Surgical site infections (SSI) after colectomy are associated with increased morbidity and health care use. Since 2012, the Michigan Surgical Quality Collaborative (MSQC) has promoted a “bundle” of ...care processes associated with lower SSI risk, using an audit-and-feedback system for adherence, face-to-face meetings, and support for quality improvement projects at participating hospitals. The purpose of this study was to determine whether practices changed over time.
We previously found 6 processes of care independently associated with SSI in colectomy. From 2012 to 2016, we promoted a bundle of 3 care measures (cefazolin/metronidazole, oral antibiotics after mechanical bowel preparation, and normoglycemia) in 52 hospitals. Primary outcome was change in use of the 3-item SSI bundle. We also used a hierarchical logistic regression model to assess the association between 6-item compliance and SSI rate, morbidity, and health care use.
The use of cefazolin/metronidazole increased from 18.6% to 32.3% (p < 0.001), oral antibiotic preparation increased from 42.9% to 62.0% (p < 0.001). The increase in normoglycemia was not significant. Concurrently, the SSI rate fell from 6.7% to 3.9% in the 52 hospitals (p = 0.012). Patients receiving more bundle measures had decreased rates of SSI, sepsis, and pneumonia. Morbidity and health care use significantly decreased with increased bundle compliance.
These data show a significant increase in use of process measures promoted by a regional quality improvement collaborative, and an associated decrease in SSI after elective colectomy. These results highlight the promise of regional collaboratives to accelerate practice change and improve outcomes.
Introduction
Diverting loop ileostomies are frequently created to divert the fecal stream in an effort to protect downstream anastomoses. These are later reversed to restore intestinal continuity. ...The goal of this study is to evaluate risk factors for postoperative complications following diverting loop ileostomy takedown.
Materials and Methods
Patients who underwent diverting loop ileostomy takedown between January 1, 2010 and April 28, 2015 were identified in the Michigan Surgical Quality Collaborative registry. Candidate covariates were identified and a hierarchical logistic regression model was used to identify risk factors for postoperative complications.
Results
1,737 patients met the inclusion criteria. Rates of postoperative complications were generally low. Mean length of stay (LOS) was 5.6 (± 4.5) days. Outcomes of interest were the following: overall morbidity, serious morbidity, extended LOS, SSI, UTI, pneumonia, readmission, reoperation, and mortality. Risk factors for these outcomes included the following: ASA class, bleeding disorder, prolonged operative time, race, tobacco use, gender, steroid use, peripheral vascular disease, weight loss, and functional status.
Conclusions
Diverting loop ileostomy takedown has a complication rate of approximately 20%. Higher ASA class, longer operative times, history of bleeding disorder, and functional status were identified as risk factors for most complications.
To assess the variation in hospitals' approaches to intraoperative fluid management and their association with postoperative recovery.
Despite increasing interest in goal-directed, restricted-volume ...fluid administration for major surgery, there remains little consensus on optimal strategies, due to the lack of institution-level studies of resuscitation practices.
Among 64 hospitals in a state-wide surgical collaborative, we profiled fluid administration practices during 8404 intestinal resections, 22,854 hysterectomies, and 1471 abdominopelvic endovascular procedures. We computed intraoperative fluid balance, accounting for patient morphometry, crystalloid, colloid, blood products, urine, blood loss, duration, and approach. We stratified hospitals by average fluid balance quartile, and compared patterns across disciplines and associations with risk-adjusted postoperative length of stay (pLOS).
There was wide variation in fluid balance between hospitals (P < 0.001, all procedures), but significant within-hospital correlation across operations (Pearson rho: intestinal-hysterectomy = 0.50, intestinal-endovascular = 0.36, hysterectomy-endovascular = 0.54, all P < 0.05). Highest fluid balance hospitals had significantly longer adjusted pLOS than lowest balance hospitals for intestinal resection (6.5 vs 5.7 d, P < 0.001) and hysterectomy (1.9 vs 1.7 d, P < 0.001), but not endovascular (2.1 vs 2.3 d, P = 0.69). Risk-adjusted complication rates were not associated with fluid balance rankings.
