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  • 1
    Language: English
    In: HPB, September 2015, Vol.17(9), pp.753-762
    Description: Bile duct reconstruction (BDR) is used to manage benign and malignant neoplasms, congenital anomalies, bile duct injuries and other non-malignant diseases. BDR outcomes overall, by year, and by indication were compared. Retrospective analysis of Nationwide Inpatient Sample discharges (2004–2011) including ICD-9 codes for BDR. All statistical testing was performed using survey weighting. Univariate analysis of admission characteristics by chi square testing. Multivariate modelling for inpatient complications and inpatient death by logistic regression. Identified 67 160 weighted patient admissions: 2.5% congenital anomaly, 37.4% malignant neoplasm, 2.3% benign neoplasm, 9.9% biliary injury, 47.9% other non-malignant disease. Most BDRs were performed in teaching hospitals (69.6%) but only 25% at centres with a BDR volume more than 35/year. 32.3% involved ≥ 1 complication, and 84.7% were discharges home. There was a 4.2% inpatient death rate. The complication rate increased but the inpatient death rate decreased over time. The rates of acute renal failure increased. Significant multivariate predictors of inpatient death include indication of biliary injury or malignancy, and predictors of any complication include public insurance and non-elective admission. This is the first national description of BDRs using a large database. In this diverse sampling, both procedure indication and patient characteristics influence morbidity and mortality.
    Keywords: Medicine
    ISSN: 1365-182X
    E-ISSN: 1477-2574
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  • 2
    In: Journal of Antimicrobial Chemotherapy, 2016, Vol. 72(1), pp.268-272
    Description: OBJECTIVES: The increase in infections caused by drug-resistant ESBL-producing Enterobacteriaceae (ESBL-ENT) is a global concern. The characteristics and outcomes of patients infected with ESBL-ENT were examined in a pooled analysis of Phase 3 clinical trials of ceftolozane/tazobactam in patients with complicated urinary tract infections (ASPECT-cUTI) and complicated intra-abdominal infections (ASPECT-cIAI).METHODS: Trials were randomized and double blind. The ASPECT-cUTI regimen was 7 days of either intravenous ceftolozane/tazobactam (1.5 g) every 8 h or levofloxacin (750 mg) once daily. The ASPECT-cIAI regimen was 4-14 days of either intravenous ceftolozane/tazobactam (1.5 g) plus metronidazole (500 mg) or meropenem (1 g) every 8 h. Baseline cultures were obtained in both indications. Enterobacteriaceae were selected for ESBL characterization based on predefined criteria and were verified genotypically. Outcomes were assessed at the test-of-cure visit 5-9 days post-therapy in ASPECT-cUTI and 24-32 days post-randomization in ASPECT-cIAI among microbiologically evaluable (ME) patients.RESULTS: Of 2076 patients randomized, 1346 were included in the pooled ME population and 150 of 1346 (11.1%) had ESBL-ENT at baseline. At US FDA/EUCAST breakpoints of ≤2/≤1 mg/L, 81.8%/72.3% of ESBL-ENT (ESBL-Escherichia coli, 95%/88.1%; ESBL-Klebsiella pneumoniae, 56.7%/36.7%) were susceptible to ceftolozane/tazobactam versus 25.3%/24.1% susceptible to levofloxacin and 98.3%/98.3% susceptible to meropenem at CLSI/EUCAST breakpoints. Clinical cure rates for ME patients with ESBL-ENT were 97.4% (76/78) for ceftolozane/tazobactam [ESBL-E. coli, 98.0% (49 of 50); ESBL-K. pneumoniae, 94.4% (17 of 18)], 82.6% (38 of 46) for levofloxacin and 88.5% (23 of 26) for meropenem.CONCLUSIONS: Randomized trial data demonstrated high clinical cure rates with ceftolozane/tazobactam treatment of cIAI and cUTI caused by ESBL-ENT.
