Think Twice: De-implementation of Laboratory Testing After Colorectal Surgery.

BACKGROUND: Clinically unindicated laboratory testing contributes to low-value care. Most postoperative day 1 laboratory tests after colorectal surgery are normal. However, no published interventions have shown that reducing overall postoperative laboratory testing is safe. OBJECTIVE: This study aimed to investigate the impact of reducing postoperative laboratory testing after colorectal surgery. DESIGN: This is a quality improvement study. SETTINGS: The study was conducted at an academic center with an enhanced recovery after surgery program that included 5 daily laboratory tests until discharge. PATIENTS: All adults undergoing colorectal or small-bowel surgery formed intervention and nonintervention cohorts based on surgeons who chose to opt into the study. Preimplementation (November 2019-October 2021), there were 545 intervention and 577 nonintervention patients. Postimplementation (November 2021-March 2023), there were 448 intervention and 437 nonintervention patients. INTERVENTIONS: The intervention included 3 postoperative day 1 laboratory tests and subsequent clinically indicated laboratory tests. MAIN OUTCOME MEASURES: Outcome measures included laboratory tests and days free of laboratory work. RESULTS: Postintervention, the intervention group had a 33% reduction in laboratory tests per hospital stay, a 26% reduction in laboratory tests per day, and a 49% increase in laboratory test-free days. There was no difference in length of stay (4 vs 4; p = 0.79) or readmissions (14.9% vs 12.9%; p = 0.39). The nonintervention group had no significant changes in laboratory work or laboratory test-free days, with no differences in length of stay (4 vs 4; p = 0.49) or readmissions (11.1% vs 11.0%; p = 0.96). LIMITATIONS: Demographics and complication rates were not reported. CONCLUSIONS: An intervention targeting reflexive laboratory testing after colorectal surgery resulted in safe, significant, sustained reductions in postoperative laboratory work, with substantial cost savings. These findings prompted a change in the laboratory order set to an opt-out system, and laboratory work reduction approaches have been implemented within other surgical divisions. Continuation and spread of these efforts are instrumental for prioritization of high-value surgical care. See Video Abstract . PINSELO DOS VECES ELIMINACIN DE LAS PRUEBAS DE LABORATORIO DESPUS DE LA CIRUGA COLORRECTAL: ANTECEDENTES:Las pruebas de laboratorio clínicamente no indicadas contribuyen a una atención de bajo valor. La mayoría de los análisis de laboratorio del primer día post operatorios de una cirugía colorrectal son normales. Sin embargo, ninguna intervención publicada ha demostrado que reducir las pruebas de laboratorio post operatorias generales sea seguro.OBJETIVO:El objetivo de este estudio fue investigar el impacto de reducir las pruebas de laboratorio pos toperatorias después de la cirugía colorrectal.DISEÑO:Este es un estudio de mejora de la calidad.AJUSTES:El estudio se llevó a cabo en un centro académico con un programa mejorado de recuperación después de la cirugía que incluye 5 laboratorios diarios hasta el alta.PACIENTES:Todos los adultos sometidos a cirugía colorrectal o de intestino delgado formaron cohortes de intervención y no intervención basadas en los cirujanos que optaron por participar en el estudio. Antes de la implementación (noviembre de 2019 - octubre de 2021) había 545 pacientes con intervención y 577 sin intervención. Después de la implementación (noviembre de 2021 - marzo de 2023) hubo 448 pacientes con intervención y 437 sin intervención.INTERVENCIONES:La intervención incluyó 3 laboratorios post operatorios del primer día y laboratorios posteriores clínicamente indicados.PRINCIPALES MEDIDAS DE RESULTADO:Las medidas de resultado incluyeron pruebas de laboratorio y días sin laboratorio.RESULTADOS:Después de la intervención, el grupo de intervención tuvo una reducción del 33 % en laboratorios por estancia hospitalaria, una reducción del 26 % en laboratorios por día y un aumento del 49 % en los días sin laboratorio. No hubo diferencias en la duración de la estancia hospitalaria (4 frente a 4; p = 0,79) ni en los reingresos (14,9% frente a 12,9%; p = 0,39). El grupo de no intervención no tuvo cambios significativos en el trabajo de laboratorio o en los días sin laboratorio, sin diferencias en la duración de la estadía (4 versus 4; p = 0,49) o reingresos (11,1% versus 11,0%; p = 0,96).LIMITACIONES:No se informaron datos demográficos ni tasa de complicaciones.CONCLUSIONES:Una intervención dirigida a pruebas de laboratorio reflexivas después de la cirugía colorrectal resultó en reducciones seguras, significativas y sostenidas en el trabajo de laboratorio post operatorio, con ahorros sustanciales de costos. Estos hallazgos provocaron un cambio en el orden del laboratorio establecido hacia un sistema de exclusión voluntaria, y se han implementado enfoques de reducción del trabajo de laboratorio en otras divisiones quirúrgicas. La continuación y difusión de estos esfuerzos son fundamentales para priorizar la atención quirúrgica de alto valor. (Traducción-Dr. Mauricio Santamaria ).

