Is an overnight stay after percutaneous nephrolithotomy safe?

BackgroundEvidence on the association between newborn length of hospital stay (LOS) and risk of readmission is conflicting. We compared methods for modelling this relationship, by gestational age, using population‐level hospital data on births in England between 2005–14.MethodsThe association between LOS and unplanned readmission within 30 days of postnatal discharge was explored using four approaches: (i) modelling hospital‐level LOS and readmission rates; (ii) comparing trends over time in LOS and readmission; (iii) modelling individual LOS and adjusted risk of readmission; and (iv) instrumental variable analyses (hospital‐level mean LOS and number of births on the same day).ResultsOf 4 667 827 babies, 5.2% were readmitted within 30 days. Aggregated data showed hospitals with longer mean LOS were not associated with lower readmission rates for vaginal (adjusted risk ratio (aRR) 0.87, 95% confidence interval (CI) 0.66, 1.13), or caesarean (aRR 0.89, 95% CI 0.72, 1.12) births. LOS fell by an average 2.0% per year for vaginal births and 3.4% for caesarean births, while readmission rates increased by 4.4 and 5.1% per year respectively. Approaches (iii) and (iv) indicated that longer LOS was associated with a reduced risk of readmission, but only for late preterm, vaginal births (34–36 completed weeks’ gestation).ConclusionsLonger newborn LOS may benefit late preterm babies, possibly due to increased medical or psychosocial support for those at greater risk of potentially preventable readmissions after birth. Research based on observational data to evaluate relationships between LOS and readmission should use methods to reduce the impact of unmeasured confounding.

Trends in Management and Outcomes of Acute Nonvariceal Upper Gastrointestinal Bleeding: 1993–2003

This study investigated the influence of body mass index (BMI) on the post-operative fall in the level of haemoglobin (Hb), length of hospital stay (LOS), 30-day re-admission rate, functional outcome and quality of life, two years after total knee arthroplasty (TKA). A total of 7733 patients who underwent unilateral primary TKA between 2001 and 2010 were included. The mean age was 67 years (30 to 90). There were 1421 males and 6312 females. The patients were categorised into three groups: BMI < 25.0 kg/m(2) (normal); BMI between 25.0 and 39.9 kg/m(2) (obese); and BMI ≥ 40.0 kg/m(2) (morbidly obese). Compared with the normal and obese groups, the mean LOS was longer by one day (95% confidence interval (CI) 0 to 2) in the morbidly obese group (p = 0.003 and p=0.001 respectively). The 30-day re-admisison rate was also higher in the morbidly obese group compared to the obese group (OR 2.323, 95% CI 1.101 to 4.900, p = 0.024); and showed a higher trend compared to the normal group (OR 1.850, 95% CI 0.893 to 3.831, p = 0.100). However, the morbidly obese group had a smaller drop in post-operative Hb level by a mean of 0.5 g/dl (0.3 to 0.6) and 0.3 g/dl (0.1 to 0.5), when compared with the normal and obese groups respectively (both p < 0.001). Furthermore, the mean improvement in Oxford Knee Score (OKS) and Knee Society Knee Score (KSKS) at two years follow-up was three points (two to four) and five points (two to seven) more in the morbidly obese group than in the normal group (both p < 0.001). The mean improvement in Knee Society Function Score, and Physical and Mental Component Scores of Short Form-36 were comparable between the three BMI groups (p = 0.736, p = 0.739 and p = 0.731 respectively). The ten-year rate of survival was 98.8% (98.0 to 99.3), 98.9% (98.5 to 99.2) and 98.0% (95.8 to 100), for the normal, obese and morbidly obese groups, respectively (p = 0.703). Although morbidly obese patients have a longer LOS and higher 30-day re-admission rate after TKA, they have a smaller drop in post-operative Hb level and larger improvement in OKS and KSKS at two years follow-up. The ten-year rate of survival of TKA was also comparable with those with a normal BMI. Morbidly obese patients should not be excluded from the benefits of TKA. Cite this article: Bone Joint J 2016;98-B:780-5.

