Application Value of High-Quality Nursing in Operating Room in Rectal Cancer Operation and its Influence on Postoperative Rehabilitation.

OBJECTIVE: To study the value of high-quality care in operating room during operation of patients with rectal cancer and the effect of this nursing model on postoperative rehabilitation. METHODS: This study recruited 72 patients with rectal cancer, including 36 in the control group and 36 in the observation group. Patients in the control group received routine care, and those in the observation group received high-quality care in operating room. RESULTS: The anxiety score (5.50 ± .77 vs 10. 08 ± 1.13), stress score (6.97 ± .60 vs 8.61 ± .99), and depression score (4.02 ± .65 vs 5.50 ± .91) in the observation group were less than the control group after treatment (P < .05). The measured values of diastolic blood pressure (73.19 ± 1.96 vs 86.13 ± 2.0), systolic blood pressure (121.08 ± 1.62 vs 130.63 ± 2.84), heart rate (73.05 ± 1.63 vs 87.11 ± 2.91) and adrenaline E(E) (58.40 ± 3.02 vs 61.42 ± 3.86) in the observation group were less than the control group after treatment (P < .05). The cooperation degree (94.44 vs 75.00) in the observation group was greater than the control group, but the operation time (308.47 ± 9.92 vs 339.47 ± 12.70), postoperative intestinal function recovery time (16.30 ± 1.14 vs 30.94 ± 2.10) and length of stay (10.47 ± 1.85 vs 13.33 ± 1.95) were all shorter than the control group (P < .05). The nasopharyngeal temperature in the observation group was greater than the control group at 30 minutes during operation (36.16 ± .50 vs 35.19 ± .40) and after operation, and fear score (2.22 ± .42 vs 3.63 ± .72) was less than the control group (P < .05). CONCLUSION: The application of high-quality care in the operating room during rectal cancer surgery has a significantly good clinical outcome.

Amplifying patient voices amid pandemic: Perspectives on tracheostomy care, communication, and connection.

OBJECTIVE: To investigate perspectives of patients, family members, caregivers (PFC), and healthcare professionals (HCP) on tracheostomy care during the COVID-19 pandemic. METHODS: The cross-sectional survey investigating barriers and facilitators to tracheostomy care was collaboratively developed by patients, family members, nurses, speech-language pathologists, respiratory care practitioners, physicians, and surgeons. The survey was distributed to the Global Tracheostomy Collaborative's learning community, and responses were analyzed. RESULTS: Survey respondents (n = 191) from 17 countries included individuals with a tracheostomy (85 [45 %]), families/caregivers (43 [22 %]), and diverse HCP (63 [33.0 %]). Overall, 94 % of respondents reported concern that patients with tracheostomy were at increased risk of critical illness from SARS-CoV-2 infection and COVID-19; 93 % reported fear or anxiety. With respect to prioritization of care, 38 % of PFC versus 16 % of HCP reported concern that patients with tracheostomies might not be valued or prioritized (p = 0.002). Respondents also differed in fear of contracting COVID-19 (69 % PFC vs. 49 % HCP group, p = 0.009); concern for hospitalization (55.5 % PFC vs. 27 % HCP, p < 0.001); access to medical personnel (34 % PFC vs. 14 % HCP, p = 0.005); and concern about canceled appointments (62 % PFC vs. 41 % HCP, p = 0.01). Respondents from both groups reported severe stress and fatigue, sleep deprivation, lack of breaks, and lack of support (70 % PFC vs. 65 % HCP, p = 0.54). Virtual telecare seldom met perceived needs. CONCLUSION: PFC with a tracheostomy perceived most risks more acutely than HCP in this global sample. Broad stakeholder engagement is necessary to achieve creative, patient-driven solutions to maintain connection, communication, and access for patients with a tracheostomy.

Pro-Con Debate: Cardiac Troponin Measurement as Part of Routine Follow-up of Myocardial Damage Following Noncardiac Surgery.

