phase I) and 3007 patients (phase II) were enrolled. Most variables did not differ significantly between the two phases. However, patients in phase II had a higher successful extubation rate (99.17% vs. 98.55%; p=0.043) and a shorter median duration of mechanical ventilation (MV) (18 vs. 19h; p<0.001). In relation to patients with MV duration >48h, those in phase II had a comparatively higher successful extubation rate (p=0.033), shorter ICU LOS (p=0.038) and a significant decrease in in-hospital mortality (p=0.039). CONCLUSIONS: The intensivist-directed care model showed improved rates of successful extubation and shorter MV durations after cardiac surgery.

Randomized trial of mask or prongs for nasal intermittent mandatory ventilation in term infants with transient tachypnea of the newborn.

BACKGROUND: The aim of this study was to compare nasal masks (NM) with binasal prongs (NP) for applying nasal intermittent mandatory ventilation (NIMV) by assessing the duration of respiratory distress, rate of intubation, and nasal trauma in term infants with transient tachypnea of the newborn (TTN). METHODS: Infants with a gestational age ≥37 weeks and birthweight ≥2,000 g who had NIMV administered for TTN were enrolled. We randomly allocated 80 neonates to the NM (n = 40) or NP (n = 40) group. Duration of respiratory distress was the primary outcome of this study. RESULTS: There were no statistically significant differences between the groups for the duration of tachypnea and NIMV (P = 0.94 and P = 0.13, respectively). No significant differences were observed between the two groups in terms of duration of oxygen supplementation and length of hospitalization (P = 0.72 and P = 0.70, respectively). The incidence of any grade of trauma and moderate trauma (grade II) was significantly higher in the NP group than in the NM group (P = 0.004 and P = 0.04, respectively). The rate of NIMV failure and other complications, including pneumothorax, pneumonia and feeding intolerance, was not significantly different in the groups. CONCLUSIONS: In term infants with TTN, delivering NIMV using NP in comparison to using NM appears to be similar with regard to the duration of respiratory distress and preventing intubation. However, the use of NP involves a greater risk of trauma than that of NM.

Effect of High-Flow Nasal Cannula Oxygen Therapy in Immunocompromised Subjects With Acute Respiratory Failure.

BACKGROUND: Various studies have been performed to examine the effect of high-flow nasal cannula (HFNC) in immunocompromised patients with acute respiratory failure (ARF). However, the results were inconsistent. Thus, we conducted a meta-analysis to evaluate the effect of HFNC oxygen therapy in immunocompromised patients with ARF versus conventional oxygen therapy and noninvasive ventilation (NIV). METHODS: Relevant studies published prior to May 11, 2019, were systematically searched. The primary outcome was intubation rate; secondary outcomes were mortality (ICU mortality, in-hospital mortality, and 90-d mortality) and ICU-acquired infections. Data were pooled using the random effects model. RESULTS: Of 832 identified studies, 8 were eligible for inclusion in our analysis (N = 2,167 subjects). HFNC was associated with lower intubation rates compared to conventional oxygen therapy (risk ratio [RR] 0.89, 95% CI 0.79-1.00, P = .040), but we found no significant difference in the rate between HFNC and NIV (RR 0.74, 95% CI 0.46-1.19, P = .22). We also found that HFNC did not increase the risk of ICU-acquired infections (RR 0.86, 95% CI 0.63-1.18, P = .35). However, in comparison to other noninvasive therapies, HFNC exhibited no differences in ICU mortality (RR 0.82, 95% CI 0.58-1.17, P = .28), in-hospital mortality (RR 0.92, 95% CI 0.74-1.15, P = .48), or 90-d mortality (RR 0.98, 95% CI 0.81-1.18, P = .82). CONCLUSIONS: Our results suggest that HFNC may be a feasible alternative to NIV, with lower intubation rates and no increased risk for ICU-acquired infections compared to standard oxygen therapy. However, HFNC did not appear to reduce mortality in immunocompromised subjects with ARF compared with other noninvasive therapies. Further high-quality randomized controlled trials should be performed to confirm these findings.

