Is the performance of acute appendectomy at different times of day equal, in terms of postoperative complications, readmission, death, and length of hospital stay? A Swedish retrospective cohort study of 4950 patients.

PURPOSE: Appendicitis is one of the most common acute surgical conditions globally, and hence appendectomy is a common procedure performed around the clock in many hospitals. The aim of the current study was to determine whether acute appendectomy due to acute appendicitis performed during day, evening, and night was equally safe, in terms of postoperative complications, readmission, death, and length of hospital stay. METHODS: A retrospective single-center cohort study, using a local quality register of all consecutive acute appendectomies performed at the Department of Surgery, Södersjukhuset, Stockholm, Sweden. During the study period from December 2015 to August 2022, 4950 patients were included. Risk of complications, readmission, and death were determined using multivariable logistic regression models. Association with length of hospital stay was determined using multiple linear regression. RESULTS: There was no significant difference in the associated risk of postoperative complications, readmission within 30 days, or death, regardless of when appendectomy was performed. Using daytime surgery as reference, hospital stay was shortened by 4.21 h (P = 0.008) for evening surgery and by 6.71 h (P < 0.001) for nightly surgery. CONCLUSION: Risks of postoperative complications, readmission, and death were similar regardless of when acute appendectomy was performed. However, surgery during evening and night was associated with shortened hospital stay, as compared to daytime surgery.

Complications of Gastrostomy Tubes in Patients With Head and Neck Cancer.

OBJECTIVES: Head and neck cancers (HNCs) include various malignant tumors of the upper aerodigestive tract. Due to their anatomical location, HNCs can cause obstruction, odynophagia, or trismus, leading to dysphagia. In addition, this patient group may be vulnerable to treatment side effects both by surgery and oncological treatment, exposing the patients to an even higher risk of malnutrition. The risk of malnourishment is often resolved by applying a feeding gastrostomy tube. The present study aims to identify complication rates after percutaneous endoscopic gastrostomy (PEG) and open gastrostomy (OG) in patients treated for HNC in a high-volume center. STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective cohort study of all patients treated for a new diagnosis of HNC at the Department of Otorhinolaryngology and Head and Neck Surgery at Karolinska University Hospital between January 1, 2000 and December 31, 2018 in whom gastrostomy was performed. RESULTS: Regarding tumor location, 165 (56.7%) were in the pharynx, 68 (23.4%) in the oral cavity, 57 (19.6%) in the larynx, and 1 (0.3%) in the nasal cavity. PEG was performed in 240 (82.5%) and OG in 51 (17.5%) patients. The overall complication rate was 28.2%: 64 (26.7%) among PEG patients and 18 (35.3%) among OG patients. The incidence of major complications was 3.1%. CONCLUSIONS: Our study confirms that enteral feeding via gastrostomy is a safe method, regardless of the technique used (PEG or OG), with a low rate of major complications and no mortality linked to the procedure. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:1778-1784, 2022.

Central pulmonary embolism in patients with Covid-19.

BACKGROUND: The purpose was to evaluate central pulmonary embolism (PE) in patients with Covid-19. The association with severe radiological pulmonary changes, prophylactic anticoagulation and ICU care was assessed. METHODS: From 1 March until 31 May 2020, all in-hospital patients with a positive PCR for SARS-CoV-2-RNA and PE diagnosed with computed tomography pulmonary angiography were identified through diagnostic codes in medical charts. PE was characterised as central/peripheral and unilateral/bilateral. Covid-19 related lung changes were evaluated scoring the proportion of affected lung (max-score score 25) for all five lobes in both lungs. ICU and non-ICU patients were included and anticoagulant regimens were assessed. RESULTS: Of 1162 patients with Covid-19, 41 were diagnosed with PE (cumulative incidence 3.5%), and of these 63.4% (=overall 2.2%) had central PE. PE on admission was present in 46.3%. No differences were seen in the distribution of central vs. peripheral PE in relation to prophylactic anticoagulation (p=.317). Of ICU patients 82.4% were diagnosed with central PE compared to 50.0% among non-ICU patients (p=.05). No association was observed between the presence of central PE and the extent of radiological Covid-19 changes (p=.451). Mild (0-12 p) and severe (13-25 p) pulmonary changes were seen in 63.4% and 36.6% of patients respectively. CONCLUSIONS: Overall, and especially in ICU-patients, a high proportion of central PE was seen and many were diagnosed at admission. No association between central PE and prophylactic anticoagulation, or the extent of pulmonary Covid-19 changes was observed.

