Postoperative Antibiotics And Time To Reach Discharge Criteria After Appendectomy For Complex Appendicitis

Background: Postoperative antibiotic treatment is indicated for 3 – 5 days following appendectomy for complex appendicitis. However, meeting discharge criteria may allow for safe discontinuation of antibiotics and discharge. This study assessed the association between time to reach discharge criteria and duration of postoperative antibiotic use and length of hospital stay. Methods: This was a multicenter retrospective cohort study including patients who underwent appendectomy for complex appendicitis and received postoperative antibiotics for >24 hours. Main outcome measures were time to reach discharge criteria, duration of postoperative antibiotic use, length of hospital stay and postoperative infectious complications. Discharge criteria were defined as absence of fever (temperature ≤38°C) for 24 hours, ability to tolerate oral intake and pain controlled by oral analgesics.Results: A total of 124 patients were included between May 2014 and January 2015. Median time to reach discharge criteria was 2 days (interquartile range 1 – 3). Postoperative antibiotics duration and hospital stay were 5 (IQR 3 – 5) and 5 (IQR 4 – 6) days, respectively. Infectious complications occurred in 15 of 124 patients (12%) and was not different between patients reaching discharge criteria before or after 2 postoperative days.Conclusions: Discharge criteria were met by a median of 2 days after appendectomy for complex appendicitis. This suggests that postoperative antibiotics and hospital stay can be reduced without an increase in infectious complications. In daily practice this is not done, prescribed antibiotics are not reduced in total days given. Prospective studies that evaluate limited postoperative antibiotic use, based on these criteria, are necessary.

Opioid Use Disorder in Patients Undergoing Primary 1- to 2-Level Anterior Cervical Discectomy and Fusion Is Associated With Longer In-Hospital Lengths of Stay and Higher Rates of Readmissions, Complications, and Costs of Care

Study Design: Retrospective study. Objective: To determine whether opioid use disorder (OUD) patients undergoing 1- to 2-level anterior cervical discectomy and fusion (1-2ACDF) have higher rates of: 1) in-hospital lengths of stay (LOS); 2) readmissions; 3) complications; and 4) costs. Methods: OUD patients undergoing primary 1-2ACDF were identified within the Medicare database and matched to a control cohort in a 1:5 ratio by age, sex, and medical comorbidities. The query yielded 80,683 patients who underwent 1-2 ACDF with (n = 13,448) and without (n = 67,235) OUD. Outcomes analyzed included in-hospital LOS, 90-day readmission rates, 90-day medical complications, and costs. Multivariate logistic regression analyses were used to calculate odds-ratios (OR) for medical complications and readmissions. Welch’s t-test was used to test for significance for LOS and cost between the cohorts. An alpha value less than 0.002 was considered statistically significant. Results: OUD patients were found to have significantly longer in-hospital LOS compared to their counterparts (3.41 vs. 2.23-days, P < .0001), in addition to higher frequency and odds of requiring readmissions (21.62 vs. 11.57%; OR: 1.38, P < .0001). Study group patients were found to have higher frequency and odds of developing medical complications (0.88 vs. 0.19%, OR: 2.80, P < .0001) and incurred higher episode of care costs ($20,399.62 vs. $16,812.14, P < .0001). Conclusion: The study can help to push orthopaedic surgeons in better managing OUD patients pre-operatively in terms of safe discontinuation and education of opioid drugs and their effects on complications, leading to more satisfactory outcomes.

Antiarrhythmic Drug Therapy for Rhythm Control in Atrial Fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and affects over 33 million people worldwide. AF is associated with stroke and systemic thromboembolism, unpleasant symptoms and reduced quality of life, heart failure, and increased mortality, and treatment of AF and its complications are associated with significant cost. Antiarrhythmic drugs (AADs) can suppress AF, allowing long-term maintenance of sinus rhythm, and have the potential to relieve symptoms and reverse or prevent adverse effects associated with AF. However, large randomized controlled studies evaluating use of AADs have not demonstrated a clear benefit to maintaining sinus rhythm, and AADs often have significant limitations, including a modest rate of overall success at maintaining sinus rhythm, frequent side effects, and potentially life-threatening toxicities. Although some of the currently available AADs have been available for almost 100 years, better tolerated and more efficacious AADs have recently been developed both for long-term maintenance of sinus rhythm and for chemical cardioversion of AF to sinus rhythm. Advances in automated AF detection with cardiac implantable electronic devices have suggested that AADs might be useful for suppressing AF to allow safe discontinuation of anticoagulation in select patients who are in sinus rhythm for prolonged periods of time. AADs may also have synergistic effects with catheter ablation of AF. This review summarizes the pharmacology and clinical use of currently available AADs for treatment of AF and discusses novel AADs and future directions for rhythm control in AF.