BACKGROUND: The gold standard treatment for urinary bladder cancer is cystectomy, which can result in postoperative complications, patient morbidities, and lengthy hospital visits post-surgery. At present, there are limited models that can predict length of stay for patients post cystectomy. Identifying risk factors associated with increased length of stay could have translational implications in mitigating such risk factors. As such, the goal of this study was to generate parsimonious models to predict length of hospital stay (LOHS) following cystectomy in bladder cancer patients. METHODS: Data from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) was used to analyze patients who underwent cystectomy between 2014 and 2016. Modeling building approaches were used to identify the most informative preoperative and postoperative covariates to predict LOHS. Separate models were identified for preoperative covariates and for postoperative covariates and the most informative pre- and postoperative covariates were combined into a single model. RESULTS: This analysis includes 6,074 patients (mean LOHS = 9.4 days). The preoperative (5 covariates; R squared= 0.245 and Adj R-squared = 0.240) and postoperative models (13 covariates; R squared= 0.237 and Adj R-squared = 0.236) were significantly better predictors compared to the ACS risk calculator model (19 covariates; R-square= 0.026 and Adj R-squared = 0.025). Likewise, the combined model (15 covariates) was a significantly better predictor (R squared= 0.241 &amp; Adj R-squared = 0.239) when compared to the ACS risk calculator model. The combined model was subjected into CART analysis to stratify patients into five risk-groups based on ventilator over 48 hours, organ/space surgical site infection, wound disruption, and pneumonia. Patients in the high-risk group had significantly longer mean LOHS of 26.29 days compared to low-risk group of 8.4 days. CONCLUSIONS: This study identified and validated a clinically important combined model that is to the ACS NSQIP surgical risk calculator to predict LOHS in patients who underwent cystectomy. Patients at high-risk may benefit from allocation of additional follow-up to prevent longer LOHS. Citation Format: Rashmi Pathak, Jaileene Perez-Morales, Sephalie Y. Patel, Michael A. Poch, Matthew B. Schabath. Parsimonious model to predict length of stay following cystectomy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 883.

BACKGROUNDDetailed data on the relation of post-operative complications with clinical outcomes after simultaneous pancreas-kidney (SPK) transplantation is lacking.AIMTo compare Clavien-Dindo classification (CDC) and comprehensive complication index (CCI) in predicting outcomes after SPK.METHODSData for patients undergoing SPK between 1999-2019 were analyzed. Information on recipients’ baseline characteristics, peri-operative management and post-operative complications were collated. Length of hospital stay (LOS) was the primary study outcome, and the associations with CDC and CCI were evaluated using Spearman’s (ρ) correlation coefficients.RESULTSIn the study period, data were available for 128 patients (female n = 44, 34.4%). Sixty-nine patients had at least one complication with the highest CDC grade of I, II, III, and IV in 8 (6.3%), 22 (17.2%), 32 (25%), and 7 (5.5%) patients, respectively. The mean LOS was 21.4 ± 17.7 days. Both classification systems were correlated with LOS, yet CCI was stronger (Spearman’s ρ: 0.694 vs 0.602, P < 0.001). Female patients (P = 0.019) and patients with pre-transplant cardiovascular events (P = 0.02) had longer LOS. After adjusted multivariable analysis, the link between LOS and both the CDC and CCI remained relevant. CCI had a superior fit compared to CDC (r2 = 0.729 vs r2 = 0.481), with every 10 CCI points being associated with a 5.27 day (P < 0.001) increased LOS.CONCLUSIONThis study showed that the CCI was better linked with LOS compared to CDC and might represent a useful score to evaluate the overall burden of postoperative complications in patients undergoing SPK.

Effects of previous unsuccessful extracorporeal shockwave lithotripsy treatment on the performance and outcome of percutaneous nephrolithotomy

