Factors associated with time to laparoscopic cholecystectomy for acute cholecystitis

AIM: To determine patient and process of care factors associated with performance of timely laparoscopic cholecystectomy for acute cholecystitis. METHODS: A retrospective medical record review of 88 consecutive patients with acute cholecystitis was conducted. Data collected included demographic data, co-morbidities, symptoms and physical findings at presentation, laboratory and radiological investigations, length of stay, complications, and admission service (medical or surgical). Patients not undergoing cholecystectomy during this hospitalization were excluded from analysis. Hierarchical generalized linear models were constructed to assess the association of pre-operative diagnostic procedures, presenting signs, and admitting service with time to surgery.RESULTS: Seventy cases met inclusion and exclusion criteria, among which 12 were admitted to the medical service and 58 to the surgical service. Mean ± SD time to surgery was 39.3 ± 43 h, with 87% of operations performed within 72 h of hospital arrival. In the adjusted models, longer time to surgery was associated with number of diagnostic studies and endoscopic retrograde cholangio-pancreatography (ERCP, P = 0.01) as well with admission to medical service without adjustment for ERCP (P < 0.05). Patients undergoing both magnetic resonance cholangiopancreatography (MRCP) and computed tomography (CT) scans experienced the longest waits for surgery. Patients admitted to the surgical versus medical service underwent surgery earlier (30.4 ± 34.9 vs 82.7 ± 55.1 h, P < 0.01), had less post-operative complications (12% vs 58%, P < 0.01), and shorter length of stay (4.3 ± 3.4 vs 8.1 ± 5.2 d, P < 0.01).CONCLUSION: Admission to the medical service and performance of numerous diagnostic procedures, ERCP, or MRCP combined with CT scan were associated with longer time to surgery. Expeditious performance of ERCP and MRCP and admission of medically stable patients with suspected cholecystitis to the surgical service to speed up time to surgery should be considered.

Use of percutaneous nephrostomy and ureteral stenting in management of ureteral obstruction

The management options for ureteral obstruction are diverse, including retrograde ureteral stent insertion or antegrade nephrostomy placement, with or without eventual antegrade stent insertion. There is currently no consensus on the ideal treatment or treatment pathway for ureteral obstruction owing, in part, to the varied etiologies of obstruction and diversity of institutional practices. Additionally, different clinicians such as internists, urologists, oncologists and radiologists are often involved in the care of patients with ureteral obstruction and may have differing opinions concerning the best management strategy. The purpose of this manuscript was to review available literature that compares percutaneous nephrostomy placement vs ureteral stenting in the management of ureteral obstruction from both benign and malignant etiologies.

Lean body mass index is a marker of advanced tumor features in patients with hepatocellular carcinoma

BACKGROUND Obesity is an independent risk factor for the development of hepatocellular carcinoma(HCC)and may influence its outcomes.However,after diagnosis of HCC,like other malignancies,the obesity paradox may exist where higher body mass index(BMI)may in fact confer a survival benefit.This is frequently observed in patients with advanced HCC and cirrhosis,who often present late with advanced tumor features and cancer related weight loss.AIM To explore the relationship between BMI and survival in patients with cirrhosis and HCC.METHODS This is a retrospective cohort study of over 2500 patients diagnosed with HCC between 2009-2019 at two United States academic medical centers.Patient and tumor characteristics were extracted manually from medical records of each institutions'cancer registries.Patients were stratified according to BMI classes:<25 kg/m^(2)(lean),25-29.9 kg/m^(2)(overweight),and>30 kg/m^(2)(obese).Patient and tumor characteristics were compared according to BMI classification.We performed an overall survival analysis using Kaplan Meier by the three BMI classes and after adjusting for Milan criteria.A multivariable Cox regression model was then used to assess known risk factors for survival in patients with cirrhosis and HCC.RESULTS A total of 2548 patients with HCC were included in the analysis of which 11.2%(n=286)were classified as noncirrhotic.The three main BMI categories:Lean(n=754),overweight(n=861),and obese(n=933)represented 29.6%,33.8%,and 36.6%of the total population overall.Within each BMI class,the non-cirrhotic patients accounted for 15%(n=100),12%(n=94),and 11%(n=92),respectively.Underweight patients with a BMI<18.5 kg/m^(2)(n=52)were included in the lean cohort.Of the obese cohort,42%(n=396)had a BMI≥35 kg/m^(2).Out of 2262 patients with cirrhosis and HCC,654(29%)were lean,767(34%)were overweight,and 841(37%)were obese.The three BMI classes did not differ by age,MELD,or Child-Pugh class.Chronic hepatitis C was the dominant etiology in lean compared to the overweight and obese patients(71%,62%,49%,P<0.001).Lean patients had significantly larger tumors compared to the other two BMI classes(5.1 vs 4.2 vs 4.2 cm,P<0.001),were more likely outside Milan(56%vs 48%vs 47%,P<0.001),and less likely to undergo transplantation(9%vs 18%vs 18%,P<0.001).While both tumor size(P<0.0001)and elevated alpha fetoprotein(P<0.0001)were associated with worse survival by regression analysis,lean BMI was not(P=0.36).CONCLUSION Lean patients with cirrhosis and HCC present with larger tumors and are more often outside Milan criteria,reflecting cancer related cachexia from delayed diagnosis.Access to care for hepatitis C virus therapy and liver transplantation confer a survival benefit,but not overweight or obese BMI classifications.