Enamel defects and caries prevalence in preterm children aged 5-10 years in Dubai.

Background: Enamel defects (EDs) are commonly reported dental findings in preterm/low birthweight children. EDs potentially increase caries susceptibility.Aim: To assess the prevalence of EDs and dental caries in a group of preterm children (aged 5-10 years) in Dubai, United Arab Emirates (UAE).Methodology: A retrospective cohort study of medical records of 62 preterm children (mean age 8.1 ± 1.54) and 62 full-term children (mean age 8.1 ± 1.73) of both genders born in a UAE children's hospital were studied. These children were dentally assessed for EDs and caries by a calibrated examiner.Results: EDs were 4.34 times more prevalent among preterm children [odd ratio (OR) = 4.338, CI 95% [2.010-9.366]. The prevalence of EDs in the pre-term group was 58.15%, significantly higher (P < 0.01) than the full-term control group (24.2%). Birth weight, intubation and type of delivery were statistically significant factors contributing to EDs. In the primary dentition, the mean dmft was 4.61 ± 4.30, while in the permanent dentition DMFT was 0.38 ± 0.99. There was a statistically significant difference in permanent teeth caries experience amongst pre-term children compared to the full-term control as measured by DMFT (P = 0.008).Conclusion: EDs and dental caries in permanent dentition in the pre-term group were significantly higher than the full-term group.

A novel technique for repositioning a nasobiliary catheter from the mouth to nostril in endoscopic retrograde cholangiopancreatography.

BACKGROUND: Endoscopic nasobiliary drainage (ENBD) is widely used for biliary decompression in patients with biliary disease. However, it is difficult to reposition a nasobiliary catheter from the mouth to nostril. We developed a new device, which has a curved flexible loop and bar-handle, for repositioning of ENBD catheter. The aim of this study was to evaluate the usefulness of the new loop-device for facilitating the repositioning of an ENBD catheter from the mouth to nostril. METHODS: Between January 2015 and December 2017, a comparative observational study was performed to evaluate the time taken for repositioning a nasobiliary catheter during endoscopic retrograde cholangiopancreatography (ERCP) and compare the results of ENBD procedure between the new loop-device and conventional techniques. In the subgroup analysis, we evaluated the occurrence of oral cavity injury and the time taken to transfer ENBD catheter from the mouth to nostril. RESULTS: In all, 145 ENBD procedures were performed using these two techniques. The procedure time was significantly shorter in the new technique group than in the conventional group. (44 s vs. 194 s, p < 0.001). The total success rate of new device technique was 97.3%. No complication, including oral cavity injury, was observed. CONCLUSIONS: The technique using our new loop-device was useful for repositioning a nasobiliary catheter from the mouth to nostril in ERCP. The new device does not require the removal of the mouthpiece before ENBD positioning, which can help perform the ENBD procedure rapidly and avoid the finger injury of endoscopists.

[Very Low Birth Weight Infants in a Portuguese Intensive Care Unit and the Vermont Oxford Network: 15 Years of Registry Data]. / Recém-Nascido de Muito Baixo Peso numa Unidade de Cuidados Intensivos Portuguesa Comparativamente ao Vermont Oxford Network: 15 Anos de Registo.

