Featured Articles in Jun 2022

Original Articles COVID-19: Hospital Acquired Infections in Surgical Patients: Impact of COVID-19-Related Infection Prevention Measures

 

Author list: 

Nicole Tham, Timothy Fazio, Douglas Johnson, Anita Skandarajah & Ian P. Hayes

 

Abstract

Background

Hospital acquired infections are common, costly, and potentially preventable adverse events. This study aimed to determine the effect of the COVID-19 pandemic-related escalation in infection prevention and control measures on the incidence of hospital acquired infection in surgical patients in a low COVID-19 environment in Australia.

 

Method

This was a retrospective cohort study in a tertiary institution. All patients undergoing a surgical procedure from 1 April 2020 to 30 June 2020 (COVID-19 pandemic period) were compared to patients pre-pandemic (1 April 2019–30 June 2019). The primary outcome investigated was odds of overall hospital acquired infection. The secondary outcome was patterns of involved microorganisms. Univariable and multivariable logistic regression analysis was performed to assess odds of hospital acquired infection.

 

Results

There were 5945 admission episodes included in this study, 224 (6.6%) episodes had hospital acquired infections in 2019 and 179 (7.1%) in 2020. Univariable logistic regression analysis demonstrated no evidence of change in odds of having a hospital acquired infection between cohorts (OR 1.08, 95% CI 0.88–1.33, P = 0.434). The multivariable regression analysis adjusting for potentially confounding co-variables also demonstrated no evidence of change in odds of hospital acquired infection (OR 0.93, 95% CI 0.74–1.16, P = 0.530).

 

Conclusion

Increased infection prevention and control measures did not affect the incidence of hospital acquired infection in surgical patients in our institution, suggesting that there may be a plateau effect with these measures in a system with a pre-existing high baseline of practice.

 

 

 

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Medical Students from Socioeconomically Disadvantaged Backgrounds are Less Likely to Match into Surgery

 

Author list: 

Emanuel Eguia, Shilpa Kolachina, Elizabeth Miller & Mary A. Eguia

 

Abstract

Background

This study aims to understand the demographic and academic characteristics that play a role in enrollment in surgical residency programs as well as any racial or socioeconomic disparities that may exist for medical students entering surgical specialties at the Loyola University Chicago Stritch School of Medicine (LUC-SSOM).

 

Methods

Demographic data for 993 medical students graduating between 2013 and 2019 from LUC-SSOM were compared using a series of t tests, Chi-square tests, and logistic regression models.

 

Results

Students entering surgical residency programs had two times greater odds of coming from a family with a median family income greater than $75,000 than those entering non-surgical residencies (OR 2.19, 95% CI [1.35, 3.53]). Students from disadvantaged backgrounds had 50% decreased odds of going into surgery when compared to those not entering surgery (OR 0.50, 95% CI [0.28, 0.90]).

 

Conclusions

Students from low socioeconomic status backgrounds face more barriers in pursuing surgical subspecialties.

 

FREE LINK - https://rdcu.be/cLH6E


Outcomes of the Macroscopically Normal Appendix Left in Situ in Patients with Suspected Appendicitis

 

 

Author list: 

Sara Lee, Tara M. Connelly, Jessica M. Ryan, Megan Power-Foley & Peter M. Neary

 

Abstract

Background

Right iliac fossa (RIF) pain is a common indication for laparoscopy to diagnose and treat appendicitis. When a macroscopically normal appendix is found, there is no standard consensus regarding excision. Some surgeons remove the appendix due to the risk of microscopic inflammation and to avoid a future, repeat laparoscopy for possible appendicitis. Alternatively, others leave the appendix in situ to avoid morbidity from a potentially unnecessary procedure. We aimed to evaluate the outcomes of patients with macroscopically normal appendices left in situ.

 

Methods

All emergency laparoscopies without appendicectomy between January 1st 2010- December 31st 2020 were identified from theatre records. All operative notes were individually evaluated and comments on the macroscopic appearance of the appendix and any intra-operative pathology were recorded. Only patients undergoing laparoscopy for suspected appendicitis with macroscopically normal appendices were included.