    Keywords: Medicine ; Pharmacy, Therapeutics, & Pharmacology;
    ISSN: 0305-7453
    E-ISSN: 1460-2091
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  • 3
    In: Journal of Wound, Ostomy and Continence Nursing, 2014, Vol.41(4), pp.365-370
    Description: PURPOSE:: The purpose of this study was to refine an instrument for assessing incontinence-associated dermatitis (IAD) and its severity for use on lighter- and darker-toned skin, the Incontinence-Associated Dermatitis and its Severity Instrument-D (IADS-D), and to test its validity and reliability among WOC nurses. METHODS:: Revisions to the existing instrument included examples of colors of normal and IAD-damaged skin that would be observed on light-, medium-, and dark-toned skin using pixels from patient photographs, additional photographs of IAD manifestations on different skin tones, and training materials. Four certified WOC nurse consultants and 2 WOC nurse clinical experts assessed the face and content validity of the IADS-D instrument. The IADS-D instrument was tested for criterion validity and interrater reliability using photo cases by attendees at the Wound, Ostomy, and Continence Nurses Society 2012 conference. RESULTS:: The IADS-D instrument had good face and content validity. The overall average intraclass correlation coefficient (ICC) of IADS-D scores for all photo cases of testers (n = 266, 95% female, age 53.0 ± 7.9 years, mean ± SD) and those of investigators, experts, and consultants serving as the criterion was 0.90. The overall ICC for interrater reliability between all nurse testers was 0.99 and the ICC for tester skin tone was 0.99. CONCLUSION:: The IADS-D instrument has excellent validity and interrater reliability among WOC nurses. Its refinement for use with lighter- and darker-toned skin addresses the lack of a much-needed instrument in nursing practice and research. Results support continued development and evaluation of the instrumentʼs use in clinical and research settings.
    Keywords: Incontinence ; Skin and Skin Disorders ; Screening ; Research Methods ; Ethnic Groups ; Professional Development ; Dermatology Nursing ; Quantitative Research ; Nurse Specialists ; Minority & Ethnic Groups ; Urinary Incontinence ; Research Methodology ; Medical Screening ; Skin ; Skin Diseases ; Dermatology ; United States–Us;
    ISSN: 1071-5754
    E-ISSN: 15283976
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  • 4
    Language: English
    In: Journal of Gastrointestinal Surgery, 2016, Vol.20(5), pp.1012-1019
    Description: This study analyzes the relationship between hospital teaching status, failure to rescue, and time of year in select gastrointestinal operations. Procedure codes for laparoscopic cholecystectomy, colectomy, and pancreatectomy were queried from the Nationwide Inpatient Sample (2004–2011). Failure to rescue was defined as inpatient mortality when ≥1 complication. A total of 2,777,267 laparoscopic cholecystectomies, 2,519,903 colectomies, and 129,619 pancreatectomies were performed. Teaching hospitals had increased overall rates of failure to rescue compared to non-teaching hospitals, 10.0 vs. 9.5 % ( p  = 0.0187), particularly between May and August. There was greater inter-month variability in non-teaching hospitals amongst individual operations. On multivariable analysis, July was not predictive of increased odds of failure to rescue. Teaching status, hospital characteristics, and patient demographics were associated with increased odds of failure to rescue. Although teaching hospitals have a higher overall failure to rescue rate amongst the selected gastrointestinal operations, odds of failure to rescue are not increased in the month of July. Non-teaching hospitals tend to exhibit more monthly variation in failure to rescue rates, and hospital/patient demographics are predictive of failure to rescue. Further investigation targeted at identifying drivers of temporal variation is warranted to optimize patient outcomes.
    Keywords: Failure to rescue ; July effect ; Teaching hospitals
    ISSN: 1091-255X
    E-ISSN: 1873-4626
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  • 5
    Language: English
    In: Occupational Therapy In Health Care, 02 January 2016, Vol.30(1), pp.16-28
    Description: The Safe at Home Screening (SAH) is an occupational therapy assessment tool designed to quickly assess home safety awareness and skills through the use of mock hazardous situations in a kitchen setting. The SAH has been standardized on community-dwelling adults. This research project involves...
    Keywords: Acquired Brain Injury ; Assessment ; Cognition ; Home Safety ; Independent Living ; Occupational Therapy ; Occupational Therapy & Rehabilitation
    ISSN: 0738-0577
    E-ISSN: 1541-3098
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  • 6
    Language: English
    In: HPB, October 2014, Vol.16(10), pp.899-906
    Description: The volume effect in pancreatic surgery is well established. Regionalization to high-volume centres has been proposed. The effect of this proposal on practice patterns is unknown. Retrospective review of pancreatectomy patients in the Nationwide Inpatient Sample 2004–2011. Inpatient mortality and complication rates were calculated. Patients were stratified by annual centre pancreatic resection volume (low 〈5, medium 5–18, high 〉18). Multivariable regression model evaluated predictors of resection at a high-volume centre. In total, 129 609 patients underwent a pancreatectomy. The crude inpatient mortality rate was 4.3%. 36.0% experienced complications. 66.5% underwent a resection at high-volume centres. In 2004, low-, medium- and high-volume centres resected 16.3%, 24.5% and 59.2% of patients, compared with 7.6%, 19.3% and 73.1% in 2011. High-volume centres had lower mortality ( 〈 0.001), fewer complications ( 〈 0.001) and a shorter median length of stay ( 〈 0.001). Patients at non-high-volume centres had more comorbidities ( = 0.001), lower rates of private insurance ( 〈 0.001) and more non-elective admissions ( 〈 0.001). In spite of a shift to high-volume hospitals, a substantial cohort still receives a resection outside of these centres. Patients receiving non-high-volume care demonstrate less favourable comorbidities, insurance and urgency of operation. The implications are twofold: already disadvantaged patients may not benefit from the high-volume effect; and patients predisposed to do well may contribute to observed superior outcomes at high-volume centres.