INTRODUCTION Intracerebral hemorrhage (ICH) is a major cause of morbidity and mortality worldwide, with a 1-mo mortality rate between 30% and 50%. Our goal was to quantify additional healthcare resource utilization (HCRU) incurred by the US health system due to complications sustained during initial ICH hospital admissions, including a cost comparison of complications treated invasively vs noninvasively. METHODS The IBM MarketScan databases were used to retrospectively identify ICH patients and quantify the prevalence and HCRU of associated complications. HCRU variables included total service costs and length of hospital stay (LOS). Complications studied included cerebral edema, hydrocephalus, delayed ischemic stroke, venous thromboembolic events (VTE), infections (urinary tract infection (UTI) and pneumonia), and seizures. Invasive interventions included craniotomies/craniectomies and CSF diversion. Costs were assessed at 7, 30, 60, and 365 d post-ICH diagnosis for complications. RESULTS A total of 29 989 adult patients were included. Of those, 18 387 (61%) developed at least 1 complication during their initial ICH admission: 35% delayed ischemic stroke, 23% cerebral edema, 15% infections, 11% hydrocephalus, 5% seizures, and 5% VTE. Overall median LOS for all ICH was 5 d (IQR 2-10 d). Patients developing VTE had the longest median LOS at 17 d (IQR 8-27 d) and highest 7-d inpatient cost (median $67,222; IQR $24,384-157,919). Hydrocephalus had similar median LOS (15 d; IQR 6-23 d) and second highest median 7-d inpatient cost (median $59,553; IQR $22,129-143,835). Patients suffering cerebral edema, hydrocephalus, or delayed ischemic stroke requiring invasive treatments had higher costs at all times, especially during the first 7 d, with differences ranging from $61,852 for hydrocephalus to $84,699 for delayed ischemic stroke. CONCLUSION Delayed ischemic stroke and cerebral edema were the most common complications during initial ICH admission. VTE and hydrocephalus had the longest LOS and highest service costs at all times after diagnosis.

Background and objectives: To perform a updated systematic review and meta-analysis comparing effectiveness of percutaneous nephrolithotomy (PCNL), retrograde intrarenal surgery (RIRS), and extracorporeal shock wave lithotripsy (ESWL) for treatment of renal stones (RS). Materials and Methods: A total of 37 studies were included in this systematic review and meta-analysis about effectiveness to treat RS. Endpoints were stone-free rates (SFR), incidence of auxiliary procedure, retreatment, and complications. We also conducted a sub-analysis of ≥2 cm stones. Results: First, PCNL had the highest SFR than others regardless of stone sizes and RIRS showed a higher SFR than ESWL in <2 cm stones. Second, auxiliary procedures were higher in ESWL than others, and it did not differ between PCNL and RIRS. Finally, in <2 cm stones, the retreatment rate of ESWL was higher than others. RIRS required significantly more retreatment procedures than PCNL in ≥2 cm stones. Complication was higher in PCNL than others, but there was no statistically significant difference in complications between RIRS and PCNL in ≥2 cm stones. For ≥2 cm stones, PCNL had the highest SFR, and auxiliary procedures and retreatment rates were significantly lower than others. Conclusions: We suggest that PCNL is a safe and effective treatment, especially for large RS.

Patients with advanced cancer often experience frequent and prolonged hospitalizations; however, the factors associated with greater health care utilization have not been described. We sought to investigate the relation between patients' physical and psychological symptom burden and health care utilization. We enrolled patients with advanced cancer and unplanned hospitalizations from September 2014-May 2016. Upon admission, we assessed physical (Edmonton Symptom Assessment System [ESAS]) and psychological symptoms (Patient Health Questionnaire 4 [PHQ-4]). We examined the relationship between symptom burden and healthcare utilization using linear regression for hospital length of stay (LOS) and Cox regression for time to first unplanned readmission within 90 days. We adjusted all models for age, sex, marital status, comorbidity, education, time since advanced cancer diagnosis, and cancer type. We enrolled 1,036 of 1,152 (89.9%) consecutive patients approached. Over one-half reported moderate/severe fatigue, poor well being, drowsiness, pain, and lack of appetite. PHQ-4 scores indicated that 28.8% and 28.0% of patients had depression and anxiety symptoms, respectively. The mean hospital LOS was 6.3 days, and the 90-day readmission rate was 43.1%. Physical symptoms (ESAS: unstandardized coefficient [B], 0.06; P < .001), psychological distress (PHQ-4 total: B, 0.11; P = .040), and depression symptoms (PHQ-4 depression: B, 0.22; P = .017) were associated with longer hospital LOS. Physical (ESAS: hazard ratio, 1.01; P < .001), and anxiety symptoms (PHQ-4 anxiety: hazard ratio, 1.06; P = .045) were associated with a higher likelihood for readmission. Hospitalized patients with advanced cancer experience a high symptom burden, which is significantly associated with prolonged hospitalizations and readmissions. Interventions are needed to address the symptom burden of this population to improve health care delivery and utilization. Cancer 2017;123:4720-4727. © 2017 American Cancer Society.