Analysis of Scientific Publications During the Early Phase of the COVID-19 Pandemic: Topic Modeling Study.

BACKGROUND: The COVID-19 pandemic has spread at an alarming speed, and effective treatment for the disease is still lacking. The body of evidence on COVID-19 has been increasing at an impressive pace, creating the need for a method to rapidly assess the current knowledge and identify key information. Gold standard methods such as systematic reviews and meta-analyses are regarded unsuitable because they have a narrow scope and are very time consuming. OBJECTIVE: This study aimed to explore the published scientific literature on COVID-19 and map the research evolution during the early phase of the COVID-19 pandemic. METHODS: We performed a PubMed search to analyze the titles, keywords, and abstracts of published papers on COVID-19. We used latent Dirichlet allocation modeling to extract topics and conducted a trend analysis to understand the temporal changes in research for each topic, journal impact factor (JIF), and geographic origin. RESULTS: Based on our search, we identified 16,670 relevant articles dated between February 14, 2020, and June 1, 2020. Of these, 6 articles were reports from peer-reviewed randomized trials on patients with COVID-19. We identified 14 main research topics, of which the most common topics were health care responses (2812/16,670, 16.86%) and clinical manifestations (1828/16,670, 10.91%). We found an increasing trend for research on clinical manifestations and protective measures and a decreasing trend for research on disease transmission, epidemiology, health care response, and radiology. Publications on protective measures, immunology, and clinical manifestations were associated with the highest JIF. The overall median JIF was 3.7 (IQR 2.6-5.9), and we found that the JIF for these publications declined over time. The top countries producing research were the United States, China, Italy, and the United Kingdom. CONCLUSIONS: In less than 6 months since the novel coronavirus was first detected, a remarkably high number of research articles on COVID-19 have been published. Here, we discuss and present the temporal changes in the available COVID-19 research during the early phase of the pandemic. Our findings may aid researchers and policy makers to form a structured view of the current COVID-19 evidence base and provide further research directions.

The effect of a terrorist attack on emergency department inflow: an observation study using difference-in-differences methodology.

STUDY OBJECTIVE: The objective of this study was to investigate how the terrorist attack in Stockholm, Sweden affected patient inflow to the general emergency departments (EDs) in close proximity of the attack. The study analyzed if, and to what extent, the attack impacted ED inflow during the following days and weeks. METHODS: In a retrospective observational study, anonymized aggregated data on ED arrivals (inflow of patients) to all seven of the EDs in the Stockholm County was analyzed using the Difference-in-Differences (DiD) estimator. The control groups were the affected hospitals in the years prior to the terrorist attack. The number of ED visits was retrieved from the Stockholm County Council administrative database. RESULTS: The study shows a statistically significant reduction in overall ED inflow of 7-9% following the attack. The effect was strongest initially after the attack, and ED inflow regained normal levels within approximately three weeks' time, without any significant rebound effect. The effect on ED inflow also decreased with distance from ground zero, and was not significant further away than 10 km. CONCLUSION: The results showed that ED inflow was significantly decreased in the weeks immediately following the Stockholm terrorist attack. The reasons for this cannot be fully explained in this observational study. However, the results suggest that some patients actively choose when, where and if they should go to the ED.

Retained sex toys: an increasing and possibly preventable medical condition.

PURPOSE: Retained foreign rectal objects may require surgical removal. To estimate the magnitude of this problem, we report the incidence and treatment of retained rectal objects at a large emergency hospital, and calculate incidence rates at the national level in Sweden. METHODS: All local patient records during 2009-2017 with the diagnosis foreign body in anus and rectum (ICD-10 T185) were accessed and analyzed retrospectively. All Swedish in- and outpatient visits during 2005-2016 with the code T185 were accessed from the National Patient Register. RESULTS: We show an increasing incidence in rectal foreign bodies in Swedish national data. The increase was most noticeable in men, and in our local register there was an overrepresentation of sex toys leading to laparotomy and stoma. CONCLUSIONS: To mitigate surgical cost and comorbidity, policies to decrease the risk of retained sex toys could be considered.