Hospitals' approaches to intraoperative fluid administration vary widely, and their practice patterns are pervasive across disparate procedures. High fluid balance hospitals have 12% to 14% longer risk-adjusted pLOS for visceral abdominal surgery, independent of patient complexity and complications. These findings are consistent with evidence that isovolemic resuscitation in enhanced recovery protocols accelerates recovery of bowel function.
Robotic colorectal surgery has been shown to have lower rates of unplanned conversion to open surgery when compared to laparoscopic surgery. Risk factors associated with conversion from robotic to ...open colectomy and comparisons of the risk factors between robotic and laparoscopic approaches have not been previously reported. Patients who underwent elective laparoscopic and robotic colorectal surgeries between July 1, 2012 and April 28, 2015, were identified in the Michigan Surgical Quality Collaborative registry. Candidate covariates were identified, and hierarchical logistic regression models were used to identify risk factors for conversion. There were 4796 cases that met study inclusion criteria. Conversion was required in 18.2 % of laparoscopic and 7.7 % of robotic cases (
p
< 0.0001). Risk factors for conversion in the laparoscopic group included the following: moderate/severe adhesions, obesity, colorectal cancer, hypertension, rectal operations, urgent priority, and tobacco use. Risk factors for conversion in the robotic group included the following: severe adhesions, bleeding disorder, presence of cancer, cirrhosis, and use of statins. Higher surgeon volume was protective in both groups. Conversion rates are lower for robotic than for laparoscopic colorectal surgery with fewer predictors of conversion. Recognition of factors predicting conversion may allow surgeons to choose an operative approach that optimizes the benefits of the available technologies.
Background
There is a large body of evidence linking muscular weakness, as determined by low grip strength, to a host of negative ageing‐related health outcomes. Given these links, grip strength has ...been labelled a ‘biomarker of aging’; and yet, the pathways connecting grip strength to negative health consequences are unclear. The objective of this study was to determine whether grip strength was associated with measures of DNA methylation (DNAm) age acceleration.
Methods
Middle age and older adults from the 2006 to 2008 waves of the Health and Retirement Study with 8–10 years of follow‐up were included. Cross‐sectional and longitudinal regression modelling was performed to examine the association between normalized grip strength (NGS) and three measures of DNAm age acceleration, adjusting for cell composition, sociodemographic variables and smoking. Longitudinal modelling was also completed to examine the association between change in absolute grip strength and DNAm age acceleration. The three DNAm clocks used for estimating age acceleration include the established DunedinPoAm, PhenoAge and GrimAge clocks.
Results
There was a robust and independent cross‐sectional association between NGS and DNAm age acceleration for men using the DunedinPoAm (β: −0.36; P < 0.001), PhenoAge (β: −8.27; P = 0.01) and GrimAge (β: −4.56; P = 0.01) clocks and for women using the DunedinPoAm (β: −0.36; P < 0.001) and GrimAge (β: −4.46; P = 0.01) clocks. There was also an independent longitudinal association between baseline NGS and DNAm age acceleration for men (β: −0.26; P < 0.001) and women (β: −0.36; P < 0.001) using the DunedinPoAm clock and for women only using the PhenoAge (β: −8.20; P < 0.001) and GrimAge (β: −5.91; P < 0.001) clocks. Longitudinal modelling revealed a robust association between change in grip strength from wave 1 to wave 3 was independently associated with PhenoAgeAA (β: −0.13; 95% CI: −0.23, −0.03) and GrimAgeAA (β: −0.07; 95% CI: −0.14, −0.01) in men only (both P < 0.05).
Conclusions
Our findings provide some initial evidence of age acceleration among men and women with lower NGS and loss of strength over time. Future research is needed to understand the extent to which DNAm age mediates the association between grip strength and chronic disease, disability and mortality.
The traditional open approach is still a common option for colectomy and the most common option chosen for rectal resections for cancer. Randomized trials and large database studies have reported the ...merits of the minimally invasive approach, while studies comparing laparoscopic and robotic options have reported inconsistent results.
This study was designed to compare open, laparoscopic, and robotic colorectal surgery outcomes in protocol-driven regional and national databases. Logistic and multiple linear regression analyses were used to compare standard 30-day colorectal outcomes in the Michigan Surgical Quality Collaborative (MSQC) and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases. The primary outcome was overall complications.
