Hospital charge and resource use analysis of extended-spectrum penicillin antibiotic therapy after pancreatoduodenectomy in intermediate- and high-risk patients.

BACKGROUND: We previously reported that an extended antibiotic mitigation pathway following pancreatoduodenectomy in patients with intermediate-/high-risk glands is associated with 83 % lower odds of clinically relevant postoperative pancreatic fistula (CR-POPF). We now describe associations between the pathway, resource utilization, and hospital charges. METHODS: We performed a retrospective cohort study of patients who underwent elective pancreatoduodenectomy with soft gland texture and fistula risk score (FRS) ≥3 who received standard or extended antibiotics. Hospital charges and resource utilization within 90 days of surgery were compared by CR-POPF status and antibiotic pathway. RESULTS: A total of 34 patients received extended antibiotics and 53 received standard antibiotics. In patients with CR-POPF, patients who received extended antibiotics had lower likelihood of surgical or percutaneous reintervention (75.0 % vs. 100.0 %, p = 0.022). Ninety-day postoperative charges associated with CR-POPF were higher than no CR-POPF ($60,527 vs.$25,631, p = 0.028). Our risk-based model predicted a $15,825 decrease in hospital charges per patient receiving extended antibiotics. CONCLUSIONS: CR-POPF is associated with higher 90-day hospital charges. Extended antibiotic therapy following pancreatoduodenectomy in patients with soft gland texture and FRS ≥3 is associated with fewer reinterventions in patients who develop CR-POPF. These outcomes will be formally tested in a randomized controlled trial (NCT05753735)

Machine learning-based model to predict long-term tumor control and additional interventions following pituitary surgery for Cushing\u27s disease.

OBJECTIVE: In this study, the authors aimed to establish a supervised machine learning (ML) model based on multiple tree-based algorithms to predict long-term biochemical outcomes and intervention-free survival (IFS) after endonasal transsphenoidal surgery (ETS) in patients with Cushing\u27s disease (CD). METHODS: The medical records of patients who underwent ETS for CD between 2013 and 2023 were reviewed. Data were collected on the patient\u27s baseline characteristics, intervention details, histopathology, surgical outcomes, and postoperative endocrine functions. The study\u27s primary outcome was IFS, and the therapeutic outcomes were labeled as under control or treatment failure, depending on whether additional therapeutic interventions after primary ETS were required. The decision tree and random forest classifiers were trained and tested to predict long-term IFS based on unseen data, using an 80/20 cohort split. RESULTS: Data from 150 patients, with a median follow-up period of 56 months, were extracted. In the cohort, 42 (28%) patients required additional intervention for persistent or recurrent CD. Consequently, the IFS rates following ETS alone were 83% at 3 years and 78% at 5 years. Multivariable Cox proportional hazards analysis demonstrated that a smaller tumor diameter that could be detected by MRI (hazard ratio 0.95, 95% CI 0.90-0.99; p = 0.047) was significantly associated with greater IFS. However, the lack of tumor detection on MRI was a poor predictor. The ML-based model using a decision tree model displayed 91% accuracy (95% CI 0.70-0.94, sensitivity 87.0%, specificity 89.0%) in predicting IFS in the unseen test dataset. Random forest analysis revealed that tumor size (mean minimal depth 1.67), Knosp grade (1.75), patient age (1.80), and BMI (1.99) were the four most significant predictors of long-term IFS. CONCLUSIONS: The ML algorithm could predict long-term postoperative endocrinological remission in CD with high accuracy, indicating that prognosis may vary not only with previously reported factors such as tumor size, Knosp grade, gross-total resection, and patient age but also with BMI. The decision tree flowchart could potentially stratify patients with CD before ETS, allowing for the selection of personalized treatment options and thereby assisting in determining treatment plans for these patients. This ML model may lead to a deeper understanding of the complex mechanisms of CD by uncovering patterns embedded within the data

Systems-Based Care of the Injured Child: Technical Report.

