To study the sensitivity and specificity of physical examination, ultrasound (US) alone, and sonopalpation (concurrent US and transoral palpation) for identification of submandibular gland (SMG) ...calculi.
Case series with prospective data collection.
Tertiary-level academic center.
Patients with suspected SMG swelling were examined by physical examination, US alone, and sonopalpation. The presence or absence and location of sialolithiasis was noted in each group. Sialendoscopy, open sialolithotomy, or sialadenectomy was performed as the gold standard for definitive diagnosis. Sensitivity and specificity for each technique was then determined.
Sixty-nine patients were identified with SMG swelling. Physical examination, US, and sonopalpation positively identified sialoliths in 49, 54, and 57 patients, respectively. Fifty-nine patients eventually demonstrated calculi. Sensitivity of physical examination, US alone, and sonopalpation for SMG calculi was 83%, 91%, and 96.6%, respectively. Specificity for physical examination was 60%, 80% for US alone, and 90% for sonopalpation. Of 59 patients with stones, 17 patients underwent purely endoscopic procedures, 36 patients underwent combined or purely transoral approaches, and 6 underwent sialadenectomy. Of the 3 modalities, only sonopalpation was able to both identify and localize pathology and guide treatment management.
US is effective in the diagnosis and management of SMG stones during sialendoscopy or sialolithotomy. Sonopalpation has increased sensitivity and specificity over US alone or physical examination not only for the detection of SMG calculi but also for localization of pathology in the ductal system.
Edema affects outcomes in Rhinoplasty. Edema and bruising influences patient satisfaction in the perioperative period.
A qualitative analysis of edema comparing piezoelectric and conventional ...osteotome, and a qualitative comparison of bruising between these methods.
A prospective cohort study of 31 aesthetic Rhinoplasty cases. Participants act as their own control measure. An osteotome is used on one side of the nasal bone and a piezoelectric is used contralaterally.
Edema is calculated by comparing a pre and post-operative 3-D image with volumetric analysis. Ecchymosis is scored and compared.
The mean volume of the piezoelectric was 1.37 cc (SD 0.87) and the mean volume of the osteotome was 1.17 cc (SD 0.70) (0.19 absolute difference 95 % CI 0.3 to 0.35, p = 0.02). Bruising scores were 0.35 points lower for the piezoelectric arm (−0.35 absolute difference 95%CI -0.7 to 0.06, p < 0.01). This corresponded to 26 % of lateral piezo osteotomies having significant bruising compared to 38 % of the lateral osteotomies using the conventional technique.
There is a difference in postoperative edema and bruising with the piezoelectric and conventional osteotome for lateral osteoetomy in Rhinoplasty. There is more edema with the piezoelectric and more ecchymosis with the conventional osteotome.
•Question: Is edema and bruising different with piezoelectric osteotomy during rhinoplasty?•Findings: Edema is greater with the piezoelectric and bruising is less with the piezoelectric.•Meaning: The piezoelectric has a different healing profile with regards to edema and bruising than the conventional osteotome in rhinoplasty.
Observational studies of anesthetic neurotoxicity may be biased because children requiring anesthesia commonly have medical conditions associated with neurobehavioral problems. This study takes ...advantage of a natural experiment associated with appendicitis, in order to determine if anesthesia and surgery in childhood were specifically associated with subsequent neurobehavioral outcomes.
We identified 134,388 healthy children with appendectomy and examined the incidence of subsequent externalizing or behavioral disorders (conduct, impulse control, oppositional defiant, or attention-deficit/hyperactivity disorder); or internalizing or mood/anxiety disorders (depression, anxiety, or bipolar disorder) when compared to 671,940 matched healthy controls as identified in Medicaid data between 2001-2018. For comparison, we also examined 154,887 otherwise healthy children admitted to the hospital for pneumonia, cellulitis, and gastroenteritis, of which only 8% received anesthesia, and compared them to 774,435 matched healthy controls. We also examined the difference-in-differences between matched appendectomy patients and their controls and matched medical admission patients and their controls.
Compared to controls, children with appendectomy were more likely to have subsequent behavioral disorders (the hazard ratio (HR) was 1.04 (95% CI 1.01, 1.06), P = 0.0010), and mood/anxiety disorders (HR: 1.15 (95% CI 1.13, 1.17), P < 0.0001). Relative to controls, children with medical admissions were also more likely to have subsequent behavioral (HR: 1.20 (95% CI 1.18, 1.22), P < 0.0001), and mood/anxiety (HR: 1.25 (95% CI 1.23, 1.27), P < 0.0001) disorders. Comparing the difference between matched appendectomy patients and their matched controls to the difference between matched medical patients and their matched controls, medical patients had more subsequent neurobehavioral problems than appendectomy patients.