    Keywords: Medicine
    ISSN: 1365-182X
    E-ISSN: 1477-2574
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  • 7
    In: Diseases of the Colon & Rectum, 2015, Vol.58(12), pp.1164-1173
    Description: BACKGROUND:: Readmission rates are a measure of surgical quality and an object of clinical and regulatory scrutiny. Despite increasing efforts to improve quality and contain cost, 6% to 25% of patients are readmitted after colorectal surgery. OBJECTIVE:: The aim of this study is to define the predictors and costs of readmission following colorectal surgery. DESIGN:: This is a retrospective cohort study of patients undergoing elective and nonelective colectomy and/or proctectomy in the Healthcare Cost and Utilization Project Florida State Inpatient Database 2007 to 2011. Readmission is defined as inpatient admission within 30 days of discharge. Univariate analyses were performed of sex, age, Elixhauser score, race, insurance type, procedure, indication, readmission diagnosis, cost, and length of stay. Multivariate analysis was performed by logistic regression. Sensitivity analysis of nonemergent admissions was conducted. SETTINGS:: This study was conducted in Florida acute-care hospitals. PATIENTS:: Patients undergoing colectomy and proctectomy from 2007 to 2011 were included. INTERVENTION(S):: There were no interventions. MAIN OUTCOME MEASURE(S):: The primary outcomes measured were readmission and the cost of readmission. RESULTS:: A total of 93,913 patients underwent colectomy; 14.7% were readmitted within 30 days. From 2007 to 2011, readmission rates remained stable (14.6%–14.2%, trend p = 0.1585). After multivariate adjustment, patient factors associated with readmission included nonwhite race, age 〈65, and a diagnosis code other than neoplasm or diverticular disease (p 〈 0.0001). Patients with Medicare or Medicaid were more likely to be readmitted than those with private insurance (p 〈 0.0001). Patients with longer index admissions, those with stomas, and those undergoing all procedures other than sigmoid or transverse colectomy were more likely to be readmitted (p 〈 0.0001). High-volume hospitals had higher rates of readmission (p 〈 0.0001). The most common reason for readmission was infection (32.9%). Median cost of readmission care was $7030 (intraquartile range, $4220–$13,247). Fistulas caused the most costly readmissions ($15,174; intraquartile range, $6725–$26,660). LIMITATIONS:: Administrative data and retrospective design were limitations of this study. CONCLUSIONS:: Readmissions rates after colorectal surgery remain common and costly. Nonprivate insurance, IBD, and high hospital volume are significantly associated with readmission.
    Keywords: Medicine;
    ISSN: 0012-3706
    E-ISSN: 15300358
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  • 8
    Language: English
    In: Surgery, March 2017, Vol.161(3), pp.592-601
    Description: Neoadjuvant therapy is an emerging paradigm in pancreatic cancer care; however, its role for resectable disease remains controversial in the absence of conclusive randomized controlled trials. The purpose of the present study is to assess the impact of neoadjuvant therapy on survival in resected pancreatic cancer patients by clinical stage. A retrospective cohort study using the National Cancer Data Base from 2004 to 2012 including nonmetastatic pancreatic adenocarcinoma patients who underwent pancreatectomy and initiated chemotherapy. Propensity score matching within each stage was used to account for potential selection bias between patients undergoing neoadjuvant therapy and upfront surgery. Overall survival was compared by the Kaplan-Meier method. In the study, 1,541 and 7,159 patients received neoadjuvant therapy followed by surgery and upfront surgery succeeded by adjuvant therapy, respectively. In clinical stage III pancreatic cancer (  = 486), neoadjuvant therapy was associated with significant survival benefit after matching (median survival 22.9 vs 17.3 months; log-rank  〈 .0001) compared with conventional upfront surgery followed by adjuvant therapy; however, no survival difference was found between the 2 treatment sequences in patients with clinical stage I (  = 3,149; median survival, 26.2 vs 25.7 months;  = .4418) and II (  = 5,065; median survival, 23.5 vs 23.0 months;  = .7751) disease after matching. The survival impact of neoadjuvant therapy is stage-dependent. Neoadjuvant therapy does not disadvantage survival compared with conventional upfront surgery followed by adjuvant therapy in any stage, and is associated with a significant survival advantage in stage III pancreatic cancer.
