Can yeast isolation be predicted in complicated secondary non-postoperative intra-abdominal infections?

INTRODUCTION: The aim of this study was to create a predictive score for yeast isolation in patients with complicated non-postoperative intra-abdominal infections (CNPIAI) and to evaluate the impact of yeast isolation on outcome. METHODS: All patients with a CNPIAI undergoing emergency surgery over a three-year period were included in the retrospective cohort (RC, n = 290). Patients with a yeast-positive peritoneal fluid culture (YP) were compared with patients with a yeast-negative culture (YN). Multivariate logistic regression was used to identify factors independently associated with yeast isolation and a predictive score was built. The score's performance was then established in the prospective cohort (PC, n = 152) over an 18-month period. Outcome of the whole cohort was evaluated and independent risks factors of mortality searched. RESULTS: In the RC, 39 patients (13.4%) were YP. Four factors were independently associated with the YP group: length of stay before surgery ≥48 h (odds ratio (OR) (95% confidence interval (CI)) = 3.1 (1.4 to 6.9), P = 0.004, 1 point), per-operative cardiovascular failure (2.4 (1.1 to 5.8), P = 0.04, 1 point), generalized peritonitis (6.8 (2.7 to 16.7), P <0.001, 2 points) and upper gastrointestinal tract perforation (2.5 (1.2 to 5.6), P = 0.02, 1 point). In the PC, the area under the curve (95%CI) of the predictive score's receiver operating characteristic curve was 0.79 (0.72 to 0.86). For predicting an intra-abdominal candidiasis (IAC), a score ≥3 had a sensitivity of 0.60, a specificity of 0.84, a positive predictive value of 0.49 and a negative predictive value of 0.89. Furthermore, yeast isolation was associated with worse outcome and independently associated with mortality in the whole cohort (OR = 2.15; 95%CI (1.03 to 4.46), P = 0.04). CONCLUSIONS: The new predictive score can be used to rule out intra-abdominal candidiasis and thus avoid the initiation of antifungal treatment. It is suited to less severe infections than previously published scores. IAC is associated independently with an increased mortality in this population.

Risk factors and mortality of patients undergoing hip fracture surgery: a one-year follow-up study.

Hip fracture (HF) remains a main issue in the elderly patient. About 1.6 million patients a year worldwide are victims of a HF. Their incidence is expected to rise with the aging of the world's population. Identifying risk factors is mandatory in order to reduce mortality and morbidity. The aim of the study was to identify risk factors of 1-year mortality after HF surgery. We performed an observational, prospective, single-center study at Amiens University Hospital (Amiens, France). After ethical approval, we consecutively included all patients with a HF who underwent surgery between June 2016 and June 2017. Perioperative data were collected from medical charts and by interviews. Mortality rate at 12 months was recorded. Univariate analysis was performed and mortality risk factors were investigated using a Cox model. 309 patients were analyzed during this follow-up. Mortality at 1 year was 23.9%. Time to surgery over 48 hours involved 181 patients (58.6%) while 128 patients (41.4%) had surgery within the 48 hours following the hospital admission. Independent factors associated with 1-year mortality were: age (HR at 1.059 (95%CI [1.005-1.116], p = 0,032), Lee score ≥ 3 (HR at 1,52 (95% CI [1,052-2,198], p = 0.026) and time to surgery over 48 hours (HR of 1.057 (95% CI [1.007-1.108], p = 0.024). Age, delayed surgical (over 48 hours) management and medical history are important risk factors of 1-year mortality in this French cohort.

Management of Uncomplicated Acute Appendicitis as Day Case Surgery: Can Outcomes of a Prospective Study Be Reproduced in Real Life?

BACKGROUND: The feasibility of day case surgery (DCS) appendectomy for uncomplicated acute appendicitis (UCAA) was evaluated by the prospective AppendAmbu (Feasibility of Outpatient Appendectomy for Acute Appendicitis) study (ClinicalTrials.gov ID NCT01839435). The aim of this study was to evaluate the real-life feasibility of DCS for UCAA. STUDY DESIGN: This single-center, retrospective, non-interventional study was conducted after the AppendAmbu study and included UCAA only. The primary end point was DCS success rate (ie length of stay <12 hours) in the intention-to-treat population (all patients with UCAA) and in the per-protocol population (population with UCAA and no preoperative and intraoperative exclusion criteria). The secondary end points were to determine the DCS quality criteria to evaluate and compare the morbidity and mortality of DCS and conventional hospitalization for UCAA (Clavien, Comprehensive Complication Index) and to externally validate the St Antoine criteria for the selection of patients for DCS. RESULTS: From January 2016 to September 2017, two hundred and ninety-six patients underwent operations for acute appendicitis. The proportion of patients with successful DCS management was 27% in the intention-to-treat population and 95% in the per-protocol population. The unplanned consultation rate was 15%, the unplanned hospitalization rate was 4%, and the unplanned reoperation rate was 0%. The postoperative morbidity of patients managed by DCS was not different from that of patients managed in conventional hospitalization. The DCS success rate was 0%, with a St Antoine score of 0, and 80% of patients had a St Antoine score of 5 (p < 0.0001). CONCLUSIONS: Day case surgery constitutes progress in surgery as a result of enhanced recovery programs. It avoids unnecessary prolonged hospitalization.

