Retinal dystrophy (RD) is a heterogeneous group of hereditary diseases caused by loss of photoreceptor function and contributes significantly to the etiology of blindness globally but especially in ...the industrialized world. The extreme locus and allelic heterogeneity of these disorders poses a major diagnostic challenge and often impedes the ability to provide a molecular diagnosis that can inform counseling and gene-specific treatment strategies. In a large cohort of nearly 150 RD families, we used genomic approaches in the form of autozygome-guided mutation analysis and exome sequencing to identify the likely causative genetic lesion in the majority of cases. Additionally, our study revealed six novel candidate disease genes (C21orf2, EMC1, KIAA1549, GPR125, ACBD5, and DTHD1), two of which (ACBD5 and DTHD1) were observed in the context of syndromic forms of RD that are described for the first time.
IMPORTANCE: Earlier studies on the cost of muscle-invasive bladder cancer treatments lack granularity and are limited to 180 days. OBJECTIVE: To compare the 1-year costs associated with trimodal ...therapy vs radical cystectomy, accounting for survival and intensity effects on total costs. DESIGN, SETTING, AND PARTICIPANTS: This population-based cohort study used the US Surveillance, Epidemiology, and End Results–Medicare database and included 2963 patients aged 66 to 85 years who had received a diagnosis of clinical stage T2 to T4a muscle-invasive bladder cancer from January 1, 2002, through December 31, 2011. The data analysis was performed from March 5, 2018, through December 4, 2018. MAIN OUTCOMES AND MEASURES: Total Medicare costs within 1 year of diagnosis following radical cystectomy vs trimodal therapy were compared using inverse probability of treatment–weighted propensity score models that included a 2-part estimator to account for intrinsic selection bias. RESULTS: Of 2963 participants, 1030 (34.8%) were women, 2591 (87.4%) were white, 129 (4.4%) were African American, and 98 (3.3%) were Hispanic. Median costs were significantly higher for trimodal therapy than radical cystectomy in 90 days ($83 754 vs $68 692; median difference, $11 805; 95% CI, $7745-$15 864), 180 days ($187 162 vs $109 078; median difference, $62 370; 95% CI, $55 581-$69 160), and 365 days ($289 142 vs $148 757; median difference, $109 027; 95% CI, $98 692-$119 363), respectively. Outpatient care, radiology, medication expenses, and pathology/laboratory costs contributed largely to the higher costs associated with trimodal therapy. On inverse probability of treatment–weighted adjusted analyses, patients undergoing trimodal therapy had $136 935 (95% CI, $122 131-$152 115) higher mean costs compared with radical cystectomy 1 year after diagnosis. CONCLUSIONS AND RELEVANCE: Compared with radical cystectomy, trimodal therapy was associated with higher costs among patients with muscle-invasive bladder cancer. The differences in costs were largely attributed to medication and radiology expenses associated with trimodal therapy. Extrapolating cost figures resulted in a nationwide excess spending of $468 million for trimodal therapy compared with radical cystectomy for patients who received a diagnosis of bladder cancer in 2017.
We sought to compare the effectiveness of narrow- versus broad-spectrum antibiotics (abx) in preventing infectious complications in adults with acute appendicitis treated with appendectomy.
In this ...post hoc analysis of a prospective multicenter observational study of appendicitis in adults (≥18 y) conducted from January 2017 to June 2018, we included only patients with simple appendicitis. Subjects were grouped based on receipt of broad-spectrum or narrow-spectrum abx before and/or after appendectomy. Outcomes compared were surgical site infection, intra-abdominal abscess, secondary interventions (percutaneous drainage or operation), emergency department (ED) visits, 30-d readmission, and hospital length of stay.
A total of 2336 subjects were analyzed. In comparing narrow (n = 778) versus broad (n = 1558) groups, there were no differences in male sex (53% versus 54%, P = 0.704), white blood cell (13.0 ± 3.9 versus 13.4 ± 4.5, P = 0.05), Alvarado score (6 5-7 versus 6 5-7, P = 0.25), or Charlson comorbidity index (0 0-1 versus 0 0-1, P = 0.09). A total of 688 (29%) received postoperative abx, 184 (24%) narrow and 504 (32%) broad, P < 0.001 for a median 5 2-7 d 42 (23%) narrow and 235 (47%) broad, P < 0.001. There were no significant differences between narrow and broad groups in surgical site infection, intra-abdominal abscess, secondary interventions, ED visits, or hospital readmissions.