Elevated troponin levels within 3 days of surgery, independent of the presence of symptoms, are strongly linked to increased risk of short- and long-term morbidity and mortality. However, the value of screening with troponin measurements is controversial. The Canadian Cardiovascular Society guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery recommends measuring daily troponin for 48 to 72 hours after surgery in high-risk patients. Nevertheless, others doubt this recommendation, in part because postoperative elevated levels of troponin describe very little in terms of disease or event-specific pathogenesis and etiology, and thus, tailoring an intervention remains a challenge. This Pro-Con debate offers evidence-based data to stimulate physician understanding of daily practice and its significance in this matter, and assist in determining whether to use (Pro) or not to use (Con) this surveillance.

Minimal clinically important difference in days at home up to 30 days after surgery.

Patient-centred outcomes are increasingly recognised as crucial measures of healthcare quality. Days alive and at home up to 30 days after surgery (DAH30 ) is a validated and readily obtainable patient-centred outcome measure that integrates much of the peri-operative patient journey. However, the minimal difference in DAH30 that is clinically important to patients is unknown. We designed and administered a 28-item survey to evaluate the minimal clinically important difference in DAH30 among adult patients undergoing inpatient surgery. Patients were approached pre-operatively or within 2 days postoperatively. We did not study patients undergoing day surgery or nursing home residents. Patients ranked their opinions on the importance of discharge home using a Likert scale (from 1, not important at all to 6, extremely important) and the minimum number of extra days at home that would be meaningful using this scale. We recruited 104 patients; the survey was administered pre-operatively to 45 patients and postoperatively to 59 patients. The mean (SD) age was 53.5 (16.5) years, and 51 (49%) patients were male. Patients underwent a broad range of surgery of mainly intermediate (55%) to major (33%) severity. The median minimal clinically important difference for DAH30 was 3 days; this was consistent across a broad range of scenarios, including earlier discharge home, complications delaying hospital discharge and the requirement for admission to a rehabilitation unit. Discharge home earlier than anticipated and discharge home rather than to a rehabilitation facility were both rated as important (median score = 5). Empirical data on the minimal clinically important difference for DAH30 may be useful to determine sample size and to guide the non-inferiority margin for future clinical trials.

Impacts of Initial Prescription Length and Prescribing Limits on Risk of Prolonged Postsurgical Opioid Use.

BACKGROUND: In response to concerns about opioid addiction following surgery, many states have implemented laws capping the days supplied for initial postoperative prescriptions. However, few studies have examined changes in the risk of prolonged opioid use associated with the initial amount prescribed. OBJECTIVE: The objective of this study was to estimate the risk of prolonged opioid use associated with the length of initial opioid prescribed and the potential impact of prescribing limits. RESEARCH DESIGN: Using Medicare insurance claims (2007-2017), we identified opioid-naive adults undergoing surgery. Using G-computation methods with logistic regression models, we estimated the risk of prolonged opioid use (≥1 opioid prescription dispensed in 3 consecutive 30-d windows following surgery) associated with the varying initial number of days supplied. We then estimate the potential reduction in cases of prolonged opioid use associated with varying prescribing limits. RESULTS: We identified 1,060,596 opioid-naive surgical patients. Among the 70.0% who received an opioid for postoperative pain, 1.9% had prolonged opioid use. The risk of prolonged use increased from 0.7% (1 d supply) to 4.4% (15+ d). We estimated that a prescribing limit of 4 days would be associated with a risk reduction of 4.84 (3.59, 6.09)/1000 patients and would be associated with 2255 cases of prolonged use potentially avoided. The commonly used day supply limit of 7 would be associated with a smaller reduction in risk [absolute risk difference=2.04 (-0.17, 4.25)/1000]. CONCLUSIONS: The risk of prolonged opioid use following surgery increased monotonically with increasing prescription duration. Common prescribing maximums based on days supplied may impact many patients but are associated with relatively low numbers of reduced cases of prolonged use. Any prescribing limits need to be weighed against the need for adequate pain management.

Perioperative management of severe brain injured patients.

