BACKGROUND:Enhanced recovery after surgery (ERAS) pathways in gynecologic surgery have been shown to decrease length of stay with no impact on readmission, but no study has assessed predictors of ...admission in this population. The purpose of this study was to identify predictors of admission after laparoscopic hysterectomy (LH) and robotic-assisted hysterectomy (RAH) performed under an ERAS pathway.
METHODS:This is a prospective observational study of women undergoing LH/RAH for benign indications within an ERAS pathway. Data collected included same-day discharge, reason for admission, incidences of urgent clinic and emergency room (ER) visits, readmissions, reoperations, and 9 postulated predictors of admission listed below. Patient demographics, markers of baseline health, and clinical outcomes were compared between groups (ERAS patients discharged on the day of surgery versus admitted) using Fisher exact and Student t tests. Multivariable logistic regression was used to assess the potential risk factors for being admitted, adjusting for age, race, body mass index, American Society of Anesthesiologists (ASA) physical status score, preoperative diagnosis indicative of hysterectomy, preoperative chronic pain, completion of a preprocedure pain-coping skills counseling session, procedure time, and compliance to the ERAS pathway.
RESULTS:There were 165 patients undergoing LH/RAH within an ERAS pathway; 93 (56%) were discharged on the day of surgery and 72 were admitted. There were no significant differences in ER visits, readmissions, and reoperations between groups (ER visitsdischarged 13% versus admitted 13%, P = .99; 90-day readmissiondischarged 4% versus admitted 7%, P = .51; and 90-day reoperationdischarged 4% versus admitted 3%, P = .70). The most common reasons for admission were postoperative urinary retention (n = 21, 30%), inadequate pain control (n = 21, 30%), postoperative nausea and vomiting (n = 7, 10%), and planned admissions (n = 7, 10%). Increased ASA physical status, being African American, and increased length of procedure were significantly associated with an increased risk of admission (ASA physical status III versus ASA physical status I or IIodds ratio OR, 3.12; 95% confidence interval CI, 1.36–7.16; P = .007; African AmericanOR, 2.47; 95% CI, 1.02–5.96; P = .04; and length of procedure, assessed in 30-minute incrementsOR, 1.23; 95% CI, 1.02–1.50; P = .04).
CONCLUSIONS:We were able to define predictors of admission for patients having LH/RAH managed with an ERAS pathway. Increased ASA physical status, being African American, and increased length of procedure were significantly associated with admission after LH/RAH performed under an ERAS pathway. In addition, the incidences of urgent clinic and ER visits, readmissions, and reoperations within 90 days of surgery were similar for patients who were discharged on the day of surgery compared to those admitted.
There is conflicting data comparing minimally invasive vein harvest (MIVH) using endoscopic technique and open vein harvest (OVH) in terms of bypass patency, wound infection incidence, and patient ...morbidity. Our institution has performed MIVH since 2003 for peripheral bypass procedures with a consistent team of specialized endoscopic vein harvesters. This study reviewed the major outcomes of MIVH infrainguinal bypass at our institution given a predominant cohort of critical limb ischemia.
We performed a 10-year, retrospective, single-institution review from January 2005 to December 2014, identifying all patients undergoing MIVH for obstructive infrainguinal disease. Primary outcomes were primary patency, operative time, intraoperative complications, surgical site infection (SSI), and freedom from amputation.
A total of 289 patients (70% male) underwent MIVH infrainguinal bypass at an average age of 68 ± 12 years old, an obesity prevalence of 28%, and with critical limb ischemia in 81% of the patient cohort (20% rest pain, 61% tissue loss/gangrene). Ninety-four percent of patients had no intraoperative complications, 2.5% had adverse cardiac or technical complications, and 4.2% of patients required transfusion. Average operative time was 4.2 h. Femoral-popliteal TASC classification C and D constituted 80% of our patient cohort. At the last follow-up, toe pressures had increased from 30 ± 30 to 62 ± 40 mmHg (
0
0001). Primary bypass patency in the first 30 days was 95%. SSI incidence requiring surgical treatment was only 6%. Our median length of stay was 4.0 days, with median intravenous narcotic use of 1 day. In addition, 77% of patients returned to their baseline mobility at first follow-up (median 19 days), and 83% of patients had freedom from amputation at last follow-up (median 820 days).
In a center with experience in MIVH and a consistent group of experienced endoscopic vein harvesters, MIVH bypass has excellent patency, low surgical site infection, short length of stay, and prompt return to baseline mobility.