Role of insulin resistance in uric acid nephrolithiasis

Metabolic syndrome has been implicated in the pathogenesis of uric acid stones.Although not completely understood,its role is supported by many studies demonstrating increased prevalence of uric acid stones in patients with metabolic syndrome and in particular insulin resistance,a major component of metabolic syndrome.This review presents epidemiologic studies demonstrating the association between metabolic syndrome and nephrolithiasis in general as well as the relationship between insulin resistance and uric acid stone formation,in particular.We also review studies that explore the pathophysiologic relationship between insulin resistance and uric acid nephrolithiasis.

Mis-estimation of coronary lesions and rectification by SYNTAX score feedback for coronary revascularization appropriateness

Background::Imprecise interpretation of coronary angiograms was reported and resulted in inappropriate revascularization.Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery(SYNTAX)score is a comprehensive system to evaluate the complexity of the overall lesions.We hypothesized that a real-time SYNTAX score feedback from image analysts may rectify the mis-estimation and improve revascularization appropriateness in patients with stable coronary artery disease(CAD).Methods::In this single-center,historical control study,patients with stable CAD with coronary lesion stenosis≥50%were consecutively recruited.During the control period,SYNTAX scores were calculated by treating cardiologists.During the intervention period,SYNTAX scores were calculated by image analysts immediately after coronary angiography and were provided to cardiologists in real-time to aid decision-making.The primary outcome was revascularization deemed inappropriate by Chinese appropriate use criteria for coronary revascularization.Results::A total of 3245 patients were enrolled and assigned to the control group(08/2016-03/2017,n=1525)or the intervention group(03/2017-09/2017,n=1720).For SYNTAX score tertiles,17.9%patients were overestimated and 4.3%were underestimated by cardiologists in the control group.After adjustment,inappropriate revascularization significantly decreased in the intervention group compared with the control group(adjusted odds ratio[OR]:0.83;95%confidence interval[CI]:0.73-0.95;P=0.007).Both inappropriate percutaneous coronary intervention(adjusted OR:0.82;95%CI:0.74-0.92;P<0.001)and percutaneous coronary intervention utilization(adjusted OR:0.88;95%CI:0.79-0.98;P=0.016)decreased significantly in the intervention group.There was no significant difference in 1-year adverse cardiac events between the control group and the intervention group.Conclusions::Real-time SYNTAX score feedback significantly reduced inappropriate coronary revascularization in stable patients with CAD.Clinical trial registration::Nos.NCT03068858 and NCT02880605;https://www.clinicaltrials.gov.

The future of journals

The launch of a new journal is an opportunity to innovate.Bringing fresh ideas and practices to academic scientific communication is an implicit responsibility for a new journal focusing on health care science and the improvement of health care and health outcomes.

China Patient-centered Evaluative Assessment of Cardiac Events Prospective Study of Acute Myocardial Infarction： Study Design

Background： Despite the rapid growth in the incidence of acute myocardial infarction （AMI） in China, there is limited information about patients＇ experiences after AMI hospitalization, especially on long-tern1 adverse events and patient-reported outcomes （PROs）. Methods： The China Patient-centered Evaluative Assessment of Cardiac Events （PEACE）-Prospective AMI Study will enroll 4000 consecutive AM I patients from 53 diverse hospitals across China and follow them longitudinally for 12 months to docunlent their treatment, recovery, and outcomes. Details of patients＇ medical history, treatment, and in-hospital outcomes are abstracted from medical charts. Comprehensive baseline interviews are being conducted to characterize patient demographics, risk factors, presentation, and healthcare utilization. As part of these interviews, validated instruments are administered to measure PROs, including quality of life, symptoms, mood, cognition, and sexual activity. Follow-up interviews, measuring PROs, medication adherence, risk factor control, and collecting hospitalization events are conducted at 1, 6, and 12 months after discharge. Supporting documents for potential outcomes are collected for adjudication by clinicians at the National Coordinating Center. Blood and urine samples are also obtained at baseline, 1 - and 12-month follow-up. In addition, we are conducting a survey of participating hospitals to characterize their organizational characteristics. Conclusion： The China PEACE-Prospective AMI study will be uniquely positioned to generate new information regarding patient＇s experiences and outcomes alter AMI in China and seiwe as a foundation for quality improveinent activities.