Effect of Cricoid Pressure Compared With a Sham Procedure in the Rapid Sequence Induction of Anesthesia: The IRIS Randomized Clinical Trial.

Importance: The use of cricoid pressure (Sellick maneuver) during rapid sequence induction (RSI) of anesthesia remains controversial in the absence of a large randomized trial. Objective: To test the hypothesis that the incidence of pulmonary aspiration is not increased when cricoid pressure is not performed. Design, Setting, and Participants: Randomized, double-blind, noninferiority trial conducted in 10 academic centers. Patients undergoing anesthesia with RSI were enrolled from February 2014 until February 2017 and followed up for 28 days or until hospital discharge (last follow-up, February 8, 2017). Interventions: Patients were assigned to a cricoid pressure (Sellick group) or a sham procedure group. Main Outcomes and Measures: Primary end point was the incidence of pulmonary aspiration (at the glottis level during laryngoscopy or by tracheal aspiration after intubation). It was hypothesized that the sham procedure would not be inferior to the cricoid pressure. The secondary end points were related to pulmonary aspiration, difficult tracheal intubation, and traumatic complications owing to the tracheal intubation or cricoid pressure. Results: Of 3472 patients randomized, mean (SD) age was 51 (19) years and 1777 (51%) were men. The primary end point, pulmonary aspiration, occurred in 10 patients (0.6%) in the Sellick group and in 9 patients (0.5%) in the sham group. The upper limit of the 1-sided 95% CI of relative risk was 2.00, exceeding 1.50, failing to demonstrate noninferiority (P = .14). The risk difference was -0.06% (2-sided 95% CI, -0.57 to 0.42) in the intent-to-treat population and -0.06% (2-sided 95% CI, -0.56 to 0.43) in the per protocol population. Secondary end points were not significantly different among the 2 groups (pneumonia, length of stay, and mortality), although the comparison of the Cormack and Lehane grade (Grades 3 and 4, 10% vs 5%; P <.001) and the longer intubation time (Intubation time >30 seconds, 47% vs 40%; P <.001) suggest an increased difficulty of tracheal intubation in the Sellick group. Conclusions and Relevance: This large randomized clinical trial performed in patients undergoing anesthesia with RSI failed to demonstrate the noninferiority of the sham procedure in preventing pulmonary aspiration. Further studies are required in pregnant women and outside the operating room. Trial Registration: ClinicalTrials.gov Identifier: NCT02080754.

Management of Uncomplicated Acute Appendicitis as Day Case Surgery: Feasibility and a Critical Analysis of Exclusion Criteria and Treatment Failure.

BACKGROUND: Day case surgery (DCS) for uncomplicated acute appendicitis (NCAA) is evaluated. The objective of this prospective, single-center, descriptive, nonrandomized, intention-to-treat cohort study was to assess the feasibility of DCS for NCAA with a critical analysis of the reasons for exclusion and treatment failures and a focus on patients discharged to home and admitted for DCS on the following day. STUDY DESIGN: From April 2013 to December 2015, NCAA patients meeting the inclusion criteria were included in the study. The primary end point was the success rate for DCS (length of stay less than 12 hours) in the intention-to-treat population (all NCAA) and in the per-protocol population (no pre- or perioperative exclusion criteria). The secondary end points were morbidity, DCS quality criteria, predictive factors for successful DCS, patient satisfaction, quality of life, and reasons for pre- or perioperative exclusion. A subgroup of patients discharged to home the day before operation was also analyzed. RESULTS: A total of 240 patients were included. The success rate of DCS was 31.5% in the intention-to-treat population and 91.5% in the per-protocol population. The rates of unplanned consultations, hospitalization, and reoperation were 13%, 4%, and 1%, respectively. An analysis of the reasons for DCS exclusion showed that 73% could have been modified. For the 68 patients discharged to home on the day before operation, the DCS success rate was 91%. CONCLUSIONS: Day case surgery is feasible in NCAA. A critical analysis of the reasons for exclusion from DCS showed that it should be possible to dramatically increase the eligible population.

Clinical proof of practicability for an ECG device without any conductive contact.

Heart rhythm disturbances are common symptoms of several heart disorders. One of the most effective screening methods is the traditional electrode-based ECG. However, this examination can be both time- and resource-consuming. Capacitive-coupling ECG (cECG) screening--working without any conductive electrical contact with the patient--might help to shorten the time required for diagnosis. In this study, we examine the practicability of employing a non-contact capacitive ECG in a clinical setting. A total of 30 volunteer patients aged over 50 years without pacemakers were included in our trial, after obtaining their written informed consent and their medical history. A cECG as well as a conventional, conductive ECG were recorded simultaneously. In addition to mathematical analysis, ECG data were manually evaluated by two clinicians blinded to the recording method and patient conditions. Data from 30 patients were collected during our study, seven of whom had experienced myocardial infarction. The obtained cECG signals showed a high correlation with the simultaneously recorded Einthoven lead II of the conventional ECG. The values for heart rate, PQ and QT time periods correlated particularly well. Significant differences were observed with regard to QRS duration. Data recorded in the supine position contained less motion artefacts and, in particular, there were fewer breathing artefacts compared to data collected from those in a sitting position. Owing to the easy and quick application of the cECG system, the feedback from the examined patients was consistently positive. In conclusion, recording cECG data in a sitting position provided sufficient quality for screening purposes. Further studies will be needed for the evaluation of cECG appropriateness in diagnosing heart disease.