 

Results

A total of 120 patients [median age 21.68 (range 9–90.8) years] were included. The cohort was predominantly female (n=105, 87.5%). Forty-eight patients (40.0%) had a positive finding during index laparoscopy. During a median duration of 94.5 (range 8–131) months’ follow-up, 16 patients (13.33%) underwent a repeat laparoscopy for recurrent RIF pain. Thirteen (10.8% of total cohort) subsequently underwent an appendicectomy. Histology confirmed acute appendicitis in six cases (4.17% of entire cohort). On subanalysis of smaller cohort, index laparoscopies with no positive findings (n=72), nine patients (12.5%) underwent appendicectomy with two (2.7%) appendices demonstrating appendicitis on histological examination.

 

Conclusion

87% of the total cohort with a normal appendix at laparoscopy for RIF pain did not undergo further laparoscopy. Less than 5% of the total cohort and 2.7% of subanalysis cohort had an appendicectomy for histologically-proven appendicitis within the follow-up period. From the evidence in this study, we conclude that leaving the appendix in situ unless macroscopically inflamed is a viable alternative to excision.

FREE LINK - https://rdcu.be/cLH94


TAP Block Prior to Open Ventral Hernia Repair Improves Surgical Outcome

 

Author list: 

Leo Licari, Simona Viola & Giuseppe Salamone

 

Abstract

Background

Ventral hernias commonly affect patients after major abdominal surgery. To reduce postoperative pain, the effects of the transversus abdominis plane (TAP) block, epidural analgesia and medication-only protocol have been investigated. The primary outcome was the cumulative dosage of opioids (morphine milligram equivalents MME), of acetaminophen and diclofenac for postoperative pain control on postoperative day (POD) 0, 1, and 2. Secondary outcomes were length of stay (LOS) and the pain scale rating using the numeric rating scale (NRS) on POD 0, 1, and 2.

 

Methods

The data were retrospectively extracted from the charts of the patients admitted for a surgical operation for OVHR from January 2015 to December 2019.

 

Results

Patients receiving medication-only analgesia had longer LOS (mean 6.1 days; p < 0.00001). Cumulative opioid consumption was significantly lower at 24 and 48 h after surgery in the TAP block group than in the other groups (mean MME 1.9 mg and 0.7 mg, respectively; p < 0.05). The cumulative consumption of diclofenac was significantly lower in the TAP block group than in the others (44.1 mg; p ≤ 0.00001 on POD 1; 4.4 mg; p = 0.03 on POD 2). TAP block is more effective in pain control in POD 0 (mean NRS 5.4; p < 0.00001), POD 1 (mean NRS 6.1; p = 0.006), and POD 2 (mean NRS 4.9; p = 0.001) if it is performed after adopting the retromuscular technique.

 

Conclusions

The comparison between the medication-only technique, epidural, and TAP block demonstrated the superiority of the last one for the aims considered in this study.

 

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Neuropsychiatric Comorbidity in Primary Hyperparathyroidism Before and After Parathyroidectomy: A Population Study

Author list: 

A. Koman, R. Bränström, Y. Pernow, R. Bränström, I.-L. Nilsson & Fredrik Granath

 

Abstract

Background

Primary hyperparathyroidism (PHPT) is often accompanied by neuropsychiatric symptoms. This study aimed to map out psychiatric comorbidity as reflected by medical treatment for psychiatric symptoms.

 

Methods

A retrospective case–control analysis and a prospective cohort analysis of psychotropic drug utilization before and after PTX. A total of 8279 PHPT patients treated with parathyroidectomy in Sweden between July 1, 2008 and December 31, 2017 compared to a matched control cohort from the total population (n = 82,790). Information on filled prescriptions was collected from the Swedish Prescribed Drug Register (SDR). Socioeconomic data and diagnoses were added by linkage to national patient and population registers. Regression analyses were used to calculate relative drug utilization (OR) within 3 years prior to PTX and relative incidence of drug treatment (RR) within 3 years postoperatively.

 

Results

Utilization of antidepressant, anxiolytic and sleep medication was more comprehensive in PHPT patients compared with the controls prior to PTX. The most common were benzodiazepines [OR 1.40 (95% CI: 1.31–1.50)] and selective serotonin reuptake inhibitors [SSRI; OR 1.38 (95% CI: 1.30–1.47)]. Postoperatively, the excess prescription rate for anxiolytic benzodiazepines decreased within three years from a 30 to 19% excess and for benzodiazepines for sleep from 31 to 14%. No corresponding decrease in excess prescription rate was observed for SSRI.