Traumatic brain injury (TBI) is a leading cause of mortality and disability worldwide. Head injured patients may frequently require emergency neurosurgery. The perioperative TBI period is very important as many interventions done in this stage can have a profound effect on the long-term neurological outcome. This practical concise narrative review focused mainly on: 1) the management of severe TBI patients with neurosurgical lesions admitted to a spoke center (i.e. hospital without neurosurgery) and therefore needing a transfer to the hub center (i.e. hospital with neurosurgery); 2) the management of severe TBI patients with intracranial hypertension/brain herniation awaiting for neurosurgery; and 3) the neuromonitoring-oriented management in the immediate post-operative period. The proposals presented in this review mainly apply to severe TBI patients admitted to high-income countries.

DEVIATION BETWEEN THE PLANNED DOSE AND THE IN VIVO DOSIMETRY RESULTS DURING POSTOPERATIVE IRRADIATION IN PATIENTS WITH UTERINE CANCER DEPENDING ON ANTHROPOMETRIC DATA. / VIDKhYLENNIa MIZh ZAPLANOVANOIu DOZOIu I REZUL'TATAMY DOZYMETRIÏ IN VIVO PRY PISLIaOPERATsIINOMU OPROMINENNI U PATsIIeNTOK, KhVORYKh NA RAK TILA MATKY, ZALEZhNO VID ANTROPOMETRYChNYKh DANYKh.

Topometry is an integral part of irradiation whose task is to repeat the position of the patient set by the simulator to repeat the PTV and the spatial relationship between the radiation field and the risk organs that were identified during planning. The dose distribution formulated in the plan is only an ideal model. There is some gap between the actual and planned dose distribution, especially in overweight patients. OBJECTIVE: evaluate the effect of anthropometric data on the deviation between the planned dose and the results of dosimetry in vivo in patients with uterine cancer during postoperative irradiation. MATERIALS AND METHODS: The authors analyzed the results of treatment of 110 patients with stage IB-II uterine can- cer who were treated at the Department of Radiation Therapy of the Institute of Medical Radiology and Oncology of the National Academy of Medical Sciences of Ukraine from 2016 to 2019. The technique of classical fractionation was used with a single focal dose of 2.0 Gy 5 times a week, the total focal dose was 42.0-50.0 Gy. To assess the effect of the patient's anthropometric data on the difference between the actual and calculated dose, the authors per- formed in vivo dosimetry after the first session and in the middle of the postoperative course of external beam radi- ation therapy. RESULTS: Рatients with BSA < 1.92 m2, had the median relative deviation at the first session -4.12 %, after 20.0 Gy - 3.61 %, patients with BSA > 1.92 m2: -2.06 % and -1.55 % respectively. After 20 Gy 34.8 % of patients with BSA < 1.92 m2 there was an increase in deviation from the planned dose, 65.2 % a decrease, while in 56.1 % of patients with BSA > 1.92 m2 there was an increase, and in 43.9 % - its reduction. With increasing BMI, the actual dose received on the rectal mucosa in the tenth session of irradiation is approaching the calculated one. CONCLUSIONS: When irradiated on the ROKUS-AM device, we did not find a probable dependence of the influence of the constitutional features of patients between the received and planned radiation dose. When treated with a Clinac 600 C, only body weight and body mass index at the tenth irradiation session have a likely effect on the dose differ- ence. Therefore, issues related to the individual approach to the treatment of uterine cancer, depending on anthro- pometric data is an urgent problem of modern radiotherapy.

ISHLT consensus document on lung transplantation in patients with connective tissue disease: Part III: Pharmacology, medical and surgical management of post-transplant extrapulmonary conditions statements.

Patients with connective tissues disease (CTD) are often on immunomodulatory agents before lung transplantation (LTx). Till now, there's no consensus on the safety of using these agents perioperative and post-transplant. The International Society for Heart and Lung Transplantation-supported consensus document on LTx in patients with CTD addresses the risk and contraindications of perioperative and post-transplant management of the biologic disease-modifying antirheumatic drugs (bDMARD), kinase inhibitor DMARD, and biologic agents used for LTx candidates with underlying CTD, and the recommendations and management of non-gastrointestinal extrapulmonary manifestations, and esophageal disorders by medical and surgical approaches for CTD transplant recipients.