Primary Trauma Triage Performed by Bystanders: An Observation Study.

OBJECTIVE: The aim of this study was to evaluate whether bystanders with no training in triage can correctly prioritize three injured patients by using a triage instrument. METHOD: An observational study was conducted. Participants performed a primary triage on three paper-based patient cases and answered 11 questions during a public event in the center of Stockholm, Sweden. RESULTS: A total of 69 persons participated in the study. The success rate among all the participants for correct triage of the three patient cases was 52 percent. The female participants and younger participants (<55 years of age) performed correct triage to a greater extent. The over-triage was 12.5 percent and under-triage was 6.3 percent. CONCLUSION: Participants with no prior knowledge of triage instruments may be capable of triaging injured patients with the help of an easy triage instrument. The over- and under-triage percentages were low, and this may indicate that the developed triage instrument is relatively easy to use. It may also indicate that bystanders can identify a severely injured patient. Nordberg M , Castrén M , Lindström V . Primary trauma triage performed by bystanders: an observation study. Prehosp Disaster Med. 2016;31(4):353-357.

The association between vital signs and mortality in a retrospective cohort study of an unselected emergency department population.

BACKGROUND: Vital signs are widely used in emergency departments. Previous studies on the association between vital signs and mortality in emergency departments have been restricted to selected patient populations. We aimed to study the association of vital signs and age with 1-day mortality in patients visiting the emergency department. METHODS: This retrospective cohort included patients visiting the emergency department for adults at Södersjukhuset, Sweden from 4/1/2012 to 4/30/2013. Exclusion criteria were: age < 18 years, deceased upon arrival, chief complaint circulatory or respiratory arrest, key data missing and patients who were directed to a certain fast track for conditions demanding little resources. Vital sign data was collected through the Rapid Emergency Triage and Treatment System - Adult (RETTS-A). Descriptive analyses and logistic regression models were used. The main outcome measure was 1-day mortality. RESULTS: The 1-day mortality rate was 0.3%. 96,512 patients met the study criteria. After adjustments of differences in the other vital signs, comorbidities, gender and age the following vital signs were independently associated with 1-day mortality: oxygen saturation, systolic blood pressure, temperature, level of consciousness, respiratory rate, pulse rate and age. The highest odds ratios was observed when comparing unresponsive to alert patients (OR 31.0, CI 16.9 to 56.8), patients ≥ 80 years to <50 years (OR 35.9, CI 10.7 to 120.2) and patients with respiratory rates <8/min to 8-25/min (OR 18.1, CI 2.1 to 155.5). DISCUSSION: Most of the vital signs used in the ED are significantly associated with one-day mortality. The more the vital signs deviate from the normal range, the larger are the odds of mortality. We did not find a suitable way to adjust for the inherent influence the triage system and medical treatment has had on mortality. CONCLUSIONS: Most deviations of vital signs are associated with 1-day mortality. The same triage level is not associated with the same odds for death with respect to the individual vital sign. Patients that were unresponsive or had low respiratory rates or old age had the highest odds of 1-day mortality.

Forecasting emergency department visits using internet data.

STUDY OBJECTIVE: Using Internet data to forecast emergency department (ED) visits might enable a model that reflects behavioral trends and thereby be a valid tool for health care providers with which to allocate resources and prevent crowding. The aim of this study is to investigate whether Web site visits to a regional medical Web site, the Stockholm Health Care Guide, a proxy for the general public's concern of their health, could be used to predict the ED attendance for the coming day. METHODS: In a retrospective, observational, cross-sectional study, a model for forecasting the daily number of ED visits was derived and validated. The model was derived through regression analysis, using visits to the Stockholm Health Care Guide Web site between 6 pm and midnight and day of the week as independent variables. Web site visits were measured with Google Analytics. The number of visits to the ED within the region was retrieved from the Stockholm County Council administrative database. All types of ED visits (including adult, pediatric, and gynecologic) were included. The period of August 13, 2011, to August 12, 2012, was used as a training set for the model. The hourly variation of visits was analyzed for both Web site and the ED visits to determine the interval of hours to be used for the prediction. The model was validated with mean absolute percentage error for August 13, 2012, to October 31, 2012. RESULTS: The correlation between the number of Web site visits between 6 pm and midnight and ED visits the coming day was significant (r=0.77; P<.001). The best forecasting results for ED visits were achieved for the entire county, with a mean absolute percentage error of 4.8%. The result for the individual hospitals ranged between mean absolute percentage error 5.2% and 13.1%. CONCLUSION: Web site visits may be used in this fashion to predict attendance to the ED. The model works both for the entire region and for individual hospitals. The possibility of using Internet data to predict ED visits is promising.

