Severely injured trauma patients are at high risk of developing deep venous thrombosis and pulmonary emboli (PE), and may have contraindications to prophylactic or therapeutic anticoagulation. ...Retrievable inferior vena cava filters (rIVCFs) are used to act as a mechanical obstruction to prevent PE in high risk populations and those with deep venous thrombosis who cannot be anticoagulated. The removal rate of rIVCFs is variable in trauma centers, including our previous published rate of 50% to 89%/year. Indwelling filters carry a risk of significant morbidity and the success of retrieval decreases as the dwell time increases. We hypothesized that once patients could receive appropriate prophylactic or therapeutic anticoagulation, rIVCF could be removed before hospital discharge without impact on occurrence or recurrence of PE.
All trauma patients with rIVCF placed and removed between January 2006 and August 2018 were reviewed. We collected data from record review from admission to 6 months postfilter removal, including demographics, filter indication, filter type, dwell time, placement and removal complications, antithrombosis medications, location of venous thromboembolism, complications, and discharge disposition. Exposure of interest was timing of filter removal: before (BEF) or after hospital discharge (AFT). The outcome of interest was whether the patient had a documented PE within 6 months of filter removal.
A total of 281 rIVCFs were placed, 218 were eligible for removal, 72.4% (158/218) were retrieved with 63% (100/158) removed before discharge. Mean filter duration was 26 days and 103 days for the before and after groups, respectively. No differences (p > 0.05) were noted in the distribution of demographic and clinical factors except for filter indication (venous thromboembolism indication, 95% in AFT vs. 74% in BEF, p = 0.0043). Postremoval PE rates were 0% BEF and 1% AFT (Fisher's exact test, p = 1.000).
Our results suggest that removal of rIVCFs before discharge once patients are appropriately anticoagulated is a safe strategy to improve retrieval rates.
Therapeutic, level V.
The cost-to-charge ratio reflects the markup of hospital services. A lower cost-to-charge ratio indicates lower costs and/or greater charges. This study examines factors associated with ...cost-to-charge ratio trends to determine whether decreasing cost-to-charge ratio is associated with worse surgical outcomes.
The Florida Agency for Healthcare Administration Inpatient database (2018–2020) was queried for common surgical procedures and linked to the Distressed Communities Index, RAND Corporation Hospital data, Center for Medicare Services Cost Reports, and American Hospital Association data. Only hospitals with monotonically increasing or decreasing cost-to-charge ratio were included in the study. Univariable analysis compared these hospitals. Using patient-level data, interpretable machine learning predicted cost-to-charge ratio trend while identifying influential factors.
The cohort had 67 hospitals (27 increasing cost-to-charge ratio and 40 decreasing cost-to-charge ratio) with 35,661 surgeries. Decreasing cost-to-charge ratio hospitals were more often proprietarily owned (78% vs 33%, P = .01) and had greater mean total charges ($134,349 ± $114,510 vs $77,185 ± $82,027, P < .01) with marginally greater mean estimated costs ($14,863 ± $12,343 vs $14,458 ± $15,440, P < .01). Patients from decreasing cost-to-charge ratio hospitals had greater rates of most comorbidities (P < .05) but no difference in mortality or overall complications. Machine-learning models revealed charges rather than clinical factors as most influential in cost-to-charge ratio trend prediction.
Decreasing cost-to-charge ratio hospitals charge vastly more despite minimally greater estimated costs and no difference in outcomes. Although differences in case-mix existed, charges were the predominant differentiators. Patient clinical factors had far less of an impact.
The impact of different phases of COVID-19 infection on outcomes from acute calculous cholecystitis (ACC) is not well understood. Therefore, we examined outcomes of acute cholecystitis during the ...COVID-19 pandemic, comparing the effect of different treatment modalities and COVID-19 infection status. We hypothesized that patients with acute COVID-19 would have worse outcomes than COVID-negative patients, but there would be no difference between COVID-negative and COVID-recovered patients.
We used 2020-2023 National COVID Cohort Collaborative data to identify adults with ACC. Treatment (antibiotics-only, cholecystostomy tube, or cholecystectomy) and COVID-19 status (negative, active, or recovered) were collected. Treatment failure of nonoperative managements was noted. Adjusted analysis using a series of generalized linear models controlled for confounders (age, sex, body mass index, Charlson comorbidity index, severity at presentation, and year) to better assess differences in outcomes among treatment groups, as well as between COVID-19 groups.
In total, 32,433 patients (skewed count) were included: 29,749 COVID-negative, 2112 COVID-active, and 572 (skewed count) COVID-recovered. COVID-active had higher rates of sepsis at presentation. COVID-negative more often underwent cholecystectomy. Unadjusted, COVID-active had higher 30-day mortality, 30-day complication, and longer length of stay than COVID-negative and COVID-recovered. Adjusted analysis revealed cholecystectomy carried lower odds of mortality for COVID-active and COVID-negative patients than antibiotics or cholecystostomy. COVID-recovered patients’ mortality was unaffected by treatment modality. Treatment failure from antibiotics was more common for COVID-negative patients.