Admission Glucose and In-hospital Mortality after Acute Myocardial Infarction in Patients with or without Diabetes： A Cross-sectional Study

Background：Hyperglycemia on admission has been found to elevate risk for mortality and adverse clinical events after acute myocardial infarction （AMI）,but there are evidences that the relationship of blood glucose and mortality may differ between diabetic and nondiabetic patients.Prior studies in China have provided mixed results and are limited by statistical power.Here,we used data from a large,nationally representative sample of patients hospitalized with AMI in China in 2001,2006,and 2011 to assess if admission glucose is of prognostic value in China and if this relationship differs depending on the presence or absence of diabetes.Methods：Using a nationally representative sample of patients with AMI in China in 2001,2006,and 2011,we categorized patients according to their glucose levels at admission （〈3.9,3.9-7.7,7.8-11.0,and ≥11.1 mmol/L） and compared in-hospital mortality across these admission glucose categories,stratified by diabetes status.Among diabetic and nondiabetic patients,separately,we employed logistic regression to assess the differences in outcomes across admission glucose levels while adjusting for the same covariates.Results：Compared to patients with euglycemia （5.8%）,patients with moderate hyperglycemia （13.1%,odds ratio [OR] =2.44,95% confidence interval [CI,2.08-2.86]）,severe hyperglycemia （21.5%,OR =4.42,95% CI [3.78-5.18]）,and hypoglycemia （13.8%,OR =2.59,95% CI [1.68-4.00]）,all had higher crude in-hospital mortality after AMI regardless of the presence of recognized diabetes mellitus.After adjustment for patients＆#39; characteristics and clinical status,however,the relationship between admission glucose and in-hospital mortality was different for diabetic and nondiabetic patients （P for interaction =0.045）.Among diabetic patients,hypoglycemia （OR =3.02,95% CI [1.20-7.63]）,moderate hyperglycemia （OR =1.75,95% CI [1.04-2.92]）,and severe hyperglycemia （OR =2.97,95% CI [1.87-4.71]） remained associated with elevated risk for mortality,but among nondiabetic patients,only patients with moderate hyperglycemia （OR =2.34,95% CI [1.93-2.84]） and severe hyperglycemia （OR =3.92,95% CI [3.04-5.04]） were at elevated mortality risk and not hypoglycemia （OR =1.12,95% CI [0.60-2.08]）.This relationship was consistent across different study years （P for interaction =0.900）.Conclusions：The relationship between admission glucose and in-hospital mortality differs for diabetic and nondiabetic patients.Hypoglycemia was a bad prognostic marker among diabetic patients alone.The study results could be used to guide risk assessment among AMI patients using admission glucose.Trial Registration：www.clinicaltrials.gov,NCT01624883;https：// clinicaltrials.gov/ct2/show/NCT01624883.

中国冠心病医疗结果评价和临床转化研究：回顾性经皮冠状动脉造影及介入治疗研究方案

研究背景既往10年，中国经皮冠状动脉介入（PCI）手术量增长超过20倍。在此期间，我们面临着心血管疾病负担的日益增长以及医疗系统的不断变革，却对不同医院、不同地区和不同年份内接受PCI治疗患者的诊疗模式和结局知之甚少。方法与设计利用“冠心病医疗结果评价和临床转化研究（Patient-centered Evaluative Assessment of Cardiac Events,China PEACE）”的协作网络，回顾性经皮冠状动脉造影及介入治疗研究（以下简称ChinaPEACE回顾性CathPCI研究）将人选具有全国代表性的11900例住院期间行冠状动脉造影或PCI的病例，病例来自55家医院，于2001、2006和2011年期间住院。研究采用两阶段整群抽样设计，采用根据经济地理区域分层抽样的方法选择协作单位和患者。研究的协调中心将在病例确定、病例信息提取和数据管理的各个阶段监测数据质量。研究旨在定量评价既往十年间中国接受冠状动脉造影或PCI患者的临床特征、诊疗模式和院内结局（包括死亡、治疗引起的并发症和医疗花费）。此外，研究将进一步分析不同医院、地区及研究年份间，患者治疗模式和结局的差异。伦理审批和结果发布ChinaPEACE研究旨在将研究结果转化为改善患者诊疗和预后的临床实践。该研究的方案获得了中国国家心血管病中心伦理委员会和协作医院伦理委员会的批准。将与协作医院、政府决策部门和科研人员共享研究结果，以期促进中国医疗质量的监控和提高，并为冠状动脉造影和PCI治疗资源的高效合理配置提供可靠依据。

降脂治疗需转变观念

Harlan Krumholz和Rodney Hayward认为预防心脏病学应当尽可能地基于能够改善患者结局的策略，而非仅关注生化标志物。

研究预印本对改善患者的医疗保健有益吗?

Harlan M Krumholz和Joseph S Ross认为,在未经同行评议的情况下,尽早发表研究成果能加速知识传播并改变临床实践。Catherine M Otto却担心无质量控制的出版物可能混淆视听且有损患者健康。