Peak Lag Between Plasma Vasopressin and Urine Aquaporin-2 Following Cardiac Surgery.

Tolvaptan, a vasopressin type-2 receptor antagonist, is utilized to ameliorate fluid retention following cardiac surgery. However, the optimal timing of tolvaptan administration considering novel biomarkers remains unknown. We prospectively included patients who underwent cardiac surgery between 2016 and 2020. We measured perioperative trends of free water reabsorption mediators including plasma arginine vasopressin and urine aquaporin-2. A total of 20 patients (68 [60, 75] years old, 18 men) were included. Urine volume decreased gradually after the initial 3 hours following cardiac surgery. The plasma arginine vasopressin level increased significantly with a peak at postoperative 6 hours, whereas the urine aquaporin-2 level increased later with a delayed peak at postoperative 12 hours. As a result, urine aquaporin-2 relative to the plasma arginine vasopressin level, which represents the activity of the collecting ducts and indicates predicted responses to tolvaptan, was a minimum at postoperative 6 hours. Tolvaptan administration immediately after cardiac surgery might not be recommended given the transient refractoriness to tolvaptan probably due to the stunning of kidney collecting ducts.

Validation of VR-12 Physical Function in Minimally Invasive Lumbar Discectomy.

BACKGROUND: Although the Veterans RAND 12-item Physical Component Survey (VR-12 PCS) has been broadly used to evaluate patient-reported outcome measures (PROMs) in spine surgery, its feasibility for use in patients undergoing minimally invasive lumbar discectomy (MIS LD) has not been well studied. This study aimed to assess the feasibility of VR-12 PCS for use up to 2 years postoperatively for MIS LD by correlation with PROMs for physical function. METHODS: Patients undergoing primary single-level MIS LD procedures were reviewed retrospectively. Results on the VR-12 PCS, 12-Item Short Form (SF-12) PCS, and Patient-Reported Outcomes Measurement Information System (PROMIS PF) were recorded preoperatively and up to 2 years postoperatively. Improvements in postoperative PROMs were calculated and assessed for significant differences from baseline values. Correlation significance and strength were evaluated between VR-12 PCS and SF-12 PCS or PROMIS PF. Scatterplots were constructed to demonstrate relationships of VR-12 PCS with SF-12 PCS and PROMIS PF at each time point. RESULTS: Our cohort comprised 402 patients. Patients improved significantly from preoperative baseline for all 3 PROMs at all postoperative time points. Both Pearson's correlation and time-independent partial correlation revealed statistically significant strong correlations of VR-12 PCS with SF-12 PCS and PROMIS PF through 2-years. DISCUSSION: Physical function scores for VR-12, SF-12, and PROMIS PF all demonstrated significant improvements following MIS LD. Strongly statistically significant correlations of VR-12 PCS with SF-12 PCS and PROMIS PF from preoperative measures through 2 years demonstrate the feasibility of VR-12 for assessing patient-reported physical function in MIS LD patients.

Standardizing postoperative care for pediatric intradural Chiari decompressions to decrease length of stay.

OBJECTIVE: Amid national and local budget crises, cutting costs while maintaining quality care is a top priority. Chiari malformation is a relatively common pediatric neurosurgical pathology, and postoperative care varies widely. The postoperative course can be complicated by pain and nausea, which can extend the hospital stay. In this study, the authors aimed to examine whether instituting a standardized postoperative care protocol would decrease overall patient hospital length of stay (LOS) as well as cost to families and the hospital system. METHODS: A retrospective study of pediatric patients who underwent an intradural Chiari decompression with expansile duraplasty at a single institution from January 2016 to September 2019 was performed. A standardized postoperative care protocol was instituted on May 17, 2018. Pre- and postprotocol groups were primarily analyzed for demographics, LOS, and the estimated financial expense of the hospital stay. Secondary analysis included readmissions, opioid consumption, and follow-up. RESULTS: The analysis included 132 pediatric patients who underwent an intradural Chiari decompression with expansile duraplasty. The preprotocol group included 97 patients and the postprotocol group included 35 patients. Patient age ranged from 0.5 to 26 years (mean 9.5 years). The mean LOS preprotocol was 55.48 hours (range 25.90-127.77 hours), and the mean postprotocol LOS was 46.39 hours (range 27.58-77.38 hours). The comparison between means showed a statistically significant decrease following protocol initiation (95% CI 1.87-16.31 hours, p = 0.014). In the preprotocol group, 21 of 97 patients (22%) were discharged the first day after surgery compared with 14 of 35 patients (40%) in the postprotocol group (p = 0.045). The estimated cost of one night on the pediatric neurosurgical intermediate ward was approximately $4500, which gives overall cost estimates for 100 theoretical cases of $927,800 for the preprotocol group and $732,900 for the postprotocol group. CONCLUSIONS: By instituting a Chiari protocol, postoperative LOS was significantly decreased, which resulted in decreased healthcare costs while maintaining high-quality and safe care.