INTRODUCTION: Our neonatal service is part of a differentiated perinatal hospital and has contributed to the Vermont Oxford Network for more than 15 years. This data base includes data on the morbidity and mortality of newborns born in the member hospitals with birth weight between 401 and 1500 g and/ or from 22 to 29 weeks and six days of gestation, or those admitted to these hospitals with up to 28 days of age. It thus allows the analysis of clinical practice and its comparison with similar units. The goal of the present paper is to disclose some of our data from the past 15 years and to compare it with the Vermont Oxford Network data trying to identify areas of possible improvement and permitting other neonatal units to compare their data with our in a benchmarking process. MATERIAL AND METHODS: Observational, retrospective study. It included newborns with birth weight ≤ 1500 g (very low birth weight newborns) born and treated at our hospital from 2001 to 2015. Descriptive data analysis, chi-square test and ANOVA, significance when p < 0.05. RESULTS: A total of 869 very low birth weight newborns were studied, median weight 1100 g and gestational age 29 weeks. Twinning was found in 37.6%. In the delivery room, 23% did not require any resuscitation, 52.2% of the newborns required invasive intubation, 78.3% had surfactant, and, since 2011, 29.7% have started noninvasive ventilation. Of the total very low birth weight newborns, 12.9% had oxygen therapy at 36 weeks of corrected age, 23% patent ductus arteriosus and late sepsis in 17.1%. There was higher neurological morbidity compared to the Vermont Oxford Network except in the case of retinopathy of prematurity. Overall mortality was 14% (122 newborns). The time of hospitalization was on average 52.7 ± 34.4 days. The 629 newborns that were discharged home had equivalent length of stay and head circumference measure but a lower weight than those in the Vermont Oxford Network, and 14.3% went home with exclusive breastfeeding. DISCUSSION: This work allowed us to study our very low birth weight newborns data and compare it with one of the largest neonatal world networks. Our population is similar from the point of view of gestational age, somatometric data, pregnancy surveillance rates and cesarean section with the most noticeable difference being the percentage of low birthweight for gestational age babies, twin pregnancies and antenatal corticosteroid treatment, superior in our center. Cardio-pulmonary and gastrointestinal disorders were overlapping. It is urgent to improve our rate of sepsis, neurologic sequelae, post-partum hypothermia control and neuroprotection with magnesium sulphate. The mortality rate and the length of stay at discharge was similar. CONCLUSION: This study allowed us to compare our population of very low birth weight newborns with those registered in the network. We have verified that we have been accompanying the evolution of Neonatology over the past years and we have identified areas for improvement.

Introdução: O nosso serviço de Neonatologia está integrado num hospital perinatal diferenciado e pertence à rede de registo Vermont Oxford Network desde há mais de 15 anos. Este registo inclui dados da morbi-mortalidade de recém-nascidos com peso de nascimento entre 401 e 1500 g e/ou das 22 às 29 semanas e seis dias de gestação, nascidos nos hospitais membros ou admitidos até aos 28 dias de vida. Permite a análise da prática clínica e comparação com unidades semelhantes. Foi nosso objetivo divulgar alguns dos nossos dados dos últimos 15 anos fazer a sua reflexão, o estudo dos resultados e evolução das práticas assistenciais neonatais ao longo dos anos, e compará-los com os dados de um grupo com o mesmo nível de cuidados da rede Vermont Oxford Network. Dado considerarmos ser fundamental o estudo dos dados de morbimortalidade das unidades de neonatologia e sua comparação com unidades congéneres no sentido de identificação de áreas suscetíveis de intervenção, consideramos a pertinência da divulgação dos nossos dados.Material e Métodos: Estudo observacional, retrospetivo. Incluídos recém-nascidos com peso de nascimento ≤ 1500 g (recém-nascido de muito baixo peso) nascidos e tratados no nosso Hospital de 2001 a 2015 e comparados em dois subgrupos temporais com os dados da rede Vermont Oxford Network. Análise dos dados descritiva, teste de qui-quadrado e ANOVA, significância quando p < 0,05.Resultados: Estudaram-se 869 recém-nascidos de muito baixo peso com uma mediana de peso 1100 g e idade gestacional 29 semanas. Eram gémeos 37,6%. Na sala de partos 23% não necessitaram de qualquer reanimação, precisaram de entubação endotraqueal 52,2% dos recém-nascidos, em 78,3% foi administrado surfactante e desde que tal começou a ser registado em 2011, 29,7% iniciaram de imediato ventilação não invasiva. Em relação às principais morbilidades estudadas do ponto de vista respiratório do total de recém-nascidos de muito baixo peso 12,9% tinham oxigenoterapia às 36 semanas de idade corrigida, em relação à persistência do canal arterial hemodinamicamente significativo esta verificou-se em 23% e do ponto de vista infecioso verificou-se sépsis tardia em 17,1%. Registámos maior morbilidade neurológica comparativamente à Vermont Oxford Network exceto na retinopatia da prematuridade. A mortalidade global foi de 14% (122 recém-nascidos). O tempo de internamento foi em média de 52,7 ± 34,4 dias. Os 629 recém-­nascidos que tiveram alta para o domicílio estiveram internados sensivelmente os mesmos dias e apresentavam valores semelhantes de perímetro cefálico, mas menor peso no dia da alta que os da rede Vermont Oxford Network, tendo tido alta da nossa unidade com aleitamento materno exclusivo 14,3% dos recém-nascidos de muito baixo peso.Discussão: Este trabalho permitiu fazer a reflexão sobre os dados do nosso serviço de Neonatologia e compará-los com os de um dos maiores registos neonatais mundiais. Verificámos que a nossa população de recém-nascidos de muito baixo peso é muito sobreponível do ponto de vista da idade gestacional e somatométrico, taxas de vigilância da gravidez e de cesarianas, sendo a diferença mais notória a percentagem de leves para a idade gestacional, de gestações gemelares e de realização de indução maturativa que foram superiores no nosso centro. As patologias do foro cardiorrespiratório e gastrointestinais foram sobreponíveis. Verificámos que é urgente melhorar a taxa de infeção associada aos cuidados de saúde, das sequelas neurológicas, do controle da hipotermia após o nascimento e da neuroprotecção com sulfato de magnésio. A taxa de mortalidade foi sobreponível assim como o tempo de internamento.Conclusão: Este trabalho permitiu-nos comparar a nossa população de recém-nascidos de muito baixo peso com os registados na rede. Verificámos que acompanhámos a evolução que a Neonatologia foi tendo ao longo dos anos e identificámos áreas suscetíveis de melhoria.