A total of 10,054 MSQC patients (open 37.5%, laparoscopic 48.8%, and robotic 13.6%) and 80,535 ACS-NSQIP patients (open 25.0%, laparoscopic 67.1%, and robotic 7.9%) met inclusion criteria. Overall complications and surgical site infections were significantly favorable for the laparoscopic and robotic approaches compared with the open approach. Anastomotic leaks were significantly fewer for the laparoscopic and robotic approaches compared with the open approach in ACS-NSQIP, while there was no significant difference between robotic and open approaches in MSQC. Laparoscopic complications were significantly less than robotic complications in MSQC but significantly more in ACS-NSQIP. Laparoscopic 30-day mortality was significantly less than for the robotic approach in MSQC, but there was no difference in ACS-NSQIP.
Minimally invasive colorectal surgery is associated with fewer complications and has several other outcomes advantages compared with the traditional open approach. Individual complication comparisons vary between databases, and caution should be exercised when interpreting results in context.
Risk Factors for Accident Death in the U.S. Army, 2004−2009 Lewandowski-Romps, Lisa, PhD; Peterson, Christopher, PhD; Berglund, Patricia A., MBA ...
American journal of preventive medicine,
12/2014, Letnik:
47, Številka:
6
Journal Article
Recenzirano
Odprti dostop
Background Accidents are one of the leading causes of death among U.S. active-duty Army soldiers. Evidence-based approaches to injury prevention could be strengthened by adding person-level ...characteristics (e.g., demographics) to risk models tested on diverse soldier samples studied over time. Purpose To identify person-level risk indicators of accident deaths in Regular Army soldiers during a time frame of intense military operations, and to discriminate risk of not-line-of-duty from line-of-duty accident deaths. Methods Administrative data acquired from multiple Army/Department of Defense sources for active duty Army soldiers during 2004−2009 were analyzed in 2013. Logistic regression modeling was used to identify person-level sociodemographic, service-related, occupational, and mental health predictors of accident deaths. Results Delayed rank progression or demotion and being male, unmarried, in a combat arms specialty, and of low rank/service length increased odds of accident death for enlisted soldiers. Unique to officers was high risk associated with aviation specialties. Accident death risk decreased over time for currently deployed, enlisted soldiers and increased for those never deployed. Mental health diagnosis was associated with risk only for previous and never-deployed, enlisted soldiers. Models did not discriminate not-line-of-duty from line-of-duty accident deaths. Conclusions Adding more refined person-level and situational risk indicators to current models could enhance understanding of accident death risk specific to soldier rank and deployment status. Stable predictors could help identify high risk of accident deaths in future cohorts of Regular Army soldiers.
The objective of this study was to use nationally-representative data on Americans greater than 50 years of age to determine the association between grip strength and inflammation as independent ...predictors of incident disability, chronic multimorbidity and dementia.
Middle age and older adults (n = 12,618) from the 2006–2008 waves of the Health and Retirement Study with 8-years of follow-up were included. Longitudinal modeling was performed to examine the association between baseline grip strength (normalized to body mass: NGS) and high sensitivity C-reactive protein (hs-CRP) (≥3.0 mg/L) with incident physical disabilities (i.e., ≥2 limitations to activities of daily living), chronic multimorbidity (≥2 of chronic conditions), and dementia.
The odds of incident disability were 1.25 (95% CI: 1.20–1.30) and 1.31 (95% CI: 1.26–1.36) for men and women respectively, for each 0.05-unit lower NGS. The odds of incident chronic multimorbidity were 1.14 (95% CI: 1.08–1.20) and 1.14 (95% CI: 1.07–1.21) for men and women respectively for each 0.05-unit lower NGS. The odds of incident dementia were 1.10 for men (95% CI: 1.02–1.20) for each 0.05-unit lower NGS, but there was no significant association for women. Elevated hs-CRP was only associated with chronic multimorbidity among men (OR = 1.29; 95% CI: 1.00–1.73) and women (OR = 1.60; 95% CI: 1.26–2.02).
Our findings indicate a robust inverse association between NGS and disability and chronic, multimorbidity in older men and women, and dementia in men. Elevated hs-CRP was only associated with chronic multimorbidity in men and women. Healthcare providers should implement measures of grip strength in routine health assessments and discuss the potential dangers of weakness as well as interventions to improve strength with their patients.
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