Injury is the leading cause of death and a cause of disability in children and negatively affects physical health, mental health, and quality of life in both the short- and long-term. The goal of a pediatric trauma system is to optimize the care for children within a state, regional, or national trauma system across the entire continuum of care regardless of where they live or where the traumatic event occurs. This continuum includes injury prevention, prehospital care, interfacility transport between hospitals providing different levels of care, acute and critical inpatient care, inpatient and outpatient rehabilitation, and reintegration into the community and primary care medical home. A systems-based approach, one that requires distinct elements of structure and function to perform together in an interrelated and cohesive manner to improve care quality, is essential. To improve outcomes after injury, a cohesive system must effectively provide optimal care for the right child, at the right place, at the right time across this continuum

Myocyte Damage and Mass Loss Drives Increasing Water Content, Compliance, and Survival in Septic Cardiomyopathy.

INTRODUCTION/PURPOSE: During the septic cardiomyopathy, the mechanism and relationship to outcome of changes in left ventricular (LV) end diastolic volume (EDV) and ejection fraction (EF) remains obscure. We compared serial changes in LVEF and LVEDV to successive alterations in LV wall ultrastructure, water content, and total mass to investigate whether these measures can explain their basis. METHODS: We performed cardiac magnetic resonance imaging at 0,6,18,30,42,54, and 92h post-bacterial challenge in a large-animal model (n=57) that mimics human septic cardiomyopathy. LV tissue was obtained for electron microscopy (EM) upon death and 66h in sacrificed survivors. RESULTS: Between 0-6h post-challenge, LV compliance and EDV reached its greatest decline. Non-survivors (n=18) exhibited significantly greater reductions in LVEDV, along with more myocyte edema, mitochondrial swelling and myofilament fragmentation on EM. This increased tissue damage may explain why non-survivors developed worse LV compliance and a greater decline in LVEDV, which persisted until death. From 6-30h, LVEDV significantly improved to baseline in non-survivors, while survivors experienced ∼20% increases (n=39). Concurrently, there was significant LV mass loss and increases in percent water content that were significantly associated with increases in LVEDV. This is consistent with a passive mechanism for rapidly improving LV compliance and EDV. Full recovery of EF required additional days. We hypothesize the prolonged significant mass loss over 5d reflects an active process for remodeling fragmented myofilaments, eliminating myocyte edema, and mitochondrial swelling, ultimately restoring contractile function. CONCLUSION: The septic cardiomyopathy constitutes a diffuse ultrastructural injury to myocytes with three phases. Initially, there is a decrease in LVEDV, and EF due to myocyte damage within 6h of bacterial challenge; next, the patient sees a passive LVEDV recovery from 6-30h, where LV mass loss increases relative wall percent water content, which facilitates wall compliance and LVEDV; and lastly, the patient sees mass loss beyond 30h consistent with an active repair mechanism of myocytes, returning systolic function to normal. Therefore, EDV changes are a pathophysiological biomarker for sepsis outcomes. A lower LVEDV indicates persistent unrepairable ultrastructure damage with worsening wall compliance and poorer outcomes. LVEDV dilation is a sign of near-full recovery of ultrastructure injury, augmenting wall compliance and improving outcomes. CLINICAL IMPLICATIONS: We explain herein why septic cardiomyopathy findings don\u27t have clinical implications like heart failure. Septic patients who exhibit signs of heart failure, low LVEF with high EDVs, are doing well - reflecting mild myocyte injury, effective damaged tissues clearance, increased relative LV wall water content, and compliance. This augments the LVEDV, lowering the LVEF. Septic patients who deteriorate rapidly, contrary to heart failure patients, show high/normal LVEF and low/normal LVEDV. Here, the myocyte damage is severe, leading to insufficient wall repair, and this decreased wall compliance persists, preventing the LV from dilating and making LVEDV low which ultimately raises the LVEF