Most posterior spinal fusion (PSF) patients do not require admission to an intensive care unit (ICU), and those who do may represent an underinvestigated, high-risk subpopulation.
To identify the ...microbial profile of and risk factors for surgical site infection (SSI) in PSF patients admitted to the ICU postoperatively.
We examined 3965 consecutive PSF patients treated at our institution between 2000 and 2015 and collected demographic, clinical, and procedural data. Comorbid disease burden was quantified using the Charlson Comorbidity Index (CCI). We performed multivariable logistic regression to identify risk factors for SSI, readmission, and reoperation.
Anemia, more levels fused, cervical surgery, and cerebrospinal fluid leak were positively associated with ICU admission, and minimally invasive surgery was negatively associated. The median time to infection was equivalent for ICU patients and non-ICU patients, and microbial culture results were similar between groups. Higher CCI and undergoing a staged procedure were associated with readmission, reoperation, and SSI. When stratified by CCI into quintiles, SSI rates show a strong linear correlation with CCI ( P = .0171, R = 0.941), with a 3-fold higher odds of SSI in the highest risk group than the lowest (odds ratio = 3.15 1.19, 8.07, P = .032).
Procedural characteristics drive the decision to admit to the ICU postoperatively. Patients admitted to the ICU have higher rates of SSI but no difference in the timing of or microorganisms that lead to those infections. Comorbid disease burden drives SSI in this population, with a 3-fold greater odds of SSI for high-risk patients than low-risk patients.
The absence of health insurance coverage has been associated with worse outcomes for patients with metastatic renal cell carcinoma (mRCC). Medicaid expansion in the United States was an important ...provision of the Affordable Care Act, which increased the number of low-income individuals eligible for Medicaid starting in January 2014 in several states. The effect of Medicaid expansion on access to healthcare for patients with mRCC is unknown.
We performed a retrospective cohort study of 6844 patients aged < 65 years with mRCC at diagnosis within the National Cancer Database. We compared the time to treatment and the rates of no insurance before (2012-2013) and after (2015-2016) expansion between patients living in states that had and had not expanded Medicaid using difference-in-difference (DID) analyses. DIDs were calculated using linear regression analysis with adjustment for sociodemographic covariates.
The rate of no insurance did not change in the expansion states compared with the nonexpansion states (DID, −0.55%; 95% confidence interval, −3.32% to 2.21%; P = .7). The percentage of patients receiving treatment within 60 days of diagnosis had increased in the expansion states from 43% to 49% and in the nonexpansion states from 42% to 46% after expansion. No change was found in treatment within 60 days of diagnosis among all patients (DID, 2.81%; 95% confidence interval, −2.61% to 8.22%; P = .3).
Medicaid expansion was not associated with improved healthcare access for patients with mRCC as reflected by timely treatment. Future work should assess the association between Medicaid expansion and oncologic outcomes.
We assessed whether Medicaid expansion has led to more timely treatment of metastatic renal cell carcinoma (mRCC). We compared the time to treatment before and after expansion between the states that had and had not expanded Medicaid for patients with mRCC within the National Cancer Database. Medicaid expansion was not associated with more timely treatment for patients with mRCC.
Fungal bezoar is a very rare clinical entity that usually results from fungemia because of uncontrolled diabetes mellitus or immunosuppression. Most cases present in the upper urinary tract, but ...there have been less than 10 reported as presenting primarily in the bladder. Treatment is largely medical with antifungal therapies with no documented cases of concomitant bacterial colonization. Rarely, surgical intervention is warranted, but there are no documented surgical approaches with a bipolar cautery loop resectoscope. We present a case of a fungal bezoar of the bladder that was treated with transurethral resection. The presence of multidrug-resistant organisms resulted in postoperative sepsis controlled with intravesical and intravenous antibiotics and fluid resuscitation.
IntroductionDelirium is a serious medical condition that is common in older adults in acute settings. Clinical practice guidelines recommend that all older patients in acute care settings should be ...screened for delirium using standardised outcome measures.ProblemIn our institution, an audit showed that only 16% of older adults presenting to the emergency department were screened for delirium. The goal of this project was to increase the number of patients being screened for delirium using Lean Six Sigma (LSS) methodology and tools and a multidisciplinary approach.MethodA multidisciplinary team in the emergency department used LSS tools and methodology over a 12-week period to first identify why patients were not being screened for delirium using root cause analysis and second to implement a multifaceted intervention including education, audits and feedback, documentation changes and team huddles. An audit was performed at the 11th week of the project to measure how many patients were being screened for delirium post project intervention.ResultsResults at 5 weeks post intervention (11th week of project) showed that the percentage of patients being screened for delirium had increased from 16% to 82%. A follow-up audit at 17 weeks post intervention showed a further improvement in delirium screening to 92%.ConclusionApplying LSS tools and methodology resulted in a healthcare quality improvement. Delirium screening in an emergency department can be improved through multifaceted interventions including education, documentation changes and team huddle changes.
Gastrointestinal bleeding has not been reported in patients with protein-losing enteropathy. The investigators describe 3 patients with protein-losing enteropathy and gastrointestinal bleeding after ...Fontan operations. Bleeding occurred at the onset of protein-losing enteropathy, was macroscopic, led to anemia, and required blood transfusion in all patients. Invasive testing failed to demonstrate gastrointestinal pathology as a source of bleeding. In conclusion, unexplained gastrointestinal bleeding may be part of the clinical spectrum of protein-losing enteropathy.
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