    Keywords: Adenocarcinoma – Analysis ; Pancreatic Cancer – Analysis ; Adjuvant Chemotherapy – Analysis ; Neoadjuvant Therapy – Analysis ; Medical Schools – Analysis ; Medical Research – Analysis;
    ISSN: 0039-6060
    E-ISSN: 1532-7361
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  • 9
    In: Journal of Wound, Ostomy and Continence Nursing, 2018, Vol.45(5), pp.449-455
    Description: PURPOSE:: The purpose of this study was to evaluate a revised version of the Incontinence-Associated Skin Damage Severity instrument (IASD.D.2) using 3 different groups of nursing staff. Revisions to the instrument included renumbering 1 body area where incontinence-associated dermatitis (IAD) occurs into 2 areas (right and left), which raised the total possible score from 52 to 56, and defining the borders of the body areas. DESIGN:: Observational, evaluative design. SAMPLE AND SETTING:: Five clinical experts certified in wound, ostomy, and/or continence (WOC) nursing evaluated content validity. Evaluators were attendees at the WOC Nurses (WOCN) Society 2014 conference, hospital nurses, and nursing staff at a nursing home. Evaluators were attendees at the WOCN Societyʼs 2014 National Conference, hospital nurses at a community hospital with Magnet designation, and nursing staff at a skilled nursing home in the Midwestern United States. The evaluator group comprised 198 conference attendees (all nurses; age 53 ± 8.2 years, mean ± SD), 67 hospital nurses (age 37 ± 11 years), and 34 nursing home nursing staff (age 45 ±13.8 years). The majority of evaluators (〉75%) in each of the groups were female. METHODS:: Clinical experts evaluated the content validity of the revised instrument. Evaluators scored 5 to 9 photographic cases using the revised instrument. Four of the cases were scored by all evaluators. The agreement of case scores among all evaluators was analyzed to assess interrater reliability. The scores of evaluators grouped by evaluatorsʼ self-identified skin color or nursing experience (〈10 years vs ≥10 years) were also tested for differences. To provide evidence for criterion validity, the agreement of evaluatorsʼ scores with expertsʼ scores (considered a “gold standard” in this study) was analyzed. RESULTS:: The agreement of the IASD.D.2 scores among all evaluators within each group ranged from 0.74 to 0.79, suggesting good interrater reliability. The agreement of each group of evaluators with the experts for all case scores ranged from 0.82 to 0.85, suggesting good criterion validity. There was no significant difference in scores by evaluatorsʼ skin color or nursing experience. CONCLUSION:: The revised IASD.D.2 has good content and criterion validity and interrater reliability. The instrument has potential to standardize reporting of IAD severity in research and clinical practice and assist communication about IAD among nursing staff.
    Keywords: Dermatitis -- Care And Treatment ; Medical Personnel -- Practice;
    ISSN: 1071-5754
    E-ISSN: 15283976
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  • 10
    In: Pancreas, 2015, Vol.44(5), pp.819-823
    Description: OBJECTIVES: To examine if surgery performed for pain of chronic pancreatitis (CP) within 3 years diagnosis has greater odds of achieving complete pain relief than later surgery and to find optimal surgical timing for attaining pain relief in CP. METHODS: Retrospective review of records at a tertiary institution 2003 to 2011 for CP where the operative indication was pain. Outcomes were pain-free status, opioid use, and pancreatic insufficiency at 3-year follow-up. Univariate analysis by Fisher exact tests. Receiver operating curve to calculate cutoff threshold time for surgery. RESULTS: Outcomes for 66 patients were included. Median preoperative CP duration was 28 months (interquartile range, 12, 67). Twenty-six patients (39.4%) were free of pain at the 3-year follow-up. Thirty-four patients (51.5%) were opioid users at follow-up. Postoperatively, 34 patients (51.5%) demonstrated endocrine, and 32 patients (48.5%) demonstrated exocrine insufficiency. The optimal cutoff point for preoperative CP duration was 26.5 months (area under the curve, 0.66). Shorter duration of CP before surgery was a predictor of pain-free status and reduced postoperative opioid use at follow-up. CONCLUSIONS: Results from a single institution analysis suggest early surgical intervention of 26.5 months or less of diagnosis is associated with improved pain control, and optimal timing for surgery may be earlier than previously thought.
    Keywords: Pancreatectomy ; Pancreaticoduodenectomy ; Time-to-Treatment ; Abdominal Pain -- Prevention & Control ; Pain, Postoperative -- Prevention & Control ; Pancreatitis, Chronic -- Surgery;
    ISSN: 0885-3177
    E-ISSN: 15364828
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