Adoption of a Urologic Oncology Perioperative Surgical Home is Associated with Decreased Total Length of Stay: A Pilot Study.

INTRODUCTION: Urologists partnered with anesthesiologists to implement a model of perioperative and postoperative care known as the multidisciplinary perioperative surgical home in order to improve the quality and efficiency of care. We describe early outcomes associated with implementation of the perioperative surgical home. METHODS: Retrospective chart review was performed of patients at a single institution undergoing radical prostatectomy, radical cystectomy, partial nephrectomy and radical nephrectomy from January 2014 to March 2016. Outcomes measured were length of stay and 30-day reoperation, readmission, unexpected intensive care unit admission and mortality rates. Statistical analysis was performed using the independent samples Mann-Whitney U test and Fisher exact test with p <0.05 considered significant. Univariate and multivariate analyses were performed to determine whether implementation of the perioperative surgical home was associated with improved outcomes. RESULTS: Length of hospital stay decreased from 4.79 to 3.19 days and 30-day complication rate decreased from 15.3% to 5.7% after implementation of the perioperative surgical home (p <0.01 for both). There was no change in the 30-day readmission rate. On multivariate analysis surgery occurring after perioperative surgical home implementation was associated with decreased length of stay (p = 0.008). The direct cost savings resulting from this length of stay reduction totaled $1,245,585 for the study period. CONCLUSIONS: The adoption of a perioperative surgical home is associated with a significantly decreased postoperative hospital stay and 30-day complication rate for urologic oncology cases.

Recurrent Stevens-Johnson syndrome secondary to herpes simplex: a follow up on a successful management program.

Herpes Simplex virus has been implicated as a cause of sporadic and recurrent erythema multiforme and Stevens-Johnson syndrome. Acyclovir has been used with success rates of 55% in treating these episodes. We have previously described and reported a successful management protocol for prevention of recurrent Stevens-Johnson syndrome due to herpes simplex virus reactivation in a 36-year-old white male. Four years later we describe the outcome of initiating this management protocol in the same patient for 17 episodes of recurrent herpes simplex virus stomatitis. Continuous low dose acyclovir with the prompt institution of a regimen of prednisone and higher dose acyclovir successfully prevented the prolonged duration of recurrent herpes simplex virus stomatitis and progression to Stevens-Johnson syndrome.

Management of asthma in the geriatric population.

Asthma remains an important cause of morbidity and mortality for patients of all ages, but it may be of particular concern in geriatric patients as the aging population increases. Asthma may vary in severity from mild to such severity that ventilatory support is required. However, with proper medical management, asthma of most patients can be adequately controlled. Although there are similarities in managing younger patients with asthma, special problems occur in the geriatric population.

The outcome of Stevens-Johnson syndrome treated with corticosteroids.

Stevens-Johnson Syndrome (SJS) may have considerable morbidity and mortality. Traditional management has been supportive with or without corticosteroids, and we have previously reported our successful experience treating 41 SJS patients with corticosteroids. We now report the outcome of prospectively treating 13 additional patients with SJS with high doses of corticosteroids. Thirteen consecutive patients with SJS were treated with corticosteroids at diagnosis. Their clinical course and outcomes were analyzed. Drug reactions were potential precipitants of SJS in 12 patients. The percent of skin involvement ranged from 30% to 90% with eight patients having greater than 80% involvement. Bullous lesions were seen in two patients. All patients made a complete recovery. Corticosteroid therapy may be lifesaving in these patients; and in our experience, early management of SJS with high dose corticosteroids has been very effective and associated with a full recovery.

Recurrent dermopathy after remission of Stevens-Johnson syndrome secondary to mild dermal trauma.

We report on three patients who had an apparent recurrence of the dermatitis of Stevens-Johnson Syndrome (SJS) after remission had been induced with corticosteroids. The recurrences were related to mild trauma to the skin, including the Red Man Syndrome, after vancomycin in two patients. Both responded to corticosteroids, and vancomycin could be continued with modification in the rate of infusion. The third patient had dry, pruritic skin and the exacerbation of SJS appeared related to the trauma associated with intense scratching. A post SJS inflammatory dermatitis may occur after remission of SJS secondary to cutaneous trauma. This recurrent SJS dermopathy is rapidly responsive to moderate dose corticosteroid therapy.

Stevens-Johnson syndrome presenting as intravenous line sepsis.

A 25-year-old Hispanic female with insulin dependent diabetes mellitus (IDDM) and endstage renal disease on chronic hemodialysis was hospitalized with paroxysms of fever and chills for a day. A day after starting piperacillin for presumed intravascular line infection, she developed a maculopapular dermatitis and abnormal liver function tests, at which point the drug was discontinued. However, the rash persisted for 10 days, after which it progressively worsened. She continued to have high fevers, abnormal liver function tests, and marked leukocytosis, despite multiple negative cultures and other nondiagnostic examinations. She was treated as a patient with sepsis of unknown etiology and received multiple antibiotics on an empiric basis without response. A diagnosis of Stevens-Johnson syndrome was then made based on the triad of cutaneous dermatitis, mucosal, and hepatic involvement. She received high dose corticosteroids and her fever, dermatitis, mucosal lesions, leukocytosis, and abnormal liver function tests improved dramatically.

Outcome of cough variant asthma treated with inhaled steroids.

BACKGROUND: Cough variant asthma is defined as a persistent nonproductive cough with minimal wheezing or dyspnea. The uncontrolled coughing may interfere with sleep, work, and social activities. Cough precipitating fecal or urinary incontinence can be extremely distressing. The diagnosis is established within 1 to 2 weeks by a trial of prednisone, 30 mg a day. The cough will be controlled within that time and subsequent management can consist of inhaled corticosteroids. OBJECTIVE: To evaluate the course of ten patients with cough variant asthma and their response to inhaled corticosteroids. METHODS: Retrospective analysis of the presentation, diagnosis, course, and response to oral and inhaled steroids in ten patients with cough variant asthma. RESULTS: Ten patients whose chief complaint was persistent debilitating cough for periods of 2 months to 20 years underwent a diagnostic and therapeutic trial of prednisone as previously described. At a mean follow-up period of 28 months all were free of debilitating cough. Eight of ten patients were still receiving inhaled steroids and two needed low dose alternate day oral steroid therapy. Two patients had complete remission of symptoms. None required daily inhaled or oral bronchodilators and there were no hospital admissions for respiratory symptoms. CONCLUSIONS: Inhaled corticosteroid therapy after a diagnostic trial of oral steroids is effective for long-term control of cough variant asthma.