Background Endobronchial valves (EBVs) are a useful adjunct in the management algorithm of patients with persistent pulmonary air leaks. They are increasingly used in the management of postsurgical ...parenchymal air leaks and carry a humanitarian use device exemption for this purpose. We report our experience with EBVs in the management of patients with bronchopleural fistula secondary to postsurgical intervention and spontaneous pneumothorax from medical comorbidities. Methods An institutional review board-approved retrospective review was conducted of our single-center EBV experience. Patients were categorized as postsurgical versus medical. Data collected included demographic characteristics, indication for and number of valves placed, and chest tube duration before and after valve placement to evaluate overall resolution of air leak. Success was defined as resolution of air leak. Results A total of 14 valve placement procedures were performed. Mean age was 60 years and 10 patients were men. Eight represented prolonged leaks secondary to postsurgical complications and six were secondary to medical comorbidities. Indications for placement of valves in medical patients included persistent leak secondary to lung biopsy, ruptured bleb disease, and pneumothorax after cardiopulmonary resuscitation. Postsurgical indications included leaks secondary to lung biopsy, lobectomy, and ruptured bleb disease. A median of two valves were placed per procedure. A postprocedure median length of stay of 14.5 days was observed in the surgical group compared with 15 days in the medical group. Overall success rate was 57% (surgical group, 62.5%; medical group, 50%). Conclusions EBVs are a useful adjunct in the management of persistent pulmonary air leaks, particularly when conventional interventions are contraindicated or not ideal. EBVs are well tolerated in the critically ill, have few known complications, are removable, and do not preclude future surgical intervention. Future studies should evaluate EBV efficacy versus the natural course of persistent pulmonary air leaks and their impact on cost and length of stay.
With increasing focus on "local formability" and fracture behavior of advanced high strength steels (AHSS), the effects of tension test specimen type and fracture area measurement method on fracture ...strain values were examined. Three 980 class AHSS and three standard tension test specimens with various widths were evaluated. Fractures types were grouped into three categories according to appearance and thickness profile "shape"-Type 1: Perpendicular to the tensile axis (across specimen width) with a V-shape thickness profile; Type 2: Irregular transition from Type 1 to Type 3 with a W-shape thickness profile; and Type 3: Angled across the specimen width with a U-shape thickness profile. All materials exhibited Type 1 fractures when tested with Subsize specimens. However, as the specimen width-to-thickness ratio increased, the fracture type changed from Type 1 to Type 2 or from Type 1 to Type 3. In contrasting the effects of specimen type and fracture area measurement method, specimen type (width) has a far greater impact on the consequent fracture strain value. For tension testing no clear universal relationship exists between the width-to-thickness ratio and the fracture strain. These observations suggest that, when reporting fracture strain values, the specimen type, the material thickness, and the fracture area measurement method must be indicated.
Enhanced recovery after surgery (ERAS) pathways in gynecologic surgery have been shown to decrease length of stay with no impact on readmission, but no study has assessed predictors of admission in ...this population. The purpose of this study was to identify predictors of admission after laparoscopic hysterectomy (LH) and robotic-assisted hysterectomy (RAH) performed under an ERAS pathway.
This is a prospective observational study of women undergoing LH/RAH for benign indications within an ERAS pathway. Data collected included same-day discharge, reason for admission, incidences of urgent clinic and emergency room (ER) visits, readmissions, reoperations, and 9 postulated predictors of admission listed below. Patient demographics, markers of baseline health, and clinical outcomes were compared between groups (ERAS patients discharged on the day of surgery versus admitted) using Fisher exact and Student t tests. Multivariable logistic regression was used to assess the potential risk factors for being admitted, adjusting for age, race, body mass index, American Society of Anesthesiologists (ASA) physical status score, preoperative diagnosis indicative of hysterectomy, preoperative chronic pain, completion of a preprocedure pain-coping skills counseling session, procedure time, and compliance to the ERAS pathway.
There were 165 patients undergoing LH/RAH within an ERAS pathway; 93 (56%) were discharged on the day of surgery and 72 were admitted. There were no significant differences in ER visits, readmissions, and reoperations between groups (ER visits: discharged 13% versus admitted 13%, P = .99; 90-day readmission: discharged 4% versus admitted 7%, P = .51; and 90-day reoperation: discharged 4% versus admitted 3%, P = .70). The most common reasons for admission were postoperative urinary retention (n = 21, 30%), inadequate pain control (n = 21, 30%), postoperative nausea and vomiting (n = 7, 10%), and planned admissions (n = 7, 10%). Increased ASA physical status, being African American, and increased length of procedure were significantly associated with an increased risk of admission (ASA physical status III versus ASA physical status I or II: odds ratio OR, 3.12; 95% confidence interval CI, 1.36-7.16; P = .007; African American: OR, 2.47; 95% CI, 1.02-5.96; P = .04; and length of procedure, assessed in 30-minute increments: OR, 1.23; 95% CI, 1.02-1.50; P = .04).
We were able to define predictors of admission for patients having LH/RAH managed with an ERAS pathway. Increased ASA physical status, being African American, and increased length of procedure were significantly associated with admission after LH/RAH performed under an ERAS pathway. In addition, the incidences of urgent clinic and ER visits, readmissions, and reoperations within 90 days of surgery were similar for patients who were discharged on the day of surgery compared to those admitted.
