Management of Freely Perforated Diverticulitis Lumpkin, Stephanie T; Chaumont, Nicole
Diseases of the colon & rectum,
2019-October, 2019-10-00, 20191001, Letnik:
62, Številka:
10
Journal Article
Recenzirano
Odprti dostop
CASE SUMMARY:A healthy 65-year-old woman presents to the emergency department with a 12-hour history of sudden-onset severe lower abdominal pain. This is her first episode. She reports nausea, ...vomiting, and anorexia. Her last colonoscopy was at age 60, and was normal, except for diverticulosis of the sigmoid colon. Physical examination is significant for fever, tachycardia, and generalized abdominal pain with rebound tenderness. Pertinent laboratory findings include a leukocytosis and metabolic acidosis. A CT scan is obtained and is consistent with freely perforated diverticulitis, including a thickened sigmoid colon, free fluid in the pelvis, and free air noted near the diaphragm (). The surgeon completes the patient evaluation, recommends initiation of intravenous fluid resuscitation and antibiotics, and plans to go immediately to the operating room for surgical resection.
IMPORTANCE: Factors contributing to underrepresentation of women in surgery are incompletely understood. Pro-male bias and stereotype threat appear to contribute to gender imbalance in surgery. ...OBJECTIVES: To evaluate the association between pro-male gender bias and career engagement and the effect of stereotype threat on skill performance among trainees in academic surgery. DESIGN, SETTING, AND PARTICIPANTS: A 2-phase study with a double-blind, randomized clinical trial component was conducted in 3 academic general surgery training programs. Residents were recruited between August 1 and August 15, 2018, and the study was completed at the end of that academic year. In phase 1, surveys administered 5 to 6 months apart investigated the association of gender bias with career engagement. In phase 2, residents were randomized 1:1 using permuted-block design stratified by site, training level, and gender to receive either a trigger of or protection against stereotype threat. Immediately after the interventions, residents completed the Fundamentals of Laparoscopic Surgery (FLS) assessment followed by a final survey. A total of 131 general surgery residents were recruited; of these 96 individuals with academic career interests met eligibility criteria; 86 residents completed phase 1. Eighty-five residents were randomized in phase 2, and 4 residents in each arm were lost to follow-up. INTERVENTION: Residents read abstracts that either reported that women had worse laparoscopic skill performance than men (trigger of stereotype threat A) or had no difference in performance (protection against stereotype threat B). MAIN OUTCOMES AND MEASURES: Association between perception of pro-male gender bias and career engagement survey scores (phase 1) and stereotype threat intervention and FLS scores (phase 2) were the outcomes. Intention-to-treat analysis was conducted. RESULTS: Seventy-seven residents (38 women 49.4%) completed both phases of the study. The association between pro-male gender bias and career engagement differed by gender (interaction coefficient, −1.19; 95% CI, −1.90 to −0.49; P = .02); higher perception of bias was associated with higher engagement among men (coefficient, 1.02; 95% CI, 0.19-2.24; P = .04), but no significant association was observed among women (coefficient, −0.25; 95% CI, −1.59 to 1.08; P = .50). There was no evidence of a difference in FLS score between interventions (mean SD, A: 395 150 vs B: 367 157; P = .51). The response to stereotype threat activation was similar in men and women (interaction coefficient, 15.1; 95% CI, −124.5 to 154.7; P = .39). The association between stereotype threat activation and FLS score differed by gender across levels of susceptibility to stereotype threat (interaction coefficient, −35.3; 95% CI, −47.0 to −23.6; P = .006). Higher susceptibility to stereotype threat was associated with lower FLS scores among women who received a stereotype threat trigger (coefficient, −43.4; 95% CI, −48.0 to −38.9; P = .001). CONCLUSIONS AND RELEVANCE: Perception of pro-male bias and gender stereotypes may influence career engagement and skill performance, respectively, among surgical trainees. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03623009
Adult colorectal surgery patients continue to have high rates of readmissions, despite known risk factors for non-routine postdischarge care (emergency department (ED) visit or rehospitalization) and ...countless interventions to address these. It is unclear how the difficult-to-quantify patient perspective frames and modifies the impact of these quantifiable risk factors.