Evaluation of severity scoring systems in patients with severe community acquired pneumonia.

Background. The aim of this study was to evaluate the ability of severity scoring systems to predict 30-day mortality in patients with severe community-acquired pneumonia. Methods. The study included 98 patients aged ≥18 years with community acquired pneumonia hospitalized at the Intensive Care Unit of the University Clinic for Infectious Diseases in Skopje, Republic of North Macedonia, during a 3-year period. We recorded demographic, clinical and common biochemical parameters. Five severity scores were calculated at admission: CURB 65 (Confusion, Urea, Respiratory Rate, Blood pressure, Age ≥65 years), SCAP (Severe Community Acquired Pneumonia score), SAPS II (Simplified Acute Physiology Score), SOFA (Sequential Organ Failure Assessment Score) and MPM (Mortality Prediction Model). Primary outcome variable was 30-day in-hospital mortality. Results. The mean age of the patients was 59.08 ± 15.76 years, predominantly males (68%). The overall 30-day mortality was 52%. Charlson Comorbidity index was increased in non-survivors (3.72 ± 2.33) and was associated with the outcome. All severity indexes had higher values in patients who died, that showed statistical significance between the analysed groups. The areas under curve (AUC) values of the five scores for 30-day mortality were 0.670, 0.732, 0,726, 0.785 and 0.777, respectively. Conclusion. Widely used severity scores accurately detected patients with pneumonia that had increased risk for poor outcome, but none of them individually demonstrated any advantage over the others.

The Impact of Pneumonia on the Course and Outcome in Patients with Seasonal Influzenza.

INTRODUCTION: Seasonal influenza, although often presented as a mild, self-limiting disease, is frequently accompanied by complications that lead to the development of a severe clinical presentation and a fatal outcome. The most common are respiratory complications, with secondary bacterial pneumonia being the leading cause. AIM: The aim of this study is to determine the impact of pneumonia on the severity of the clinical presentation and outcome in patients with seasonal influenza. MATERIALS AND METHODS: This research is comparatively group-based and has been conducted at the University Clinic for Infectious Diseases and Febrile Conditions during a three-year period. The analysis consists of 122 adult patients with clinically and laboratory-confirmed influenza. Based on the severity of the clinical picture, the patients are divided into two groups, severe (n=87) and mild (n=35) forms of the disease. The study included demographic, general data, clinical symptoms, and signs as well as complications. RESULTS: Of 122 patients with seasonal influenza, complications were registered among 108(88.52%), with a significantly more frequent emergence among the group with severe influenza 93.1% vs 77.14% (p=0.012). Pneumonia was the most common 98(80.33%) and had a significant effect on disease severity (p=0.002). Complications from the types of ABI 8(6.56%), ARDS 7(5.74%), sepsis 5(4.1%), DIC 4 (3.28%) and otitis 2(1.64%) were reported only in the group with severe influenza. Acute meningoencephalitis was registered among 5(4.1%), gastroenterocolitis among 3(2.46%), and hepatic damage among 14(11.47%) of patients. CONCLUSION: Pneumonia as the most common complication among patients with seasonal influenza significantly impacts the clinical course and outcome of the illness.

Association of Systemic Inflammatory Response Syndrome with Bacteremia in Patients with Sepsis.

The aim of this study was to evaluate the usability of systemic inflammatory response syndrome (SIRS) and commonly used biochemical parameters as predictors for positive blood culture in patients with sepsis. The study included 313 patients aged ≥18 years with severe sepsis and septic shock consecutively admitted in the Intensive Care Unit (ICU) of the University Clinic for Infectious Diseases in Skopje, Republic of North Macedonia. The study took place from January 1, 2011 to December 31, 2017. We recorded demographic variables, common laboratory tests, SIRS parameters, site of infection, comorbidities and Sequential Organ Failure Assessment (SOFA) score. Blood cultures were positive in 65 (20.8%) patients with sepsis. Gram-positive bacteria were isolated from 35 (53.8%) patients. From the evaluated variables in this study, only the presence of four SIRS parameters was associated with bacteremia, finding that will help to predict bacteremia and initiate early appropriate therapy in septic patients.