Physician-led team triage based on lean principles may be superior for efficiency and quality? A comparison of three emergency departments with different triage models.

BACKGROUND: The management of emergency departments (EDs) principally involves maintaining effective patient flow and care. Different triage models are used today to achieve these two goals. The aim of this study was to compare the performance of different triage models used in three Swedish EDs. Using efficiency and quality indicators, we compared the following triage models: physician-led team triage, nurse first/emergency physician second, and nurse first/junior physician second. METHODS: All data of patients arriving at the three EDs between 08:00- and 21:00 throughout 2008 were collected and merged into a database. The following efficiency indicators were measured: length of stay (LOS) including time to physician, time from physician to discharge, and 4-hour turnover rate. The following quality indicators were measured: rate of patients left before treatment was completed, unscheduled return within 24 and 72 hours, and mortality rate within 7 and 30 days. RESULTS: Data from 147,579 patients were analysed. The median length of stay was 158 minutes for physician-led team triage, compared with 243 and 197 minutes for nurse/emergency physician and nurse/junior physician triage, respectively (p < 0.001). The rate of patients left before treatment was completed was 3.1% for physician-led team triage, 5.3% for nurse/emergency physician, and 9.6% for nurse/junior physician triage (p < 0.001). Further, the rates of unscheduled return within 24 hours were significantly lower for physician-led team triage, 1.0%, compared with 2.1%, and 2.5% for nurse/emergency physician, and nurse/junior physician, respectively (p < 0.001). The mortality rate within 7 days was 0.8% for physician-led team triage and 1.0% for the two other triage models (p < 0.001). CONCLUSIONS: Physician-led team triage seemed advantageous, both expressed as efficiency and quality indicators, compared with the two other models.

Reproducibility of methods for assessing baroreflex sensitivity and temporal QT variability in end-stage renal disease and healthy subjects.

Spontaneous baroreflex sensitivity (BRS), the reflex heart rate modulation in response to blood pressure changes (predominantly an index of cardiac vagal activity) and temporal QT variability (an index of myocardial repolarization) have been demonstrated to convey important prognostic information. The information about reproducibility of BRS and temporal QT variability is limited and there is lack of information regarding patients with cardiovascular diseases. We investigated reproducibility of spontaneous BRS using the sequence technique and temporal QT variability index (QTVI) in terms of intra-, interexaminer and within-subject variability in end-stage renal disease patients (ESRD, n=17, age 55+/-14 years) and healthy subjects (HS, n=29, age 32+/-12 years, P<0.01). ECG and blood pressure (Portapres) were recorded on two separate days and BRS and QTVI were evaluated by two independent examiners. The mean heart rate was similar in ESRD patients in comparison to healthy controls, whereas the mean arterial pressure was 13 % higher in ESRD patients (P<0.01). Spontaneous BRS was 62% lower (P<0.01) and QTVI was 41% higher in ESRD patients (P<0.01) compared to healthy subjects, respectively. Coefficient of variation (CV) of within-subject reproducibility of BRS and QTVI measurements was moderate (BRS: 33 % for ESRD, 27% for HS; QTVI: 40% for ESRD, 18% for HS). The 95% limit of within-subject reproducibility of BRS measurements was 3.8 ms/mm Hg for ESRD patients and 8.1 ms/mm Hg for healthy subjects; whereas the 95% limit of reproducibility of within-subject reproducibility of QTVI measurements was 0.73 for ESRD patients and 0.55 for healthy subjects. Concordance correlation coefficients of within-subject variability of BRS and QTVI were between 0.74 and 0.83 in both groups. CV of intra- and inter-examiner reproducibility of BRS and QTVI measurements in both groups ranged between 1 and 11%. In conclusion, the intra- and inter-examiner reproducibility/agreement of BRS and QTVI were high, whereas the within-subject reproducibility of these two methods was moderate, in both ESRD patients and healthy subjects. Thus, small differences in BRS and QTVI in longitudinal/interventional studies should be interpreted with caution.