We identified consecutive adult inpatient colorectal surgery patients from 2017 to 2018. This mixed methods study merged data from electronic health records and in-depth patient interviews.
We enrolled 258 participants, surveyed 167, and interviewed 18. Depressive symptoms represent one of many risk factors confirmed to increase non-routine healthcare utilization (RR 1.85, 95% CI 1.02–3.37), though the patient perspective explained why these symptoms seemed to greatly impact some patients more than others. Additionally, consistent with patient report, patients with non-routine postdischarge care (26%) were less likely to report communication with their surgical team (80% vs 97%, p < 0.001).
Patient perspectives add depth and understanding of the impact of risk factors on non-routine post-discharge care. This expanded knowledge explains why one patient is more likely to visit an ED close to home whereas another patient might prefer to visit their surgeon’s clinic directly. Effective strategies to reduce unplanned postdischarge care should be tailored.
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•Rigorous mixed methods explain why colorectal surgery patients return to the emergency department.•Self-reported depressive symptoms increase risk of unplanned emergency department visits.•Variations in standard risk prediction statistics are explained by rich-patient narratives.
This mixed methods prospective cohort study integrated quantitative and qualitative findings to understand how and why certain individual risk-factors for readmission led a patient to seek non-routine postdischarge care after surgery, such as an ED visit or rehospitalization. The importance of these findings is that future adaptive implementation studies are warranted to target interventions not only towards discrete risk factors, but also to compensate for a patient’s preferences, background, and values.
As the older adult population increases, hospitals treat more older adults with injuries. After leaving, these patients suffer from decreased mobility and independence, relying on care from others. ...Family members often assume this responsibility, mostly informally and unpaid. Caregivers of other older adult populations have increased stress and decreased caregiver-related quality of life (CRQoL). Validated CRQoL measures are essential to capture their unique experiences. Our objective was to review existing CRQoL measures and their validity in caregivers of older adult trauma patients.
A professional librarian searched published literature from the inception of databases through August 12, 2022 in MEDLINE (via PubMed), Embase (via Elsevier), and CINAHL Complete (via EBSCO). We identified 1063 unique studies of CRQoL in caregivers for adults with injury and performed a systematic review following COnsensus-based Standards for the selection of health Measurement Instruments guidelines for CRQoL measures.
From the 66 studies included, we identified 54 health-related quality-of-life measures and 60 domains capturing caregiver-centered concerns. The majority (83%) of measures included six or fewer CRQoL content domains. Six measures were used in caregivers of older adults with single-system injuries. There were no validated CRQoL measures among caregivers of older adult trauma patients with multisystem injuries.
While many measures exist to assess healthcare-related quality of life, few, if any, adequately assess concerns among caregivers of older adult trauma patients. We found that CRQoL domains, including mental health, emotional health, social functioning, and relationships, are most commonly assessed among caregivers. Future measures should focus on reliability and validity in this specific population to guide interventions.
Readmissions and emergency department (ED) visits after colorectal surgery (CRS) are common, burdensome, and costly. Effective strategies to reduce these unplanned postdischarge health care visits ...require a nuanced understanding of how and why patients make the decision to seek care. We used a purposefully stratified sample of 18 interview participants from a prospective cohort of adult CRS patients. Thirteen (72%) participants had an unplanned postdischarge health care visit. Participant decision-making was classified by methodology (algorithmic, guided, or impulsive), preexisting rationale, and emotional response to perceived health care needs. Participants voiced clear mental algorithms about when to visit an ED. In addition, participants identified facilitators and barriers to optimal health care use. They also identified tangible targets for health care utilization reduction efforts, such as improved care coordination with streamlined discharge instructions and improved communication with the surgical team. Efforts should be directed at improving postdischarge communication and care coordination to reduce CRS patients’ high-resource health care utilization.