Severe traumatic brain injury (TBI) is a leading cause of disability and death in the pediatric population. While intracranial pressure (ICP) monitoring is the gold standard in acute neurocritical care following pediatric severe TBI, brain tissue oxygen tension (PbtO2) monitoring may also help limit secondary brain injury and improve outcomes. The authors hypothesized that pediatric patients with severe TBI and ICP + PbtO2 monitoring and treatment would have better outcomes than those who underwent ICP-only monitoring and treatment. Patients ≤ 18 years of age with severe TBI who received ICP ± PbtO2 monitoring at a quaternary children's hospital between 1998 and 2021 were retrospectively reviewed. The relationships between conventional measurements of TBI were evaluated, i.e., ICP, cerebral perfusion pressure (CPP), and PbtO2. Differences were analyzed between patients with ICP + PbtO2 versus ICP-only monitoring on hospital and pediatric intensive care unit (PICU) length of stay (LOS), length of intubation, Pediatric Intensity Level of Therapy scale score, and functional outcome using the Glasgow Outcome Score-Extended (GOS-E) scale at 6 months postinjury. Forty-nine patients, including 19 with ICP + PbtO2 and 30 with ICP only, were analyzed. There was a weak negative association between ICP and PbtO2 (β = -0.04). Conversely, there was a strong positive correlation between CPP ≥ 40 mm Hg and PbtO2 ≥ 15 and ≥ 20 mm Hg (β = 0.30 and β = 0.29, p < 0.001, respectively). An increased number of events of cerebral PbtO2 < 15 mm Hg or < 20 mm Hg were associated with longer hospital (p = 0.01 and p = 0.022, respectively) and PICU (p = 0.015 and p = 0.007, respectively) LOS, increased duration of mechanical ventilation (p = 0.015 when PbtO2 < 15 mm Hg), and an unfavorable 6-month GOS-E score (p = 0.045 and p = 0.022, respectively). An increased number of intracranial hypertension episodes (ICP ≥ 20 mm Hg) were associated with longer hospital (p = 0.007) and PICU (p < 0.001) LOS and longer duration of mechanical ventilation (p < 0.001). Lower minimum hourly and average daily ICP values predicted favorable GOS-E scores (p < 0.001 for both). Patients with ICP + PbtO2 monitoring experienced longer PICU LOS (p = 0.018) compared to patients with ICP-only monitoring, with no significant GOS-E score difference between groups (p = 0.733). An increased number of cerebral hypoxic episodes and an increased number of intracranial hypertension episodes resulted in longer hospital LOS and longer duration of mechanical ventilator support. An increased number of cerebral hypoxic episodes also correlated with less favorable functional outcomes. In contrast, lower minimum hourly and average daily ICP values, but not the number of intracranial hypertension episodes, were associated with more favorable functional outcomes. There was a weak correlation between ICP and PbtO2, supporting the importance of multimodal invasive neuromonitoring in pediatric severe TBI.

Length of hospital stay and cost of Staphylococcus and Streptococcus infections among hospitalized patients