Although there is an association between neurobehavioral diagnoses and appendectomy, this association is not specific to anesthesia exposure, and is stronger in medical admissions. Medical admissions, generally without anesthesia exposure, displayed significantly higher rates of these disorders than appendectomy-exposed patients.
To compare general surgery outcomes at flagship systems, flagship hospitals, and flagship hospital affiliates versus matched controls.
It is unknown whether flagship hospitals perform better than ...flagship hospital affiliates for surgical patients.
Using Medicare claims for 2018 to 2019, we matched patients undergoing inpatient general surgery in flagship system hospitals to controls who underwent the same procedure at hospitals outside the system but within the same region. We defined a "flagship hospital" within each region as the major teaching hospital with the highest patient volume that is also part of a hospital system; its system was labeled a "flagship system." We performed 4 main comparisons: patients treated at any flagship system hospital versus hospitals outside the flagship system; flagship hospitals versus hospitals outside the flagship system; flagship hospital affiliates versus hospitals outside the flagship system; and flagship hospitals versus affiliate hospitals. Our primary outcome was 30-day mortality.
We formed 32,228 closely matched pairs across 35 regions. Patients at flagship system hospitals (32,228 pairs) had lower 30-day mortality than matched control patients 3.79% vs. 4.36%, difference=-0.57% (-0.86%, -0.28%), P<0.001. Similarly, patients at flagship hospitals (15,571/32,228 pairs) had lower mortality than control patients. However, patients at flagship hospital affiliates (16,657/32,228 pairs) had similar mortality to matched controls. Flagship hospitals had lower mortality than affiliate hospitals difference-in-differences=-1.05% (-1.62%, -0.47%), P<0.001.
Patients treated at flagship hospitals had significantly lower mortality rates than those treated at flagship hospital affiliates. Hence, flagship system affiliation does not alone imply better surgical outcomes.
Background
We define a “flagship hospital” as the largest academic hospital within a hospital referral region and a “flagship system” as a system that contains a flagship hospital and its affiliates. ...It is not known if patients admitted to an affiliate hospital, and not to its main flagship hospital, have better outcomes than those admitted to a hospital outside the flagship system but within the same hospital referral region.
Objective
To compare mortality at flagship hospitals and their affiliates to matched control patients not in the flagship system but within the same hospital referral region.
Design
A matched cohort study
Participants
The study used hospitalizations for common medical conditions between 2018-2019 among older patients age ≥ 66 years. We analyzed 118,321 matched pairs of Medicare patients admitted with pneumonia (N=57,775), heart failure (N=42,531), or acute myocardial infarction (N=18,015) in 35 flagship hospitals, 124 affiliates, and 793 control hospitals.
Main Measures
30-day (primary) and 90-day (secondary) all-cause mortality.
Key Results
30-day mortality was lower among patients in flagship systems versus control hospitals that are not part of the flagship system but within the same hospital referral region (difference= -0.62%, 95% CI -0.88%, -0.37%,
P
<0.001). This difference was smaller in affiliates versus controls (-0.43%, -0.75%, -0.11%,
P
=0.008) than in flagship hospitals versus controls (-1.02%, -1.46%, -0.58%,
P
<0.001; difference-in-difference -0.59%, -1.13%, -0.05%,
P
=0.033). Similar results were found for 90-day mortality.
Limitations
The study used claims-based data.
Conclusions
In aggregate, within a hospital referral region, patients treated at the flagship hospital, at affiliates of the flagship hospital, and in the flagship system as a whole, all had lower mortality rates than matched controls outside the flagship system. However, the mortality advantage was larger for flagship hospitals than for their affiliates.
OBJECTIVE:To determine if surgery and anesthesia in the elderly may promote Alzheimerʼs Disease and Related Dementias (ADRD).
BACKGROUND:There is a substantial conflicting literature concerning the ...hypothesis that surgery and anesthesia promotes ADRD. Much of the literature is confounded by indications for surgery or has small sample size. This study examines elderly patients with appendicitis, a common condition that strikes mostly at random after controlling for some known associations.
METHODS:A matched natural experiment of patients undergoing appendectomy for appendicitis versus control patients without appendicitis using Medicare data from 2002 to 2017, examining 54,996 patients without previous diagnoses of ADRD, cognitive impairment, or neurological degeneration, who developed appendicitis between ages 68 through 77 years and underwent an appendectomy (the “Appendectomy” treated group), matching them 5:1 to 274,980 controls, examining the subsequent hazard for developing ADRD.