Factors Associated with Lethal Outcome in Patients with Severe Form of Influenza.

INTRODUCTION: Clinical manifestations of influenza range from relatively mild and self-limiting respiratory infections to severe clinical manifestations with significant morbidity and mortality. The awareness of predictive indicators for the lethal outcome of influenza is of particular significance in making timely and exact decision for adequate treatment. The aim of this study was to identify the factors in patients with a severe form of influenza, resulting in lethal outcome. MATERIALS AND METHODS: The investigation was a prospective group comparison conducted at the University Clinic for Infectious Diseases in Skopje, R. Macedonia in the period from January 01, 2012 to January 01, 2015. The study included adult patients with a severe form of influenza who were further categorized into a group of either survived patients or a group of deceased patients. Demographic, clinical and biochemical data were noted in all patients included in the study on admission. The variables of the univariate analysis that showed a significant difference in terms of the outcome were used for creating multivariate logistic and regression analysis of the outcome as dependent factors. The independent predictors for lethal outcome in severe cases of influenza were identified by using logistic regression. RESULTS: The study included 87 patients with a severe form of clinical and laboratory confirmed influenza. The patients were divided in two groups: survived (n = 75) and deceased (n = 75). The overall mortality was 13.79%. Multivariate analysis conducted on admission to hospital identified cardiovascular comorbid diseases (p = 0.014), urea values higher than 8.3 U/L (p = 0.045) and SAPS score (p = 0.048) as independent predictors of the outcome in patients with severe form of influenza. Influenza patients with cardiovascular diseases had 2.024 times greater risk of death from influenza in comparison to the patients having influenza without history of such a disease (OR = 2.024 95% CI 1.842-17.337). Patients with serum urea values higher than 8.3 U/L had 1.89 times higher chance of death compared to patients with normal values (OR = 1.89 95% CI 1.091-11.432). The increase of the SAPS score in one point increased the chance of death in patients with influenza by 1.2% (OR = 1.12 95% CI 1.01-2.976). The ROC analysis indicated that cardiovascular diseases, increased urea values and SAPS score in combination act as a good prognostic model for the fatal outcome. The global authenticity of this predictive model to foresee lethal outcome amounts to 80%, sensitivity being 82%, and specificity 70%. CONCLUSION: Cardiovascular diseases, increased values of urea over 8.3 mmol/l and SAPS score are independent predictive indicators for lethal outcome in severe influenza. Early identification of the outcome predictors in patients with severe influenza will allow implementation of adequate medical treatment and will contribute to decreasing of mortality in patients with severe form of influenza.

Osteoarticular involvement in childhood brucellosis: experience with 133 cases in an endemic region.

AIM: To describe the main clinical and laboratory characteristics, frequency and distribution of osteoarticular involvement, therapeutic options and outcome in children with osteoarticular brucellosis. METHODS: This descriptive study includes 133 pediatric patients with osteoarticular brucellosis who were treated at the University Clinic for Infectious Diseases and Febrile Conditions in Skopje, Republic of Macedonia, during the period between 1989 and 2011. Brucellosis was presumptively diagnosed on the basis of clinical signs and confirmed by the detection of specific antibodies at significant titers. RESULTS: The median age of patients was 9 years (range, 2-14 years) and 63.9% were males. Family history of brucellosis was present in 54.1%. The dominant clinical symptoms were arthralgia and fever in 77.4% and 73.7%, respectively, and the dominant sign was hepatomegaly in 73.7% of patients. The main laboratory abnormalities were elevated C-reactive protein (81.0%) and circulating immunocomplexes (80.7%). In 71.4% of patients, the osteoarticular involvement was monoarticular. Hip arthritis was present in 49.6%, followed by the knee in 30.1%. Various therapeutic regimens with a duration of 6 weeks were used. In 87 patients during a follow-up of at least 6 months, relapse occurred in 13.8%. CONCLUSIONS: Osteoarticular involvement is frequent in children with brucellosis. It is most often manifested with monoarthritis of the large weight-bearing joints. Brucellosis should be included in the differential diagnosis of childhood arthritis in endemic countries, especially in the presence of family history, contact with infected animals or ingestion of unpasteurized food products, fever and hepatomegaly.