 

Conclusion

PHPT is associated with increased utilization of antidepressive medications and benzodiazepines before PTX. This study implies that psychiatric symptoms should be considered in PHPT patients and continuous medication should be reevaluated after PTX.

 

 

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We Asked the Experts: How Does a Surgeon Select the Optimal Approach for Minimally Invasive Adrenalectomy?

 

Author list:

Jina Kim & Sanziana Roman

 

No abstract

 

FREE LINK -  https://rdcu.be/cLIbX

 

 


My First Paper: Early Versus Delayed Cholecystectomy for Acute Biliary Pancreatitis: A Systematic Review and Meta-Analysis

 

Author list: 

Jayaraj Prasanth, Manya Prasad, Soumya Jagannath Mahapatra, Asuri Krishna, Om Prakash, Pramod Kumar Garg & Virinder Kumar Bansal

 

Abstract

Background

Recommendations regarding the timing of cholecystectomy for acute biliary pancreatitis (ABP) require a systematic summary of current evidence to guide clinical practice. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing early cholecystectomy (EC) versus delayed cholecystectomy (DC) in patients with ABP.

 

Methods

We searched databases Medline, Embase, SCOPUS, Web of Science and Cochrane CENTRAL for randomized controlled trials addressing this question. Pairs of reviewers abstracted data and assessed the risk of bias in included studies. A random-effects meta-analysis was done to study the effect of the timing of cholecystectomy on outcomes of interest in patients with ABP. GRADE methodology was used to rate the quality in the body of evidence for each outcome as high, moderate, low, or very low.

 

Results

11 randomized trials (1176 participants) were included. High-quality evidence from seven RCTs (867 participants) showed a statistically significant reduction in the risk for recurrent biliary events in favour of early cholecystectomy (RR 0.10, 95% CI 0.05 to 0.19, I2 = 0%). High-quality evidence from five trials was in favour of early cholecystectomy with a significant reduction in the risk 7of recurrent pancreatitis (RAP) in comparison to delayed cholecystectomy (RR 0.21, 95% CI 0.09 to 0.51, I2 = 0%).

 

Conclusion

This review showed that EC has definite advantages over DC in terms of reducing recurrent pancreaticobiliary events and LOS following mild ABP. However, more RCTs are required to study the role of EC in patients with moderately-severe and severe ABP.

 

FREE LINK - https://rdcu.be/cLIcn


Systematic Reviews and Meta-Analyses: My First Paper: Mortality Following Appendicectomy in Patients with Liver Cirrhosis: A Systematic Review and Meta-Analysis

 

Author list:  Adil Rashid, Alisha Gupta, Alfred Adiamah, Joe West, Matthew Grainge & David J. Humes

Abstract:

Introduction

With the global prevalence of liver cirrhosis rising, this systematic review aimed to define the perioperative risk of mortality in these patients following appendicectomy.

Methods

Systematic searches of Medline, EMBASE, Cochrane Library databases, ICTRP, and Clinical trials.gov were undertaken to identify studies including patients with cirrhosis undergoing appendicectomy, published since database inception to March 2021. Studies had to report mortality. Two review authors independently identified eligible studies and extracted data. Pooled analysis of in-patient and 30-day mortality was performed.

Results

Of the 948 studies identified, four were included and this comprised three nationwide database studies (USA and Denmark) and one multi-centre observational study (Japan). A total of 923 patients had cirrhosis and 167,211 patients did not. In-patient mortality ranged from 0 to 1.7% in patients with cirrhosis and 0.17 to 0.3% in patients without. 30-day mortality was 9% in patients with cirrhosis compared to 0.3% in those without. One study stratified cirrhotic patients into compensated and decompensated groups. In patients with compensated cirrhosis, mortality following laparoscopic appendicectomy (0.5%) was significantly lower than open appendicectomy (3.2%). The meta-analysis highlighted a tenfold increase in perioperative mortality in cirrhotic patients (OR 9.92 (95% CI 4.67 to 21.06, I2 = 28%). All studies reported an increased length of stay in patients with cirrhosis.

Conclusion

This review suggests that appendicectomy in the cirrhotic population is associated with increased mortality. LA may be safer in this population. Lack of information on cirrhosis severity and failure to control for age and co-morbidities make the results difficult to interpret. Further large population-based studies are required.

Link: https://rdcu.be/cFMkQ

 


 

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