Rib fractures are commonly encountered in the setting of trauma. The aim of this study was to assess the association between the clinical outcome of rib fracture and epidural analgesia (EA) versus ...paravertebral block (PVB) using the National Trauma Data Bank (NTDB).
Using the 2011 and 2012 versions of the NTDB, we retrieved completed records for all patients above 18 years of age who were admitted with rib fractures. Primary outcome was in-hospital mortality. Secondary outcomes were length of stay (LOS), intensive care unit (ICU) admission, ICU LOS, mechanical ventilation, duration of mechanical ventilation, development of pneumonia, and development of any other complication. Clinical outcomes were first compared between propensity score-matched EA and PVB patients. Then, EA and PVB patients were combined into the procedure group and the outcomes were compared with propensity score-matched patients that received neither intervention (no-procedure group).
A total of 194,766 patients were included in the study with 1073 patients having EA, 1110 patients having PVB, and 192,583 patients having neither procedure. After propensity score matching, comparison of primary and secondary outcomes between EA and PVB patients showed no difference. Comparison of propensity score-matched procedure and no-procedure patients showed prolonged LOS and more frequent ICU admissions in patients receiving a procedure (both P < .0001), yet having no procedure was associated with a significantly increased odds of mortality (odds ratio: 2.25; 95% confidence interval, 1.14-3.84; P = .002).
Using the NTDB, EA and PVB were not found to be significantly different in management of rib fractures. There was an association between use of a block and improved outcome, but this could be explained by selection of healthier patients to receive a block. Prospective study of this association is recommended.
ABSTRACT
Purpose
Survival nomograms offer individualized predictions using a more diverse set of factors than traditional staging measures, including the American Joint Committee on Cancer Tumor Node ...Metastasis (AJCC TNM) Staging System. A nomogram predicting overall survival (OS) for resected, non-metastatic non-small cell lung cancer (NSCLC) has been previously derived from Asian patients. The present study aims to determine the nomogram’s predictive capability in the US using the National Cancer Database (NCDB).
Methods
This was a retrospective review of adults with resected, non-metastatic NSCLC entered into the NCDB between 2004 and 2012. Concordance indices and calibration plots analyzed discrimination and calibration, respectively. Multivariate analysis was also used.
Results
A total of 57,313 patients were included in this study. The predominant histologies were adenocarcinoma (48.2%) and squamous cell carcinoma (31.3%), and patients were diagnosed with stage I-A (38.3%), stage I-B (22.7%), stage II-A (14.2%), stage II-B (11.5%), and stage III-A (13.3%). Median OS was 74 months. 1-, 3- and 5-year OS rates were 89.8% 95% confidence interval (CI) 89.5–90.0%, 71.1% (95% CI 70.7–71.6%), and 55.7% (95% CI 54.7–56.6%), respectively. The nomogram’s concordance index (C-index) was 0.804 (95% CI 0.792–0.817). AJCC TNM staging demonstrated higher discrimination (C-index 0.833, 95% CI 0.821–0.840).
Conclusions
The nomogram’s individualized estimates accurately predicted survival in this patient collective, demonstrating higher discrimination in this population than in the developer’s cohorts. However, the generalized survival estimates provided by traditional staging demonstrated superior predictive capability; therefore, AJCC TNM staging should remain the gold standard for the prognostication of resected NSCLC in the US.
This study characterized the failure rate of non-operative management (NOM) for complicated appendicitis (CA; perforation, abscess, phlegmon), and compared outcomes among patients undergoing acute ...appendectomy (AA), elective interval appendectomy (EIA), and unplanned appendectomy after failing to improve with NOM.
Adults treated at one facility between 2007 and 2014 were retrospectively studied.
Ninety-five patients presented with CA. Sixty individuals underwent AA. The remaining 35 patients initially underwent NOM: 14 underwent EIA, nine (25.7%) failed NOM, 12 never underwent surgery.
All patients failing NOM had an open operation with most (55.6%) requiring bowel resection. AA and EIA were comparable in surgical approach, bowel resection and post-operative readmission. However, AA demonstrated a lower incidence of bowel resection (3.3% vs 17.1%, P = 0.048) when compared to all patients initially undergoing NOM.
Due to the high incidence of failed NOM and the morbidity associated with failure, AA may be appropriate for CA.