Reduction in Pediatric Ambulatory Adenotonsillectomy Length of Stay Using Clinical Care Guidelines.

OBJECTIVE: Standardization of postoperative care using clinical care guidelines (CCG) improves quality by minimizing unwarranted variation. It is unknown whether CCGs impact patient throughput in outpatient adenotonsillectomy (T&A). We hypothesize that CCG implementation is associated with decreased postoperative length of stay (LOS) in outpatient T&A. METHODS: A multidisciplinary team was assembled to design and implement a T&A CCG. Standardized discharge criteria were established, including goal fluid intake and parental demonstration of medication administration. An order set was created that included a hard stop for discharge timeframe with choices "meets criteria," "4-hour observation," and "overnight stay." Consensus was achieved in June 2018, and the CCG was implemented in October 2018. Postoperative LOS for patients discharged the same day was tracked using control chart analysis with standard definitions for centerline shift being utilized. Trends in discharge timeframe selection were also followed. RESULTS: Between July 2015 and August 2017, the average LOS was 4.82 hours. This decreased to 4.39 hours in September 2017 despite no known interventions and remained stable for 17 months. After CCG implementation, an initial trend toward increased LOS was followed by centerline shifts to 3.83 and 3.53 hours in March and October 2019, respectively. Selection of the "meets criteria" discharge timeframe increased over time after CCG implementation (R2  = 0.38 P = .003). CONCLUSIONS: Implementation of a CCG with standardized discharge criteria was associated with shortened postoperative LOS in outpatient T&A. Concurrently, surgeons shifted practice to discharge patients upon meeting criteria rather than after a designated timeframe. LEVEL OF EVIDENCE: NA Laryngoscope, 131:2610-2615, 2021.

Development of Care Curves Following the Stage 1 Palliation: A Comparison of Intensive Care Among 5 Centers.

Background Comparison of care among centers is currently limited to major end points, such as mortality, length of stay, or complication rates. Creating "care curves" and comparing individual elements of care over time may highlight modifiable differences in intensive care among centers. Methods and Results We performed an observational retrospective study at 5 centers in the United States to describe key elements of postoperative care following the stage 1 palliation. A consecutive sample of 502 infants undergoing stage 1 palliation between January 2009 and December 2018 were included. All electronic health record entries relating to mandatory mechanical ventilator rate, opioid administration, and fluid intake/outputs between postoperative days (POD) 0 to 28 were extracted from each institution's data warehouse. During the study period, 502 patients underwent stage 1 palliation among the 5 centers. Patients were weaned to a median mandatory mechanical ventilator rate of 10 breaths/minute by POD 4 at Center 5 but not until POD 7 to 8 at Centers 1 and 2. Opioid administration peaked on POD 2 with extreme variance (median 6.9 versus 1.6 mg/kg per day at Center 3 versus Center 2). Daily fluid balance trends were variable: on POD 3 Center 1 had a median fluid balance of -51 mL/kg per day, ranging between -34 to 19 mL/kg per day among remaining centers. Intercenter differences persist after adjusting for patient and surgical characteristics (P<0.001 for each end point). Conclusions It is possible to detail and compare individual elements of care over time that represent modifiable differences among centers, which persist even after adjusting for patient factors. Care curves may be used to guide collaborative quality improvement initiatives.