Significant practice variation in duration and spectrum of antibiotic adjunct for surgical treatment of simple acute appendicitis treatment is evident, and broad-spectrum abx did not offer clinical advantages over narrow-spectrum abx. Restriction of antibiotic spectrum should be considered, although randomized trials are required to overcome selection bias.
IMPORTANCE: Medical malpractice litigation against surgical residents is rarely discussed owing to assumed legal doctrine of respondeat superior, or “let the master answer.” OBJECTIVE: To better ...understand lawsuits targeting surgical trainees to prevent future litigation. DESIGN, SETTING, AND PARTICIPANTS: Westlaw, an online legal research database containing legal records from across the United States, was retrospectively reviewed for malpractice cases involving surgical interns, residents, or fellows from January 1, 2005, to January 1, 2015. Infant-related obstetric and ophthalmologic procedures were excluded. EXPOSURES: Involvement in a medical malpractice case. MAIN OUTCOMES AND MEASURES: Data were collected on patient demographics, case characteristics, and outcomes and were analyzed using descriptive statistics. RESULTS: During a 10-year period, 87 malpractice cases involving surgical trainees were identified. A total of 50 patients were female (57%), and 79 were 18 years of age or older (91%), with a median patient age of 44.5 years (interquartile range, 45-56 years). A total of 67 cases (77%) resulted in death or permanent disability. Most cases involved elective surgery (61 70%) and named a junior resident as a defendant (24 of 35 69%). Cases more often questioned the perioperative medical knowledge, decision making errors, and injuries (53 61%: preoperative, 19 of 53 36%) and postoperative, 34 of 53 64%) than intraoperative errors and injuries (43 49%). Junior residents were involved primarily with lawsuits related to medical decision making (21 of 24 87%). Residents’ failure to evaluate the patient was cited in 10 cases (12%) and lack of direct supervision by attending physicians was cited in 48 cases (55%). A total of 42 cases (48%) resulted in a jury verdict or settlement in favor of the plaintiff, with a median payout of $900 000 (range, $1852 to $32 million). CONCLUSIONS AND RELEVANCE: This review of malpractice cases involving surgical residents highlights the importance of perioperative management, particularly among junior residents, and the importance of appropriate supervision by attending physicians as targets for education on litigation prevention.
Skin and soft tissue infections (SSTIs) present with variable severity. The American Association for the Surgery of Trauma (AAST) developed an emergency general surgery (EGS) grading system for ...several diseases. We aimed to determine whether the AAST EGS grade corresponds with key clinical outcomes.
Single-institution retrospective review of patients (≥18 years) admitted with SSTI during 2012 to 2016 was performed. Patients with surgical site infections or younger than 18 years were excluded. Laboratory Risk Indicator for Necrotizing Fasciitis score and AAST EGS grade were assigned. The primary outcome was association of AAST EGS grade with complication development, duration of stay, and interventions. Secondary predictors of severity included tissue cultures, cross-sectional imaging, and duration of inpatient antibiotic therapy. Summary and univariate analyses were performed.
A total of 223 patients were included (mean ± SD age of 55.1 ± 17.0 years, 55% male). The majority of patients received cross sectional imaging (169, 76%) or an operative procedure (155, 70%). Skin and soft tissue infection tissue culture results included no growth (51, 24.5%), monomicrobial (83, 39.9%), and polymicrobial (74, 35.6%). Increased AAST EGS grade was associated with operative interventions, intensive care unit utilization, complication severity (Clavien-Dindo index), duration of hospital stay, inpatient antibiotic therapy, mortality, and hospital readmission.
The AAST EGS grade for SSTI demonstrates the ability to correspond with several important outcomes. Prospective multi-institutional study is required to determine its broad generalizability in several populations.
Prognostic, level IV.
Breast Cancer Litigation in the 21st Century Murphy, Brittany L.; Ray-Zack, Mohamed D.; Reddy, Pooja N. ...
