The American Association for the Surgery of Trauma (AAST) has developed a new grading system for uniform description of anatomic severity of emergency general surgery (EGS) diseases, ranging from ...Grade I (mild) to Grade V (severe). The purpose of this study was to determine the relationship of AAST grades for acute colonic diverticulitis with patient outcomes. A secondary purpose was to propose an EGS quality improvement program using risk-adjusted center outcomes, similar to National Surgical Quality Improvement Program and Trauma Quality Improvement Program methodologies.
This was a retrospective study of 1,105 patients (one death) from 13 centers. At each center, two reviewers (blinded to each other's assignments) assigned AAST grades. Interrater reliability was measured using κ coefficient. Relationship between AAST grade and clinical events (complications, intensive care unit use, surgical intervention, and 30-day readmission) as well as length of stay was measured using regression analyses to control for age, comorbidities, and physiologic status at the time of admission. Final model was also used to calculate observed-to-expected (O-E) ratios for adverse outcomes (death, complications, readmissions) for each center.
Median age was 54 years, 52% were males, 43% were minorities, and 22% required a surgical intervention. Almost two thirds had Grade I or II disease. There was a high level of agreement for grades between reviewers (κ = 0.81). Adverse events increased from 13% for Grade I, to 18% for Grade II, 28% for Grade III, 44% for Grade IV, and 50% for Grade V. Regression analysis showed that higher disease grades were independently associated with all clinical events and length of stay, after adjusting for age, comorbidities, and physiology. O-E ratios showed statistically insignificant variations in risk of death, complications, or readmissions.
AAST grades for acute colonic diverticulitis are independently associated with clinical outcomes and resource use. EGS quality improvement program methodology that incorporates AAST grade, age, comorbidities, and physiologic status may be used for measuring quality of EGS care. High-quality EGS registries are essential for developing meaningful quality metrics.
Prognostic study, level V.
Abstract Objective Timely transport to designated trauma centers impacts mortality following serious injury. We examined whether the distribution of trauma centers in Chicago has created disparities ...in access to trauma care. Methods Using the Illinois State Trauma Registry, locations of Chicago-area gunshot wounds (GSWs) from 1999-2009 were geocoded and transport times were analyzed for pediatric (age ≤15) and adult (age ≥16) GSWs. Results A total of 11,744 included pediatric and adult GSWs were analyzed. Adults experienced longer mean transport times (11.3 vs 10.2 minutes, p<0.001). Disproportionate numbers of adult GSW victims experienced over 30-minute transport times on Chicago’s south side. Pediatric GSWs demonstrated no such disparity, likely attributable to the presence of a pediatric trauma center on the southeast side. Conclusions Geographic disparities in access to trauma care exist even within urban trauma systems. The absence of an adult trauma center on Chicago’s southeast side has contributed to these disparities.
Introduction
Prophylactic placement of intra‐aortic balloon pumps (IABPs) for hemodynamic support has been used in high‐risk patients undergoing coronary artery bypass grafting (CABG) surgery. The ...use of the Impella CP (ICP) heart pump in high‐risk patients undergoing CABG has not been reported. In this study, we report our experience using ICP and IABP devices in high‐risk patients during the postoperative period.
Methods
This is a case series and retrospective comparison of ICP vs IABP at a single institution using data from 2017. Twenty‐eight patients underwent postoperative placement of either the ICP or an IABP. Nineteen patients received IABP and nine received the ICP heart pump. Patient characteristics, comorbidities, and complications were compared using bivariate analysis. Exact logistic regression was used to compare risk‐adjusted mortality.
Results
There were no statistically significant differences in epidemiologic characteristics, risk factors, or outcomes between both groups, except the ICP group had a lower preoperative left ventricular ejection fraction (22.5 vs 35; P = .028). Exact logistic regression analysis did not show a difference in 30‐day mortality between both groups (P = .086).