Background
Fatigue after thyroidectomy is common, but there is a paucity of data regarding its prevalence and duration. We hypothesized that total thyroidectomy (TT) patients would have more ...long-term fatigue than thyroid lobectomy (TL) patients.
Methods
Statewide survey of thyroidectomy patients (2004-2017) was carried out.
Results
281 patients completed the survey. 216 respondents (77%) had TT and 65 (23%) had TL. Within one year of surgery, 172 (61%) respondents recalled being troubled by new fatigue all, most, or some of the time. Total thyroidectomy patients were more likely to report new fatigue (69% vs. 44%, aOR 2.72, 95% CI 1.44 to 5.18). Of patients (n = 172) reporting new fatigue, 67 (39%) reported at least moderate improvement. Nineteen (28%) saw improvement within 1 year, 35 (52%) saw improvement in 1-2 years, and 11 (16%) saw improvement after 2 years.
Conclusion
Long-term fatigue after TT can be debilitating, long-lasting, and less prevalent after TL.
Background
It is unknown if opioid naïve patients who undergo minimally invasive, benign foregut operations are at risk for progressing to persistent postoperative opioid use. The purpose of our ...study was to determine if opioid naïve patients who undergo minimally invasive, benign foregut operations progress to persistent postoperative opioid use and to identify any patient- and surgery-specific factors associated with persistent postoperative opioid use.
Methods
Opioid-naïve, adult patients who underwent laparoscopic fundoplication, hiatal hernia repair, or Heller myotomy from 2010 to 2018 were identified within the IBM® MarketScan® Commercial Claims and Encounters Database. Daily drug logs of the preoperative and postoperative period were evaluated to assess for changes in drug use patters. The primary outcome of interest was persistent postoperative opioid use, defined as at least 33% of the proportion of days covered by opioid prescriptions at 365-day follow-up. Patient demographic information and clinical risk factors for persistent postoperative opioid use at 365 days postoperatively were estimated using log-binomial regression.
Results
A total of 17,530 patients met inclusion criteria; 6895 underwent fundoplication, 9235 underwent hiatal hernia repair, and 1400 underwent Heller myotomy. 9652 patients had at least one opioid prescription filled in the perioperative period. Sixty-five patients (0.4%) were found to have persistent postoperative opioid use at 365 days postoperatively. Lower Charlson comorbidity index scores and a history of mental illness or substance use disorder had a statistically but not clinically significant protective effect on the risk of persistent postoperative opioid use at 365 days postoperatively.
Conclusions
Only half of opioid naïve patients undergoing minimally invasive, benign foregut operations filled an opioid prescription postoperatively. The risk of progression to persistent postoperative opioid use was less than 1%. These findings support the current guidelines that limit the number of opioid pills prescribed following general surgery operations.
BACKGROUND:Thirty-day readmissions, emergency department visits, and observation stays are common after colorectal surgery (9%–25%, 8%–12%, and 3%–5%), yet it is unknown to what extent planned ...postdischarge care can decrease the frequency of emergency department visits.
OBJECTIVE:This study’s aim was to determine whether early follow-up with the surgical team reduces 30-day emergency department visits.
DESIGN:This retrospective cohort study used a central data repository of clinical and administrative data for 2013 through 2018.
SETTING:This study was conducted in a large statewide health care system (10 affiliated hospitals, >300 practices).
PATIENTS:All adult patients undergoing colorectal surgery were included unless they had a length of stay <1 day or died during the index hospitalization.
INTERVENTION:Early (<10 days after discharge) versus late (≥10 days) follow-up at the outpatient surgery clinic, or no outpatient surgery clinic follow-up, was assessed.
MAIN OUTCOME MEASURES:The primary outcome measured was the time to 30-day postdischarge emergency department visit.
RESULTS:Our cohort included 3442 patients undergoing colorectal surgery; 38% of patients had an early clinic visit. Overall, 11% had an emergency department encounter between 11 and 30 days after discharge. Those with early follow-up had decreased emergency department encounters (adjusted HR 0.13; 95% CI, 0.08–0.22). An early clinic visit within 10 days, compared to 14 days, prevented an additional 142 emergency department encounters. Nationwide, this could potentially prevent 8433 unplanned visits each year with an estimated cost savings of $49 million annually.