Until now the hole expansion ratio has been generally regarded as a relative “local formability” parameter with limited application to edge-cracking analysis and prediction. In this study a ...constrained statistical test data analysis methodology is introduced, where the lower-bound hole expansion ratio is the basis for three practical edge-cracking failure criteria. The Maximum Edge Stretch Criterion is directly compatible with CAE simulation. The Edge Thinning Limit Criterion and the Critical Thickness Criterion are more useful in field work and post mortem laboratory failure analysis. Two case studies are described, where hole expansion test data are used to analyze edge cracking of Advanced High Strength Steel (AHSS) in real-world automotive seating applications. Finally the intrinsic local and global formability parameters of the subject AHSS materials were explored, and a linear relationship between the hole expansion ratio and reduction of area at fracture in tension was demonstrated.
The present paper reports the results of a blind round robin test dedicated to the measurement of the retained austenite content of different TRIP assisted multiphase steels. Various surface and ...volume techniques, i.e. light microscopy, X-ray diffraction, electron backscattered diffraction (EBSD), magnetic saturation, thermal diffusivity and laser ultrasonics, were used by different partners. The compiled results show a quite large variability of the estimated retained austenite content, particularly for well established techniques, such as X-ray diffraction (XRD) and magnetisation. On the other hand, emerging techniques like EBSD, thermal diffusivity and laser ultrasonics warrant further investigations.
The PathoSystems Resource Integration Center (PATRIC) is one of eight Bioinformatics Resource Centers (BRCs) funded by the National Institute of Allergy and Infection Diseases (NIAID) to create a ...data and analysis resource for selected NIAID priority pathogens, specifically proteobacteria of the genera Brucella, Rickettsia and Coxiella, and corona-, calici- and lyssaviruses and viruses associated with hepatitis A and E. The goal of the project is to provide a comprehensive bioinformatics resource for these pathogens, including consistently annotated genome, proteome and metabolic pathway data to facilitate research into counter-measures, including drugs, vaccines and diagnostics. The project's curation strategy has three prongs: 'breadth first' beginning with whole-genome and proteome curation using standardized protocols, a 'targeted' approach addressing the specific needs of researchers and an integrative strategy to leverage high-throughput experimental data (e.g. microarrays, proteomics) and literature. The PATRIC infrastructure consists of a relational database, analytical pipelines and a website which supports browsing, querying, data visualization and the ability to download raw and curated data in standard formats. At present, the site warehouses complete sequences for 17 bacterial and 332 viral genomes. The PATRIC website (https://patric.vbi.vt.edu) will continually grow with the addition of data, analysis and functionality over the course of the project.
Enhanced recovery after surgery (ERAS) is an evidence-based, multidisciplinary perioperative care model shown to reduce complications and hospital length of stay (LOS). While some thoracic ERAS ...studies were inconclusive, others demonstrated that ERAS improves patient outcomes after lung resections and provides more cost-effective care. We aimed to investigate the effects of preliminary implementation of an ERAS protocol, in comparison with conventional care, on lung resection outcomes at a single academic institution.
In this observational study, adult patients undergoing lung resections during the pre-ERAS (April 2014 to September 2015) and post-ERAS (January 2016 to May 2017) periods were identified. Relevant demographic, preoperative, anesthesia, and surgical variables were collected. Pre-ERAS and post-ERAS cohorts were compared in terms of hospital LOS, postoperative complications, and 30-day outcomes.
We identified 264 patients, half in each cohort. Pre-ERAS and post-ERAS groups were similar with respect to age, race, and comorbidities. There were no significant differences in LOS, complications, 30-day readmission and mortality rates, or patient-reported outcomes. Of the patients with prolonged LOS, 31% had pulmonary complications, almost half of which were prolonged air leaks. ERAS adherence rate was approximately 60%.
In the first year of implementation, median LOS, complications, and 30-day outcomes did not differ significantly between the pre-ERAS and post-ERAS groups. Prolonged air leaks commonly led to prolonged LOS; therefore, thoracic ERAS protocols could include interventions to reduce air leak and consideration for discharging patients with chest tubes placed to Heimlich valves. Buy-in and adherence to a new protocol are necessary for implementation to be effective.
Display omitted
The PathoSystems Resource Integration Center (PATRIC) is one of eight Bioinformatics Resource Centers (BRCs) funded by the National Institute of Allergy and Infection Diseases (NIAID) to create a ...data and analysis resource for selected NIAID priority pathogens, specifically proteobacteria of the genera Brucella, Rickettsia and Coxiella, and corona-, calici- and lyssaviruses and viruses associated with hepatitis A and E. The goal of the project is to provide a comprehensive bioinformatics resource for these pathogens, including consistently annotated genome, proteome and metabolic pathway data to facilitate research into counter-measures, including drugs, vaccines and diagnostics. The project's curation strategy has three prongs: 'breadth first' beginning with whole-genome and proteome curation using standardized protocols, a 'targeted' approach addressing the specific needs of researchers and an integrative strategy to leverage high-throughput experimental data (e.g. microarrays, proteomics) and literature. The PATRIC infrastructure consists of a relational database, analytical pipelines and a website which supports browsing, querying, data visualization and the ability to download raw and curated data in standard formats. At present, the site warehouses complete sequences for 17 bacterial and 332 viral genomes. The PATRIC website (https://patric.vbi.vt.edu) will continually grow with the addition of data, analysis and functionality over the course of the project.
PDF