Percutaneous nephrolithotomy (PCNL) is the first-line treatment for large and complex renal calculi. Accepted UK practice is to insert a nephrostomy tube at the end of the procedure to drain the kidney and reduce potential complications. 'Tubeless' or 'nephrostomy-free' PCNL has been advocated in selected patients as it is thought to reduce length of hospital stay, analgesia requirements and pain experienced. We present our outcomes of a consecutive series (n = 101) of 'nephrostomy-free' PCNLs compared to standard PCNL over a 4-year period. Between January 2004 and October 2006, we performed 55 standard (with nephrostomy tube) PCNLs (Group 1). From October 2006 onwards, we changed our technique and have performed 46 consecutive 'nephrostomy-free' PCNLs (JJ stent inserted), independent of patient and stone factors (Group 2). We have compared the two groups in terms of length of hospital stay (LOS), analgesia requirements, transfusion rates, haemoglobin (Hb) decrease and immediate, early and late complications. 'Nephrostomy-free' PCNL significantly reduced the length of hospital stay (2.8 vs 5.1 days; P < 0.001), morphine-based analgesia requirements (23% no morphine required vs 2.8%; P < 0.001), transfusion rate (2.5% vs 7%; P < 0.01) and mean Hb decrease (1.89 g/dl vs 2.25 g/dl; P > 0.05). Overall, no patient experienced a serious complication. All attempted 'nephrostomy-free' PCNLs were completed (stone clearance 95%) and no patient needed an unplanned nephrostomy. Only 5% in Group 2 needed their ureteric JJ stent removing earlier than planned secondary to pain. Both groups were comparable in terms of immediate, early and late complications, though three patients in Group 1 developed chronic loin pain and one patient in the 'nephrostomy-free' group developed a delayed perirenal haematoma. 'Nephrostomy-free' percutaneous nephrolithotomy is a safe, effective and feasible procedure independent of patient and stone factors. It decreases the length of hospital stay, the pain experienced and the need for morphine-based analgesia; we feel it should be the standard of care for patients undergoing a PCNL.

To evaluate the efficacy of the current clinical pathway for pulmonary resections. This study examined variances from expected clinical pathway outcomes for pulmonary resections performed between 2005 and 2009. Data on a total of 383 patients were retrospectively analyzed. The median length of hospital stay (LOS) using the clinical pathway was 12 days (range: 1-188 days); the mean LOS was 15.5 days. The cost per day with use of the clinical pathway was 102 726 yen. Poor control of pain from intercostal neuralgia was the most frequently observed variance from expected outcomes. It affected 119 of 168 electronic clinical pathway patients (70.8%). The clinical pathway was terminated in 3.9% of patients (15/383) due to serious or life-threatening complications. This study showed the single institutional experience of the clinical pathway for pulmonary resections. These findings indicate a need to revise certain aspects of the pathway, based on data from our analysis of variances.

Background: Renal stones, particularly those between 2 cm and 3.5 cm in size, present a significant challenge in urology. Despite the availability of modern techniques, the optimal treatment for stones within this size range remains a contentious issue. Percutaneous Nephrolithotomy (PCNL) and Retrograde Intrarenal Surgery (RIRS) are two popular minimally invasive procedures used to treat renal stones. However, there is limited consensus on the superiority of one over the other in terms of clinical outcomes, complications, and patient satisfaction. Objective: To compare the clinical outcomes of PCNL and RIRS in the treatment of renal stones sized between 2 cm and 3.5 cm, specifically focusing on stone-free rate (SFR), complications, hospital stay, blood loss, the need for repeat procedures, and patient satisfaction. Method: This was a prospective, randomized study conducted from June 2024 TO December 2024 at CMH nephrology and urology department district peshawer, with 150 patients presenting with renal stones between 2 cm and 3.5 cm. The patients were randomly assigned to either the PCNL group (n = 75) or the RIRS group (n = 75). Preoperative imaging (CT or ultrasound) confirmed stone size. Patients with bilateral kidney stones, a history of previous kidney surgeries, or significant comorbidities were excluded. Clinical outcomes, including SFR, hospital stay, complications (postoperative fever, infection, stent-related symptoms), blood loss, and the need for repeat procedures, were analyzed. Patient satisfaction was also evaluated using a 1-10 scale. Result: The study found that PCNL had a significantly higher stone-free rate (95%) compared to RIRS (82%). The mean hospital stay for RIRS was shorter (1.56 ± 0.4 days) compared to PCNL (6.5 ± 1.2 days). While the incidence of postoperative postoperative infection was higher in the RIRS group (44% vs. 2.7%), blood loss was greater in the PCNL group (12% vs. 4%). The need for additional procedures was higher in the RIRS group, with 44% requiring further sessions, compared to just 2.7% in the PCNL group. Patient satisfaction was higher in the PCNL group (94.7%) compared to RIRS (77.3%). The treatment of renal stones larger than 2 cm and smaller than 3.5 cm remains controversial, and Percutaneous Nephrolithotomy (PCNL) and Retrograde Intrarenal Surgery (RIRS) are two popular treatment options. This study compares these two techniques in terms of clinical outcomes, including stone-free rate (SFR), complications, hospital stay, and patient satisfaction. This prospective study was conducted June 2024 TO December 2024 at CMH neprology and urology department district peshawer involving 150 patients with renal stones who were randomized into two treatment arms, PCNL and RIRS, with 75 patients in each arm. They critically evaluated the following parameters: SFR, duration of hospital stay, blood loss during surgery, complications, requirement for re-procedures, and patient satisfaction. The puncture access of the PCNL group was decided according to the Guy's Score classification. The stone-free rate was significantly higher in the PCNL group (95%) compared to the group treated with other methods (82%). The mean hospitalization time was shorter for RIRS (6.5 ± 1.2 vs. 1.56 ± 0.4 days). PostoperativePostoperative infective complications were seen more in the RIRS group (44%) along with the stent -related symptoms (34.6%) but had the least postoperative morbidity in the PCNL group (2.7% infection). Blood loss was greater for the PCNL group (12%) compared to the RIRS group (4%), but both groups had low requirements for blood transfusions (2.7% for PCNL and 1.3% for RIRS). Furthermore, RIRS required a greater proportion of repeat sessions (44%) for total stone clearance, especially in cases involving larger stones or increased stone density, whereas PCNL required fewer repeat procedures (2.7%). The patient satisfaction was excellent in the PCNL group (94.7%) and was slightly higher than in the RIRS group (77.3%). Conclusion: Both PCNL and RIRS are effective treatments for renal stones between 2 and 3.5 cm, with PCNL offering superior stone-free rates and greater patient satisfaction, particularly for stones with favorable anatomy. RIRS is a less invasive approach but may require multiple sessions for complete stone clearance and is associated with a higher incidence of postoperative postoperative complications. The choice of procedure should be individualized based on patient characteristics, stone features, and treatment preferences.