Annals of surgical oncology,
10/2018, Letnik:
25, Številka:
10
Journal Article
Recenzirano
Background
Approximately 15% of general surgeons practicing in the United States face a medical malpractice lawsuit each year. This study aimed to determine the reasons for litigation for breast ...cancer care during the past 17 years by reviewing a public legal database.
Methods
The LexisNexis legal database was queried using a comprehensive list of terms related to breast cancer, identifying all cases from 2000 to 2017. Data were abstracted, and descriptive analyses were performed.
Results
The study identified 264 cases of litigation pertaining to breast cancer care. Delay in breast cancer diagnosis was the most common reason for litigation (
n
= 156, 59.1%), followed by improperly performed procedures (
n
= 26, 9.8%). The medical specialties most frequently named in lawsuits as primary defendants were radiology (
n
= 76, 28.8%), general surgery (
n
= 74, 28%), and primary care (
n
= 52, 19.7%). The verdict favored the defendant in 145 cases (54.9%) and the plantiff in 60 cases (22.7%). In 59 cases (22.3%), a settlement was reached out of court. The median plaintiff verdict payouts ($1,485,000) were greater than the settlement payouts ($862,500) (
p
= 0.04).
Conclusion
Failure to diagnose breast cancer in a timely manner was the most common reason for litigation related to breast cancer care in the United States. General surgery was the second most common specialty named in the malpractice cases studied. Most cases were decided in favor of the defendant, but when the plaintiff received a payout, the amount often was substantial. Identifying the most common reasons for litigation may help decrease this rate and improve the patient experience.
The centralization of cancer care is associated with better clinical outcomes and may be a method for optimizing value-based health care systems.
To systematically review the literature regarding the ...impact of centralization of care on clinical outcomes for genitourinary malignancies.
A systematic review was conducted using Ovid and MEDLINE to identify studies between 1970 and 2018 reporting on the centralization of care for genitourinary malignancies. Prospective and retrospective studies were screened.
There were no published randomized control trials (RCTs) on the centralization of care for genitourinary malignancies. Twenty-two retrospective studies met inclusion criteria. Centralization of radical cystectomy was the most studied. Care for bladder cancer, prostate cancer, penile cancer, testicular cancer, and renal cancer was reportedly associated with better morbidity and survival outcomes for patients treated at high-volume centers. However, evidence of better outcomes for centralization of care remains limited for penile, renal, and testicular cancers owing to the paucity of data and/or the lower incidence of these genitourinary malignancies.
Care for genitourinary malignancies by high-volume providers was associated with greater utilization of cancer surgery, lower morbidity, and better survival outcomes. Centralization of care was most appropriate for complex procedures such as radical cystectomy when interpreted in the context of survival outcomes. Further research is needed to address the impact of centralizing care for all urologic malignancies with consideration of the associated costs and patient-reported measures, including quality of life and patient experience.
We explored the evidence for moving major operations into larger centers. We focused on surgery for cancers of the bladder, prostate, testicle, penis, and kidney, and found that larger-volume hospitals had better survival outcomes and fewer complications when compared to smaller hospitals. The difference may be greatest for complex major surgeries such as radical cystectomy.
We explored the evidence for moving major operations into larger centers. We focused on surgery for cancers of the bladder, prostate, testicle, penis, and kidney and found that larger-volume hospitals had better survival outcomes and fewer complications when compared to smaller-volume hospitals. The difference may be greatest for complex major surgeries such as radical cystectomy.
Screening for blunt cerebrovascular injuries (BCVIs) in asymptomatic high-risk patients has become routine. To date, the length of this asymptomatic period has not been defined. Determining the time ...to stroke could impact therapy including earlier initiation of antithrombotics in multiply injured patients. The purpose of this study was to determine the time to stroke in patients with a BCVI-related stroke. We hypothesized that the majority of patients suffer stroke between 24 hours and 72 hours after injury.
Patients with a BCVI-related stroke from January 2007 to January 2017 from 37 trauma centers were reviewed.
During the 10-year study, 492 patients had a BCVI-related stroke; the majority were men (61%), with a median age of 39 years and ISS of 29. Stroke was present at admission in 182 patients (37%) and occurred during an Interventional Radiology procedure in six patients. In the remaining 304 patients, stroke was identified a median of 48 hours after admission: 53 hours in the 144 patients identified by neurologic symptoms and 42 hours in the 160 patients without a neurologic examination and an incidental stroke identified on imaging. Of those patients with neurologic symptoms, 88 (61%) had a stroke within 72 hours, whereas 56 had a stroke after 72 hours; there was a sequential decline in stroke occurrence over the first week. Of the 304 patients who had a stroke after admission, 64 patients (22%) were being treated with antithrombotics when the stroke occurred.