Establishing a non-intubated thoracoscopic surgery programme for bilateral uniportal sympathectomy.

AIM OF THE STUDY: Non-intubated, video-assisted thoracoscopic surgery (NiVATS) has been successfully developed in several centres worldwide. Local anaesthesia techniques and techniques to perform thoracoscopic surgery on a spontaneously breathing lung are the two key elements which must be adopted to establish a NiVATS programme. We established NiVATS by performing bilateral, uniportal sympathectomies, and compared it to classical video-assisted thoracoscopic surgery (VATS) under general anaesthesia with double-lumen intubation. METHODS: Ten consecutive bilateral VATS sympathectomies were compared with ten consecutive NiVATS procedures. Nineteen of the procedures were for palmar hyperhidrosis and one was for facial blushing. Duration of anaesthesia, surgery and hospitalisation, perioperative complications, side effects and quality of life before and after sympathectomy were analysed. RESULTS: Median age was 26.5 years (range 17–55) and mean BMI in the NiVATS group was 21.8 (range 19.1–26.3). NiVATS sympathectomies were performed as outpatient procedures significantly more often (9/10 vs 3/10, p = 0.008). Quality of life was significantly increased after sympathectomy in all patients, with no significant differences between the NiVATS and the VATS groups. There were no differences between the two groups regarding compensatory sweating (40 vs 50%, p = 0.66). The duration of anaesthesia, not including the time required for the surgery, was significantly shorter in the NiVATS group (p <0.001). The duration of surgery, from the first local anaesthesia until the last skin suture, was significantly longer in the NiVATS group (p = 0.04), but showed a constant decline during the learning curve, from 95 minutes initially to 48 minutes for the last procedure. Costs were significantly lower in the NiVATS group (p = 0.04). CONCLUSION: Thoracoscopic sympathectomy is a suitable procedure with which to establish a NiVATS programme. Patients are usually young and of healthy weight, facilitating the learning curve for the local anaesthesia techniques and the surgery. Compared to VATS, sympathectomy is more likely to be performed as an outpatient procedure and has a lower cost, while safety and efficacy are maintained.