Acute cholecystitis outcomes are affected by phase of COVID-19 infection and treatment modality. Cholecystectomy does not lead to worse outcomes for COVID-active and COVID-recovered patients than nonoperative treatments; thus, these patients can be considered for cholecystectomy if their physiology is not prohibitive.
Identifying contributors to lung transplant survival is vital in mitigating mortality. To enhance individualized mortality estimation and determine variable interaction, we employed a survival tree ...algorithm utilizing recipient and donor data.
United Network Organ Sharing data (2000-2021) were queried for single and double lung transplants in adult patients. Graft survival time <7 d was excluded. Sixty preoperative and immediate postoperative factors were evaluated with stepwise logistic regression on mortality; final model variables were included in survival tree modeling. Data were split into training and testing sets and additionally validated with 10-fold cross validation. Survival tree pruning and model selection was based on Akaike information criteria and log-likelihood values. Estimated survival probabilities and log-rank pairwise comparisons between subgroups were calculated.
A total of 27,296 lung transplant patients (8175 single; 19,121 double lung) were included. Stepwise logistic regression yielded 47 significant variables associated with mortality. Survival tree modeling returned six significant factors: recipient age, length of stay from transplant to discharge, recipient ventilator duration post-transplant, double lung transplant, recipient reintubation post-transplant, and donor cytomegalovirus status. Eight subgroups consisting of combinations of these factors were identified with distinct Kaplan–Meier survival curves.
Survival trees provide the ability to understand the effects and interactions of covariates on survival after lung transplantation. Individualized survival probability with this technique found that preoperative and postoperative factors influence survival after lung transplantation. Thus, preoperative patient counseling should acknowledge a degree of uncertainty given the influence of postoperative factors.
To determine whether lack of insurance is a predictor of poor outcomes and increased healthcare expenditure for SCI patients.
Retrospective cohort study of trauma patients admitted with an acute, ...severe (AIS ≥ 3) SCI and admission score of ASIA-A to a Level 1 trauma center (2012–2016). Patient characteristics and outcomes (LOS, complications) were compared between insured and uninsured patients. Multivariable adjustment was performed using linear regression.
Of 76 patients who met eligibility, 44 had insurance and 32 were uninsured (NOINSUR). Despite having similar ventilator days (13 vs. 12.1) and ICU LOS (20.1 vs. 16.8), the NOINSUR group had more ventilator-free days (22.3 vs 6.6; p < 0.0001), longer Stepdown Unit length of stay (10.2 vs 2.3; p = 0.0036), and a longer hospital length of stay (35.3 vs 18.7; p = 0.0062).
Uninsured SCI patients face longer hospital LOS due to their insurance status and lack of funding for timely rehabilitation placement. This utilizes valuable hospital resources and puts them at risk for hospital related complications and further increased healthcare expenditures.
•No difference in ventilator or ICU days between SCI payer source groups.•Uninsured SCI patients face longer hospital LOS due to their insurance status.•Uninsured SCI patients are less likely to be discharged to rehabilitation facility.
Too Many Rain Showers Masters, Heidi; Daggett, Kayden; Fonk, Amanda ...
Science and children,
08/2019, Letnik:
57, Številka:
1
Journal Article
Recenzirano
Natural phenomena provide wonderful learning opportunities for students to identify solutions to problems using engineering practices. Engineering is a pivotal discipline within the Next Generation ...Science Standards because children can apply their knowledge of science concepts to solve real-life problems. Here, Masters et al detail how they utilized the natural phenomena of rain to set the stage for an integrated science and engineering unit wherein second-grade students learn to build water diversion structures to protect plants from getting too much water.
Too Many Rain Showers Masters, Heidi; Daggett, Kayden; Fonk, Amanda ...
Science and children,
08/2019, Letnik:
57, Številka:
1
Journal Article
Recenzirano
Severe flooding was prevalent within the authors' region at the beginning of the school year. Many homes and fields were affected by the amount of rain that fell within a short period of time over ...multiple days. Their students were concerned about the impact this natural phenomena was having on their local community. Natural phenomena can provide wonderful learning opportunities for students to identify solutions to problems using engineering practices (Achieve 2016). Engineering is a pivotal discipline within the Next Generation Science Standards (NGSS Lead States 2013) because children can apply their knowledge of science concepts to solve real-life problems (NRC 2012). Therefore, the authors utilized this natural phenomena the students were experiencing to set the stage for an integrated science and engineering unit. Students in an afterschool program were given the problem that the local basketball team needed extra energy so they needed the students help with growing plants. However since the area was getting too much water, the plants were dying. What could the students do to help with this problem? The students worked on a solution for one hour a week over a six-week period. After reflecting on the unit, the authors believe it would have been better to implement the lessons in the spring. During the spring, garden plants are available and investigations could occur outdoors for a more authentic learning experience. In addition, they recommend providing more opportunities for students to observe their plants throughout the week so that they can document daily rather than weekly changes. However, regardless of these changes, they found the unit helped the students learn about the needs of plants and allowed them to apply this knowledge when designing a water diversion structure.
PDF