Conclusion
The postoperative use of the ICP heart pump, to support high‐risk patients undergoing CABG, is a safe option. This practice has allowed us to perform CABG on sicker patients, specifically with depressed ejection fractions, with comparable results to the IABP. Further studies with larger patient populations are needed to draw definitive conclusions, but this pilot study demonstrates a possible expanded use of the Impella device.
Abstract Background In India, motorized two-wheeler (MTW) road traffic accidents injure or kill 72,000 women annually. Before the Motor Vehicle Act of 1988, which required mandatory helmet use for ...MTW riders, a study found 0.6% of all MTW pillions (backseat passengers) were helmeted. Citing religious protests to the legislation, Delhi's high court exempted the city's 12 million women from the law. We hypothesize that currently male pillions use helmets more frequently than females, and that overall pillion helmet usage has increased over the last 20 y. Methods Continuous video was recorded in half-hour blocks at four locations in Delhi on separate days, totaling 8 hours of high- and low-volume traffic. Videos were reviewed with at least two reviewers extracting the number of MTW pillions, as well as their gender, approximate age, and helmet usage. Results Of 4010 pillions identified, 63.8% were male, 32.4% female, and 3.3% children. Among males, there were significantly more helmeted pillions (88.4%, P < 0.001); among females, there were significantly more unhelmeted pillions (99.4%, P < 0.001). Among unhelmeted pillions, significantly more were female (81.4%) than male ( P < 0.001). Current overall pillion helmet use is significantly higher than historical rate ( P < 0.001). Conclusions The significantly higher male pillion helmet usage compared with females indicates Delhi's helmet law is associated with increased compliance among those who fall under its jurisdiction. This augments the growing body of evidence that mandatory helmet laws are efficacious, thus repealing the exemption of women is an important step in increasing female pillion helmet usage.
Elder Abuse Van Den Bruele, Astrid Botty; Dimachk, Moustapha; Crandall, Marie
Clinics in geriatric medicine,
02/2019, Letnik:
35, Številka:
1
Journal Article
Recenzirano
Elder abuse is generally defined as the maltreatment of individuals over the age of 60, although no precise definition exists in the literature. Types of abuse include, but are not limited to, ...psychological/emotional, physical, sexual abuse, and financial exploitation. Certain risk factors exist leaving an individual more susceptible to abuse, and many obstacles exist preventing the elimination of abuse. There are also identifiable risk factors that increase the likelihood of perpetration of abuse. This systematic review provides an overview of the scope of the problem, types of abuse, risk factors, characteristics of abusers, and key aspects of elder abuse prevention.
The burden of postoperative adverse events (AE) weighs immediately on the patient as unanticipated stress and on the healthcare system as unreimbursed cost. Applying the Clavien-Dindo (C-D) system of ...AE gradation as a surrogate of cost, we analyzed 4 years' data from a single-state National Surgical Quality Improvement Program (NSQIP) collaboration, hypothesizing that trends of AE were consistent over time and that more frequently performed cases would be associated with less and more minor AE.
The NSQIP defined AEs, consisting of 21 listed postoperative occurrences, which were analyzed using deidentified 30-day postoperative data for 2015 to 2018. Each AE was graded using (C-D) severity (1, lowest; 4, highest with survival). The C-D severity weight, as defined in previous multi-institutional studies, was used as a surrogate for cost and unplanned patient burden. Adverse event incidence was calculated as sum AE/case volume, and population burden as total AE burden/case volume.
There were 12,567 surgical cases recorded by members of the state collaborative. The overall data demonstrated no significant difference in AE incidence; however, the burden of AE increased by 18.8%. The 8 most common Current Procedural Terminology codes had approximately 50% lower AE incidence compared with overall cases; however, the incidence increased by 56.0% and the AE burden/case increased by 48.0%.
Although the 8 most common Current Procedural Terminology codes showed a 50% lower AE incidence compared with overall cases, the incidence increased over the study period. Surgical quality initiatives should be patient centered and focus on high burden AE.