Manuka Honey: Feasibility and Safety in Postoperative Neurosurgical Wound Care.

OBJECTIVE: To date, no reports have been published on active Leptospermum manuka honey (ALH) feasibility as a postoperative topical wound supplement in neurosurgical patients. The objective of the study is to present the authors' initial experience with using ALH in postoperative neurosurgical patients. METHODS: A single-surgeon retrospective case series review of cranial and spinal operations between 2018 and 2020 was performed in patients with nonhealing wounds or wounds deemed "at risk" as defined by grade 1 Sandy surgical wound dehiscence grading classification. An ALH gel or ointment was applied to these incisions once a day for 2 to 4 weeks. Patients were followed up in the clinic every 2 weeks until incisions had healed. RESULTS: Twenty-five postoperative patients (12 cranial, 13 spinal) were identified to be at high risk of operative debridement. All 25 patients were prescribed a topical application of ALH, which was easily adopted without patient-related adverse events. Seven (four cranial, three spinal) patients required operative debridement and treatment with long-term antibiotic therapy. CONCLUSIONS: In this small case series of neurosurgical patients who were at risk of poor wound healing, the application of medical-grade ALH was well tolerated without patient-reported adverse events. The ALH may have prevented the need for operative debridement in the majority of patients. Further prospective studies are necessary to establish its efficacy in wound healing in the neurosurgical population.

First but not second postoperative day growth hormone assessments as early predictive tests for long-term acromegaly persistence.

PURPOSE: Postoperative assessment of acromegaly activity is typically performed at least 3 months after neurosurgery (NS). Few studies have evaluated the use of early postoperative growth hormone (GH) levels as a test to predict short- and long-term remission of acromegaly. Our objective was to evaluate the diagnostic performance of serum random GH on a postoperative day one (D1-rGH) and two (D2-rGH), particularly in predicting long-term disease persistence. MATERIALS AND METHODS: Forty-one subjects with acromegaly who were undergoing NS were enrolled (mean age ± SD 47.4 ± 13.1 years at diagnosis; women 54%; macroadenomas 71%). The final assessment of disease activity was performed one year after NS. ROC curves were used to evaluate the diagnostic performance of D1-rGH and D2-rGH. RESULTS: After a 1-year follow-up, the overall remission rate was 55%. ROC analysis identified an optimal D1-rGH cut-off value of 2.1 ng/mL for diagnosing long-term disease persistence (55.6% SE; 90.9% SP). The cut-off point became 2.5 ng/mL after maximizing specificity for disease persistence (yielding a 100% positive predictive value) and 0.3 ng/mL after maximizing sensitivity for disease remission. The optimal D2-rGH cut-off value was 0.6 ng/mL (81.8% SE; 50% SP); the cut-off point became 2.9 ng/mL after maximizing specificity and 0.1 ng/mL after maximizing sensitivity, with no clinical utility. CONCLUSIONS: D1-rGH could be a highly specific test for the early diagnosis of long-term acromegaly persistence, which is predicted by a value > 2.5 ng/mL with a great degree of certainty. The diagnostic performance of D2-rGH was insufficient. Further research is required to validate these preliminary results prior to modifying the postoperative management of acromegaly.

Postoperative Surveillance in Older Adults With T1N0M0 Low-risk Papillary Thyroid Cancer.