LIMITATIONS:We used retrospective data and were unable to assess for health care utilization outside our health system.
CONCLUSIONS:Early follow-up within 10 days of adult colorectal surgery is associated with decreased subsequent emergency department encounters. See Video Abstract at http://links.lww.com/DCR/B330.
EL SEGUIMIENTO TEMPRANO DESPUÉS DE LA CIRUGÍA COLORRECTAL REDUCE LAS VISITAS AL SERVICIO DE URGENCIAS POSTERIOR AL ALTALos readmisión a los treinta días, las visitas al servicio de urgencias y las estancias de observación son comunes después de la cirugía colorrectal, 9-25%, 8-12% y 3-5%, respectivamente. Sin embargo, se desconoce en qué medida la atención planificada posterior al alta puede disminuir la frecuencia de las visitas al servicio de urgencias.Determinar si el seguimiento temprano con el equipo quirúrgico reduce las visitas a 30 días al servicio de urgencias.Este estudio de cohorte retrospectivo utilizó un depósito central de datos clínicos y administrativos para 2013-2018.Gran sistema de salud estatal (10 hospitales afiliados,> 300 consultorios).Se incluyeron todos los pacientes adultos de cirugía colorrectal a menos que tuvieran una estadía <1 día o murieran durante el índice de hospitalización.Temprano (<10 días después del alta) versus tardío (≥10 días) o sin seguimiento en la clínica de cirugía ambulatoria.Tiempo para la visita al servicio de urgencias a 30 días después del alta.Nuestra cohorte incluyó 3.442 pacientes de cirugía colorrectal; El 38% de los pacientes tuvieron una visita temprana a clínica. En total, el 11% tuvo un encuentro con el servicio de urgencias entre 11 y 30 días después de ser dado de alta. Aquellos con seguimiento temprano disminuyeron las visitas al servicio de urgencias (HR 0,13; IC del 95%0,08 a 0,22). Además, una visita temprana a la clínica en un plazo de 10 días, en comparación con 14 días, evitó 142 encuentros adicionales en el servicio de urgencias. A nivel nacional, esto podría prevenir 8.433 visitas no planificadas cada año con un ahorro estimado de $ 49 millones anuales.Utilizamos datos retrospectivos y no pudimos evaluar la utilización de la atención médica fuera de nuestro sistema de salud.El seguimiento temprano dentro de los 10 días de la cirugía colorrectal en adultos se asocia con una disminución de los encuentros posteriores en el servicio de urgencias. Consulte Video Resumen en http://links.lww.com/DCR/B330. (Traducción—Dr. Gonzalo Hagerman)
Abstract Background Patient satisfaction is often measured using the Hospital Consumer Assessment of Healthcare Providers and Systems survey. Our aim was to examine the structural and clinical ...determinants of satisfaction among inpatients with prolonged lengths of stays (LOS). Methods Adult patients who were admitted between 2009 and 2012, had a LOS of 21 days or more, and completed the Hospital Consumer Assessment of Healthcare Providers and Systems survey, were included. Univariate analyses assessed the relationship between satisfaction and patient/system variables. Recursive partitioning was used to examine the relative importance of the identified variables. Results One hundred one patients met inclusion criteria. The average LOS was 35 days and 58% were admitted to a surgical service. Satisfaction with physician communication was significantly associated with fewer consultations ( P < .01), nonoperative admission ( P < .001), no intensive care unit stay ( P < .01), nonsurgical service ( P < .01), and non-emergency room admissions ( P = .03). Among these, having fewer consultations had the highest relative importance. Conclusions In long stay patients, having fewer inpatient consultations was the strongest predictor of patient satisfaction with physician communication. This suggests that examination of patient-level data in clinically relevant subgroups may be a useful way to identify targets for quality improvement.
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