RESULTS:The hazard ratio (HR) for developing ADRD or death was lower in the Appendectomy group than controlsHR = 0.96 (95% CI 0.94, 0.98), P < 0.0001, (28.2% in Appendectomy versus 29.1% in controls, at 7.5 years). The HR for death was 0.97 (0.95, 0.99), P = 0.002, (22.7% versus 23.1% at 7.5 years). The HR for developing ADRD alone was 0.89 (0.86, 0.92), P < 0.0001, (7.6% in Appendectomy versus 8.6% in controls, at 7.5 years). No subgroup analyses found significantly elevated rates of ADRD in the Appendectomy group.
CONCLUSIONS:In this natural experiment involving 329,976 elderly patients, exposure to appendectomy surgery and anesthesia did not increase the subsequent rate of ADRD.
Evaluate the authorship, content, quality, and readability of information on Transoral Robotic Surgery (TORS) available to patients online.
The technical search term “TORS Surgery” and layperson's ...term “robotic surgery of the mouth” were utilized to conduct a search of the top 50 websites on Google, Bing, and Yahoo. Websites were evaluated according to the HONcode evaluation of content and quality, and readability was assessed using the Flesch Reading Ease Formula, Flesch-Kincaid Grade Level Formula, SMOG readability formula, Coleman Liau Index formula, and Gunning Fog Index. Statistical analysis was conducted using the Fisher Freeman- Halton test to compare differences in authorship, quality, and content between the three search engines and the Fisher exact test was used to determine if there was a difference in these variables between the two search terms.
Overall, websites were predominantly from academic institutions with 97% mentioning benefits of TORS with 24% mentioning risks. 45% of TORS websites had no description of the TORS procedure, while 62% allowed individuals to make appointments. There was a significant difference in authorship with the layperson's terms yielding more news sources, but there were no significant differences in quality and content of information elicited through the technical and layperson search terms. The mean readability scores were Flesch Kincaid Grade Level 13.81(±3.32), Gunning-Fog Index 16.51(±3.39), SMOG 12.53(±2.40), and Automated Readability Index 14.05 (±4.17).
Current online information on TORS surgery may not provide balanced information for patients to make informed healthcare decisions. The current readability of online information regarding TORS far exceeds the average literacy level of average American adults.
Multimorbidity in surgery is common and associated with worse postoperative outcomes. However, conventional multimorbidity definitions (≥2 comorbidities) label the vast majority of older patients as ...multimorbid, limiting clinical usefulness. We sought to develop and validate better surgical specialty-specific multimorbidity definitions based on distinct comorbidity combinations.
We used Medicare claims for patients aged 66 to 90 years undergoing inpatient general, orthopaedic, or vascular surgery. Using 2016 to 2017 data, we identified all comorbidity combinations associated with at least 2-fold (general/orthopaedic) or 1.5-fold (vascular) greater risk of 30-day mortality compared with the overall population undergoing the same procedure; we called these combinations qualifying comorbidity sets. We applied them to 2018 to 2019 data (general = 230,410 patients, orthopaedic = 778,131 patients, vascular = 146,570 patients) to obtain 30-day mortality estimates. For further validation, we tested whether multimorbidity status was associated with differential outcomes for patients at better-resourced (based on nursing skill-mix, surgical volume, teaching status) hospitals vs all other hospitals using multivariate matching.
Compared with conventional multimorbidity definitions, the new definitions labeled far fewer patients as multimorbid: general = 85.0% (conventional) vs 55.9% (new) (p < 0.0001); orthopaedic = 66.6% vs 40.2% (p < 0.0001); and vascular = 96.2% vs 52.7% (p < 0.0001). Thirty-day mortality was higher by the new definitions: general = 3.96% (conventional) vs 5.64% (new) (p < 0.0001); orthopaedic = 0.13% vs 1.68% (p < 0.0001); and vascular = 4.43% vs 7.00% (p < 0.0001). Better-resourced hospitals offered significantly larger mortality benefits than all other hospitals for multimorbid vs nonmultimorbid general and orthopaedic, but not vascular, patients (general surgery difference-in-difference = -0.94% -1.36%, -0.52%, p < 0.0001; orthopaedic = -0.20% -0.34%, -0.05%, p = 0.0087; and vascular = -0.12% -0.69%, 0.45%, p = 0.6795).
Our new multimorbidity definitions identified far more specific, higher-risk pools of patients than conventional definitions, potentially aiding clinical decision-making.