•Non-operative management failed in 25.7% of patients with complicated appendicitis.•Most patients who failed non-operative management required major bowel resection.•The incidence and morbidity of failed non-operative management favors acute surgery.
Abstract Background Oncotype DX (ODX) is a multi-gene tumor assay for breast cancer patients. Our objective is to assess whether eligible ODX patients received the test and whether recommendations ...were followed based on respective risk. Methods We retrospectively analyzed testing in patients deemed eligible for ODX using the National Cancer Data Base. Results A total of 158,235 patients met ODX eligibility criteria. Sixty-four percent of eligible patients did not receive the test. Non-testing rose with age. White patients were more likely to be tested (56%) versus black patients (46%, p < 0.0001). Testing was highest at academic facilities (40%). Privately insured patients were more likely to get the test compared to uninsured (45 versus 34%, p < 0.0001). Those in the highest income quartile were more likely to be tested (p < 0.001). Conclusions ODX is under-utilized, with racial and socio-economic factors influencing testing. Further studies are necessary to identify ways to remove disparities and increase testing when appropriate. Summary This study uses the National Cancer Data Base to analyze compliance with the NCCN guidelines for Oncotype DX. Compliance with testing was thirty-six percent. Several factors influenced testing in our study, including facility type, racial and socio-economic factors.
It is estimated that choledocholithiasis is present in 5% to 20% of patients at the time of laparoscopic cholecystectomy (LC). Several European studies have found decreased length of stay (LOS) when ...performing LC and intraoperative endoscopic retrograde cholangiopancreatography (ERCP) on the same day for choledocholithiasis. In the United States, common bile duct stones are usually managed preoperatively and typically on a day separate from the day LC was performed. Our aim was to evaluate LOS and total hospital cost for separate-day versus same-day ERCP/cholecystectomy.
This was a retrospective study of patients undergoing ERCP and cholecystectomy during the same admission for the management of choledocholithiasis from 2010 to 2014 at Geisinger Medical Center. The separate-day group underwent ERCP at least 1 day before cholecystectomy and often underwent two separate anesthesia events, while the same-day group had ERCP and cholecystectomy performed on the same day under one general anesthesia event. The primary outcome measured was LOS.
The study population included 240 patients. There were 175 patients in the separate-day group and 65 patients in the same-day group. Median age was similar between the two groups. The separate-day group had a median of one minor comorbidity compared with zero within the same-day group using the Charlson Comorbidity Index. Overall, LOS for the separate-day group was 5 days compared with 3 days in the same-day group (p < 0.0001). There was no difference in conversion rates to open cholecystectomy between the two groups (14% in the separate-day vs. 12% in the same-day group). Total median hospital cost for the separate-day group was $102,537 compared with $90,269 in the same-day group (p < 0.0001).
Same-day ERCP and cholecystectomy is feasible and minimizes costs. Same-day procedures decreased hospital LOS by 2 days and had approximately $12,000 in cost savings. Future goals include a multidisciplinary protocol to study outcomes in larger numbers.
Therapeutic study, level IV. Economic study, level III.
Clostridium difficile infection (CDI) is one of the most common health care-associated infections, and it continues to have significant morbidity and mortality. The onset of fulminant colitis often ...requires total abdominal colectomy with ileostomy, which has a mortality rate of 35% to 57%. University of Pittsburgh Medical Center (UPMC) developed a scoring system for severity and recommended surgical consultation for severe complicated disease. The aim of this study was to evaluate if the UPMC-proposed scoring system for severe complicated CDI can predict the need for surgical intervention.
This is a retrospective review of all patients who developed severe complicated CDI at Geisinger Medical Center between January 2007 and December 2012 as defined by the UPMC scoring system. Main outcomes were the need for surgical intervention and 30-day mortality.
Eighty-eight patients had severe complicated CDI based on the UPMC scoring system. Fifty-nine patients (67%) required surgery and 29 did not. All patients had a diagnosis of CDI as shown by positive toxin assays. There was no difference between the groups with respect to age, sex, body mass index, or comorbidities. When comparing the surgical group to the nonsurgical cohort, the surgical cohort averaged 20 points on the scoring system compared to 9 in the nonoperative cohort. In patients with severe complicated CDI, 15 or more points predicted the need for surgery 75% of the time. Forty-two percent of the surgical cohort had respiratory failure requiring mechanical ventilation compared to 0% in the nonsurgical cohort (p < 0.0001). Forty-nine percent of the surgical cohort required vasopressors for septic shock before surgery compared to 0% in the nonsurgical cohort (p < 0.0001). Acute kidney injury was present in 92% of the surgical cohort versus 72% within the nonsurgical cohort (p = 0.026). Seventy-six percent of the surgical patients were admitted to the ICU before surgery. Within the nonsurgical cohort, only 24% of patients required ICU stay during admission. Overall, 30-day mortality in the surgical cohort was 30%, and there was no mortality in the nonsurgical cohort.