The purpose of this study was to examine the clinical outcomes of negative pressure wound therapy (NPWT) using reticulated open-cell foam (ROCF) in the adjunctive management of abdominal wounds with exposed and known infected synthetic mesh. A non randomised, retrospective review of medical records for 21 consecutive patients with infected abdominal wounds treated with NPWT was conducted. All abdominal wounds contained exposed synthetic mesh [composite, polypropylene (PP), or knitted polyglactin 910 (PG) mesh]. Demographic and bacteriological data, wound history, pre-NPWT and comparative post-NPWT, operative procedures and complications, hospital length of stay (LOS) and wound healing outcomes were all analysed. Primary endpoints measured were (1) hospital LOS prior to initiation of NPWT, (2) total time on NPWT, (3) hospital LOS from NPWT initiation to discharge and (4) wound closure status at discharge. A total of 21 patients with abdominal wounds with exposed, infected mesh were treated with NPWT. Aetiology of the wounds was ventral hernia repair (n = 11) and acute abdominal wall defect (n = 10). Prior to NPWT initiation, the mean hospital LOS for the composite, PP and PG meshes were 76 days (range: 21-171 days), 51 days (range: 32-62 days) and 19 days (range: 12-39 days), respectively. The mean hospital LOS following initiation of NPWT for wounds with exposed composite, PP and PG mesh were 28, 31 and 32 days, respectively. Eighteen of the 21 wounds (86%) reached full closure after a mean time of 26 days of NPWT and a mean hospital LOS of 30 days postinitiation of NPWT. Three wounds, all with composite mesh left in situ, did not reach full closure, although all exhibited decreased wound dimensions, granulating beds and decreased surface area exposure of mesh. During NPWT/ROCF, one hypoalbuminemic patient with exposed PP mesh developed an enterocutaneous fistula over a prior enterotomy site. This patient subsequently underwent total mesh extraction, takedown of the fistula and PP mesh replacement followed by reinstitution of NPWT and flap closure. In addition to appropriate systemic antibiotics and nutritional optimisation, the adjunctive use of NPWT resulted in successful closure of 86% of infected abdominal wounds with exposed prosthetic mesh. Patient hospital LOS (except those with PG mesh), operative procedures and readmissions were decreased during NPWT compared with treatment prior to NPWT. Future multi-site prospective, controlled studies would provide a strong evidence base from which treatment decisions could be made in the management of these challenging and costly cases.