BACKGROUND: The frequency and cost of postoperative surveillance for older adults (>65 y) with T1N0M0 low-risk papillary thyroid cancer (PTC) have not been well studied. METHODS: Using the SEER-Medicare (2006-2013) database, frequency and cost of surveillance concordant with American Thyroid Association (ATA) guidelines (defined as an office visit, ≥1 thyroglobulin measurement, and ultrasound 6- to 24-month postoperatively) were analyzed for the overall cohort of single-surgery T1N0M0 low-risk PTC, stratified by lobectomy versus total thyroidectomy. RESULTS: Majority of 2097 patients in the study were white (86.7%) and female (77.5%). Median age and tumor size were 72 y (interquartile range 68-76) and 0.6 cm (interquartile range 0.3-1.1 cm), respectively; 72.9% of patients underwent total thyroidectomy. Approximately 77.5% of patients had a postoperative surveillance visit; however, only 15.9% of patients received ATA-concordant surveillance. Patients who underwent total thyroidectomy as compared with lobectomy were more likely to undergo surveillance testing, thyroglobulin (61.7% versus 24.8%) and ultrasound (37.5% versus 29.2%) (all P < 0.01), and receive ATA-concordant surveillance (18.5% versus 9.0%, P < 0.001). Total surveillance cost during the study period was $621,099. Diagnostic radioactive iodine, ablation, and advanced imaging (such as positron emission tomography scans) accounted for 55.5% of costs ($344,692), whereas ATA-concordant care accounted for 44.5% of costs. After multivariate adjustment, patients who underwent total thyroidectomy as compared with lobectomy were twice as likely to receive ATA-concordant surveillance (adjusted odds ratio 2.0, 95% confidence interval: 1.5-2.8, P < 0.001). CONCLUSIONS: Majority of older adults with T1N0M0 low-risk PTC do not receive ATA-concordant surveillance; discordant care was costly. Total thyroidectomy was the strongest predictor of receiving ATA-concordant care.

Eliminating Use of Home Oral Antibiotics in Pediatric Complicated Appendicitis.

BACKGROUND: Postoperative oral antibiotic management at discharge for perforated appendicitis varies by institution. A prior study at our institution led to a decrease in antibiotic therapy in patients without leukocytosis. A subsequent protocol change eliminated the white blood cell count check and oral antibiotics if discharge criteria were met by postoperative day seven. We hypothesized this change could be made without an increase in abscess or readmission rates. METHODS: We conducted a retrospective review of patients with perforated appendicitis over two 1-year periods after institutional review board approval (262061). In the pre-protocol group, a white blood cell count was checked at discharge and patients with leukocytosis were prescribed oral antibiotics to complete a total of 7 d. In the post-protocol group, no white blood cell count was checked and patients were discharged home without antibiotics. RESULTS: There were a total of 174 patients with complicated appendicitis in the two 1-year periods with 129 (74%) patients with perforated appendicitis discharged before postoperative day seven. The pre-protocol group included 71 children, and post-protocol included 58 children. There were no differences between mean postoperative days to discharge (2.57 versus 3, P = 0.0896), postoperative abscess rate (12.7% versus 12.1%, P = 1.0000), or readmission rate (12.7% versus 17.2%, P = 0.6184). None of the patients in the post-protocol group were discharged home with oral antibiotics compared with 22.5% in the pre-protocol group (P < 0.001). CONCLUSIONS: For pediatric patients with perforated appendicitis discharged before postoperative day seven, stopping antibiotics at the time of discharge significantly decreased our home antibiotic use without an increase in postoperative morbidity.

American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer

Venous thromboembolism (VTE) is a common complication among patients with cancer. Patients with cancer and VTE are at a markedly increased risk for morbidity and mortality. These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about the prevention and treatment of VTE in patients with cancer. ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The guideline development process was supported by updated or new systematic evidence reviews. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess evidence and make recommendations. Recommendations address mechanical and pharmacological prophylaxis in hospitalized medical patients with cancer, those undergoing a surgical procedure, and ambulatory patients receiving cancer chemotherapy. The recommendations also address the use of anticoagulation for the initial, short-term, and long-term treatment of VTE in patients with cancer. Strong recommendations include not using thromboprophylaxis in ambulatory patients receiving cancer chemotherapy at low risk of VTE and to use low-molecular-weight heparin (LMWH) for initial treatment of VTE in patients with cancer. Conditional recommendations include using thromboprophylaxis in hospitalized medical patients with cancer, LMWH or fondaparinux for surgical patients with cancer, LMWH or direct oral anticoagulants (DOAC) in ambulatory patients with cancer receiving systemic therapy at high risk of VTE and LMWH or DOAC for initial treatment of VTE, DOAC for the short-term treatment of VTE, and LMWH or DOAC for the long-term treatment of VTE in patients with cancer.