The UPMC scoring system for severe complicated CDI can help us predict patients who need a surgical consult and the need for surgical intervention. In patients with severe complicated CDI, evidence of end-organ failure predicts surgical intervention.
Prognostic study, level III; therapeutic study, level IV.
Recent case series have reported successful nonoperative management (NOM) using interventional radiology-guided (IR) drainage; however, the incidence and outcomes of failed NOM have not been well ...described.1-3 This study aims to characterize outcomes of operative and NOM for splenic abscess patients while also describing the characteristics of those who fail NOM. ...the third treatment group (failed NOM) underwent drainage with a nonoperative intent to treat, but ultimately required an unplanned splenectomy. Nearly all patients in the failed NOM group were readmitted to the hospital and had considerable hospitalization duration, with four patients readmitted multiple times. Because of the high morbidity among failed NOM patients, it is important to identify the factors that could possibly relate to failed NOM.
Abstract Background The majority of the US population live in urban areas, yet more than half of all trauma deaths occur in rural areas. The Rural Trauma Team Development Course (RTTDC) is developed ...to improve the outcomes of rural trauma and we aimed to study its effect on patient transfer. Methods Trauma referrals 2 years before the RTTDC training were compared with referrals 2 years after the course. Results Of the 276 studied patients, 97 were referred before the RTTDC training and 179 patients were referred after the course. Transfer acceptance time was significantly shorter after the RTTDC training (139.2 ± 87.1 vs 110 ± 66.3 min, P = .003). The overall transfer time was also significantly reduced following the RTTDC training (257.4 ± 110.8 vs 219.2 ± 86.5 min, P = .002). Patients receiving pretransfer imaging had a significantly higher transfer time both before and after RTTDC training (all P s < .01). Mortality was nearly halved (6.2% vs 3.4%) after the RTTDC training. Conclusion The RTTDC training was associated with reduced transfer acceptance time and reduced transfer time.
We sought to determine the outcome of suicidal hanging and the impact of targeted temperature management (TTM) on hanging-induced cardiac arrest (CA) through an Eastern Association for the Surgery of ...Trauma (EAST) multicenter retrospective study.
We analyzed hanging patient data and TTM variables from January 1992 to December 2015. Cerebral performance category score of 1 or 2 was considered good neurologic outcome, while cerebral performance category score of 3 or 4 was considered poor outcome. Classification and Regression Trees recursive partitioning was used to develop multivariate predictive models for survival and neurologic outcome.
A total of 692 hanging patients from 17 centers were analyzed for this study. Their overall survival rate was 77%, and the CA survival rate was 28.6%. The CA patients had significantly higher severity of illness and worse outcome than the non-CA patients. Of the 175 CA patients who survived to hospital admission, 81 patients (46.3%) received post-CA TTM. The unadjusted survival of TTM CA patients (24.7% vs 39.4%, p < 0.05) and good neurologic outcome (19.8% vs 37.2%, p < 0.05) were worse than non-TTM CA patients. However, when subgroup analyses were performed between those with an admission Glasgow Coma Scale score of 3 to 8, the differences between TTM and non-TTM CA survival (23.8% vs 30.0%, p = 0.37) and good neurologic outcome (18.8% vs 28.7%, p = 0.14) were not significant. Targeted temperature management implementation and post-CA management varied between the participating centers. Classification and Regression Trees models identified variables predictive of favorable and poor outcome for hanging and TTM patients with excellent accuracy.
Cardiac arrest hanging patients had worse outcome than non-CA patients. Targeted temperature management CA patients had worse unadjusted survival and neurologic outcome than non-TTM patients. These findings may be explained by their higher severity of illness, variable TTM implementation, and differences in post-CA management. Future prospective studies are necessary to ascertain the effect of TTM on hanging outcome and to validate our Classification and Regression Trees models.
Therapeutic study, level IV; prognostic study, level III.
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