The majority of patients suffer BCVI-related stroke in the first 72 hours after injury. Time to stroke can help inform clinicians about initiation of treatment in the multiply injured patient.
Prognostic/Epidemiologic, level III.
Hospital discharge instructions provide critical information necessary for patients to manage their own care; however, often they are written at a substantially higher readability level than ...recommended (ie, 6th-grade level) by the American Medical Association and the National Institutes of Health. We hypothesize that improving the reading level of discharge instructions will decrease the number of patient telephone calls and readmissions in the posthospital setting.
We conducted a prospective observational study. Patient discharge instructions were edited and incorporated to enhance the readability level in August 2015. Return telephone call and readmissions of patients admitted before the intervention from August 1, 2014, to January 31, 2015, were compared with the prospective cohort studied from September 1, 2015, to September 30, 2016.
A total of 1,072 patients were included (preintervention: n = 493, postintervention: n = 579). Patient demographics, injury characteristics, and education level were similar among both groups. The median discharge instruction readability level in the postintervention group was significantly lower (10.0, 95% CI 10.0–10.2 vs 8.6, 95% CI 8.8–8.9; P < .0001). The proportion of patients calling after hospital discharge was significantly reduced after the intervention (21.9% vs 9.0%; P < .0001). Monthly hospital readmissions were decreased by 50% for every 100 patients discharged after the intervention (1.9% vs 0.9%; P = .002). The proportion of patients calling and readmissions for poor pain control significantly decreased after the intervention (7.1% vs 2.59%; P = .0005 and 2.8% vs 1.0%; P = .029, respectively).
Enhanced readability of discharge instructions was associated with a decrease in the number of telephone calls and readmissions in the posthospital setting, enhancing health literacy and simultaneously reducing the burden on providers. Improved patient instructions written to an appropriate level may also allow for better pain control in the posthospital setting.
Background
Coagulopathy can delay or complicate surgical diseases that require emergent surgical treatment. Prothrombin complex concentrates (PCC) provide concentrated coagulation factors which may ...reverse coagulopathy more quickly than plasma (FFP) alone. We aimed to determine the time to operative intervention in coagulopathic emergency general surgery patients receiving either PCC or FFP. We hypothesize that PCC administration more rapidly normalizes coagulopathy and that the time to operation is diminished compared to FFP alone.
Methods
Single institution retrospective review was performed for coagulopathic EGS patients during 2/1/2008 to 8/1/2016. Patients were divided into three groups (1) PCC alone (2) FFP alone and (3) PCC and FFP. The primary outcome was the duration from clinical decision to operate to the time of incision. Summary and univariate analyses were performed.
Results
Coagulopathic EGS patients (
n
= 183) received the following blood products: PCC (
n
= 20, 11%), FFP alone (
n
= 119, 65%) and PCC/FFP (
n
= 44, 24%). The mean (± SD) patient age was 71 ± 13 years; 60% were male. The median (IQR) Charlson comorbidity index was similar in all three groups (PCC = 5(4–6), FFP = 5(4–7), PCC/FFP = 5(4–6),
p
= 0.33). The mean (± SD) dose of PCC administered was similar in the PCC/FFP group and the PCC alone group (2539 ± 1454 units vs. 3232 ± 1684,
p
= .09). The mean (±SD) time to incision in the PCC alone group was significantly lower than the FFP alone group (6.0 ± 3.6 vs. 8.8 ± 5.0 h,
p
= 0.01). The mean time to incision in the PCC + FFP group was also significantly lower than the FFP alone group (7.1 ± 3.6 vs. 8.8 ± 5.0,
p
= 0.03). The incidence of thromboembolic complications was similar in all three groups.
Conclusions
PCC, alone or in combination with FFP, reduced INR and time to surgery effectively and safely in coagulopathic EGS patients without an apparent increased risk of thromboembolic events, when compared to FFP use alone.
Level of evidence
IV single institutional retrospective review.
PDF