Treatment Cessation in Chronic Myeloid Leukemia As a Part of Treatment Process: Toxicity Determined and Active Stop of Tyrosine Kinase Inhibitors

Background: Clinical trials demonstrate a safe discontinuation possibility of tyrosine kinase inhibitors (TKI) in patients with deep molecular response (MR). However reasons and indications for TKI cessation as a part of treatment process have not been studied. Aims: To evaluate the eligibility of long term TKI cessation in CML patients with deep and long lasting MR. To describe the reasons of stopping therapy, principles and terms of observation without treatment, preserving and restoring of MR. Methods: We summarized retrospectively and prospectively 25 TKI discontinuation cases in 2 clinics of Russian Federation (Moscow, St.Petersburg, 2008-2014). Inclusion criteria were: 1) Ph+CML 2) MR4 (BCR-ABL<0,01%) for >12 months confirmed by >2 consecutive analyses 3) discontinuation of TKI treatment. Chronic phase (CP)/accelerated phase (AP) at diagnosis was 24/1. Sokal score for CP patients was 15/8/1 for low/intermediate/high risl group. Therapy before discontinuation was the following: imatinib 1st line (n=16), 2nd generation TKI (TKI2) 2nd-3rd line (n=9): 5 dasatinib/ 4 nilotinib. Me TKI duration was 7,2 (range 2,5-13) years, Me MR4 duration was 50 (range 12-97) months. IFN before TKI was received by 13(52%) of 25 patients for Me 18 months (2-60 months). Results: We specify 2 reasons of TKI discontinuation: 1) adverse events (AE) of TKI (Toxicity Group), n=18 2) self decision of patients (Active Group), n=7 (Table 1). Table 1. Characteristics of CML patients according to reason of stopping TKI (n=25) Toxicity Group (n=18) Active Group (n=7) Ме of age, years (min-max) 55 (27-74) 36 (23-58) Ratio male/female (m:f) 9m:9f 3m:4f Ме duration of TKI therapy, years (min-max) 5,9 (2,5-13) 8,6 (4,4-10,1) Ме duration of МО4 at treatment cessation, months (min-max) 41 (12-97) 67 (33-79) In Toxicity Group therapy was stopped for 1) AE grade 1-3 in 5 of 18 patients: unstable angina (2), hepatotoxicity (1), acute renal failure (1), menstrual dysfunction and infections (1); 2) AE grade 1-2 in 13 of 18 patients including recurrent or long lasting: fatigue, edema, arthralgia, muscle cramps, diarrhea, recurrent pleural effusion. The key clinical decision was not to restart TKI after AE termination and to continue monitoring of BCR-ABL transcript levels by RQ-PCR. For Active Group self-made discontinuation was in 7 patients with long lasting MR4 due to knowledge of safe discontinuation (4) and for conception (3). In 6 of 7 patients BCR-ABL monitoring was performed, 1 patient refused from monitoring. Treatment was restarted at major molecular response (MMR) loss (BCR-ABL>0,1%) or by decision of physician. In case of severe AE the patients were switched to alternative TKI. Thirteen (52%) of 25 patients were observed without treatment for Me 23 months (6-77 months), in 12 MR4 was maintained, 1 patient being off treatment for 54 months refused from monitoring (Active Group). Therapy was resumed in 10 patients with MMR loss and in 2 without MMR loss, by physician decision. All MMR loss cases occurred within first 6 months, no CML progression observed. Response restoration to MR4 was in 8 of 10 patients in 3-16 months, in other 2 it is early to estimate Summary/Conclusion: Observation without therapy may become an option in CML patients with mostly low/intermediate Sokal risk group, stable MR4 and recurrent/severe TKI toxicity. Self declared decisions of young patients with durable deep MR should be accompanied by regular RQ-PCR especially within first 6 months after TKI discontinuation. Resuming therapy at MMR loss shows to be safe. Disclosures No relevant conflicts of interest to declare.