Abstract The once disparate fields of public health and medicine are slowly converging and reintegrating. Public health principles of community interventions and partnerships to effect better ...population health are included in the curricula of more medical schools. For graduate medical education, the specialties of internal medicine, family medicine, and preventive medicine are intuitively obvious population health partners, whereas surgeons have been relatively silent in this area. Despite the fact that many common surgical diseases are directly attributable to preventable causes, including cancer, trauma, and obesity, surgical residents receive little formal population health education. However, surgeons have always been and are increasingly active within the public health sphere. Examples of surgical population health initiatives include trauma systems development and improvement, research on disparities, and global health initiatives, including disaster relief. This article describes a single institution experience utilizing modest curriculum changes, increased global health opportunities, and direct service learning to help integrate population health principles into a general surgical residency program.
Context: Hypertonic saline (HTS) is a pharmacologic therapy used in patients with severe traumatic brain injuries to decrease intracranial pressure (ICP) associated with cerebral edema. Aims: The ...purpose of this study was to compare ICP reduction between fixed doses of 23.4% HTS and weight-based doses. Setting and Design: This was a retrospective study that included adult patients at a level 1 trauma center who had nonpenetrating traumatic brain injury, an ICP monitor, and received at least one dose of 23.4% HTS. Subjects and Methods: Doses were classified as either high weight-based (>0.6 ml/kg), low weight-based (<0.6 ml/kg), or standard fixed dose (30 ml). Only doses given within 5 days post-injury were evaluated. Percent reduction in ICP was compared pre- and post-dose between dosing groups, and each dose was evaluated as a separate episode. Statistical Analysis: The primary and secondary endpoints for the study were analyzed using mixed-model, repeated-measures analysis of covariance. Results: A total of 97 doses of HTS were evaluated. The primary endpoint of ICP reduction showed a 42.5% decrease in ICP after the administration of a high weight-based dose, a 36.7% reduction after a low weight-based dose, and a 31.5% reduction after a fixed dose. There was no significant relationship between dose group and percent change in ICP (P = 0.25). A sub-analysis of doses received within 48 h postinjury found a significant relationship between both dose group and percent change in ICP, and initial ICP and percent change in ICP (P = 0.04, and <0.0001 respectively). Conclusions: Our data did not show a significant difference between fixed- and weight-based doses of 23.4% HTS for ICP reduction.
Major health care agencies recommend real-time ultrasound (RTUS) guidance during insertion of percutaneous central venous catheters (CVC) based on studies in which CVCs were placed by nonsurgeons. We ...conducted a meta-analysis to compare outcomes for surgeon-performed RTUS-guided CVC insertion versus traditional landmark technique.
A systematic review of the literature was performed, identifying randomized controlled trials (RCT) and prospective "safety studies" of surgeon-performed CVC insertions comparing landmark to RTUS techniques. Searches were conducted in MEDLINE, Cochrane, and Web of Science, with additional relevant articles identified through examination of the bibliographies and citations of the included studies. Two independent reviewers selected relevant studies that matched inclusion criteria, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. A meta-analysis was conducted using random effects models to compare success and complication rates.
Three RCTs were identified totaling 456 patients. The RTUS guidance was associated with better first attempt success (odds ratio OR, 4.7; 95% confidence interval CI, 1.5-14.7, p = 0.008) and overall success (OR 6.5, 95% CI: 2.7-15.7, p < 0.0001). However, there were no differences in overall complication (OR 1.9 (95% CI, 0.8-4.4, p = 0.14)) or arterial puncture (OR 2.0 (95% CI, 0.7-5.6, p = 0.18) rates between the two methods.
Despite many studies involving nonsurgeons, there are only three RCTs comparing RTUS versus landmark technique for surgeon-performed CVC placement. The RTUS guidance is associated with better success than landmark technique, but no difference in complication rates. No study evaluated how RTUS was implemented. Larger studies examining RTUS use during surgeon-performed CVC placements are needed.
Systematic review and meta-analysis, level III.
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