RESUMEN
Background: Patients with prior abdominal surgeries are at higher risk for intra-abdominal adhesive tissue formation and subsequently higher risk for small bowel obstruction (SBO).Purpose: In this study, we investigated whether surgical intervention for SBO was more likely following specific types of abdominal surgeries.Research Design: With retrospective chart review, we pooled data from 799 patients, ages 18 to 89, admitted with SBO between 2012 and 2019. Patients were evaluated based on whether they underwent surgery or were managed conservatively. They were further compared with regard to past surgical history by way of type of abdominal surgery (or surgeries) undergone prior to admission.Results: Of the 799 patients admitted for SBO, 206 underwent surgical intervention while 593 were managed nonoperatively. There was no significant difference in number of prior surgeries (2.07 ± 1.56 vs 2.36 ± 2.11, P = .07) or in number of comorbidities (2.39 ± 1.97 vs 2.65 ± 1.93, P = .09) for surgical vs non-surgical intervention. Additionally, of the operations evaluated, no specific type of abdominal surgery predicted need for surgical intervention in the setting of SBO. However, for both surgical and non-surgical intervention following SBO, pelvic surgery was the most common type of prior abdominal surgery (45% vs 43%). There are significantly more female pelvic surgeries in both the operative (91.4% vs 8.6%, P < .0001) and nonoperative groups (89.9% vs 10.2%, P < .0001).Conclusion: Ultimately, no specific type of prior operation predicted the need for surgical intervention in the setting of SBO.
Asunto(s)
Obstrucción Intestinal , Intestino Delgado , Humanos , Obstrucción Intestinal/cirugía , Obstrucción Intestinal/etiología , Femenino , Masculino , Estudios Retrospectivos , Persona de Mediana Edad , Intestino Delgado/cirugía , Anciano , Adulto , Anciano de 80 o más Años , Adolescente , Adulto Joven , Adherencias Tisulares/cirugía , Adherencias Tisulares/complicaciones , Tratamiento ConservadorRESUMEN
Small bowel obstruction (SBO) impacts the health care system and patient quality of life. Previously, we evaluated differences between medical and surgical admissions in the management of SBO. This study investigates indications for readmission based on original admission to medical (MS) or surgical services (SS). A retrospective chart review was performed for 799 patients aged 18 to 89 admitted between 2012 and 2019 with a diagnosis of SBO. Patient characteristics examined included length of stay (LOS), prior abdominal operations, prior SBO, use of small bowel follow through imaging, operative intervention, mortality, and 30-day readmission. There was no difference in readmission rates in patients originally admitted to MS or SS (13.2% vs 12.7%, P = .86). Patients admitted to SS were more likely to be readmitted for recurrent SBO (39% vs 8.6%, P = .006). Patients admitted to MS were more likely to be readmitted for other reasons (73.9% v. 40.2%, P = .004). In the MS cohort, 30.4% (7 patients) had surgery during their initial admission for SBO, and none of those patients were readmitted for recurrent SBO (rSBO). In the SS cohort, 23% had surgery during their initial admission and 31.6% were readmitted for rSBO (P = .002). Patients admitted to SS were more likely to be readmitted for rSBO and to require surgery. Patients admitted to MS were more likely to be readmitted for other reasons. None of the MS patients who had surgery were readmitted for SBO. 31.6% of SS patients who had surgery were readmitted for SBO.
Asunto(s)
Obstrucción Intestinal , Intestino Delgado , Readmisión del Paciente , Humanos , Obstrucción Intestinal/cirugía , Readmisión del Paciente/estadística & datos numéricos , Persona de Mediana Edad , Estudios Retrospectivos , Anciano , Masculino , Femenino , Intestino Delgado/cirugía , Adulto , Anciano de 80 o más Años , Adolescente , Adulto Joven , Tiempo de Internación/estadística & datos numéricos , RecurrenciaAsunto(s)
Cirugía General/organización & administración , Prejuicio , Sociedades Médicas/organización & administración , Cirugía General/estadística & datos numéricos , Humanos , Tutoría , Cultura Organizacional , Objetivos Organizacionales , Grupo Paritario , Comunicación Persuasiva , Médicos Mujeres , Salarios y Beneficios , Sexismo , Red Social , Sudeste de Estados UnidosRESUMEN
The development of surgical attire is well documented in historical photographs and evolved in response to the changing understanding of aseptic and antiseptic techniques. Surgeons throughout time remained significantly opposed to changes in attire, and it was over a century that we evolved from wearing black frock coats to the current attire of today. Interestingly, surgical attire remains a source of controversy even today, with a recent argument regarding skull versus bouffant caps that was quite publicly debated.
Asunto(s)
Vestimenta Quirúrgica/historia , Asepsia/historia , Europa (Continente) , Historia del Siglo XIX , Historia del Siglo XX , Historia del Siglo XXI , Humanos , Estados UnidosRESUMEN
Colorectal cancer remains common, with the "80 per cent by 2018" initiative proposed by the National Colorectal Cancer Roundtable. This study was designed to examine obstacles for patients who did not receive their scheduled colonoscopy, focusing on the impact of insurance status. Retrospective chart review was carried out on patients who did not complete their colonoscopy as scheduled from January 2013 to June 2017. The control group consisted of patients who completed their scheduled colonoscopy. One hundred and seventy five patients missed 200 colonoscopies. The most common reasons for cancellation were patient illness (16%), no-show (14%), no prep carried out (13%), inadequate prep (10%), and no transportation (11%). The canceled patients were significantly more likely to have the combination of no insurance and no Primary Care Provider (PCP) (13% vs 4%, P = 0.008), personal history of cancer (22% vs 12%, P = 0.02), and higher rates of prior GI issues (78% vs 50%, P < 0.001). The canceled group had a significantly lower history of colon polyps (37% vs 53%, P = 0.006). Difficulty with the bowel prep in addition to lack of insurance and poverty likely does create a barrier, even in a system that has a safety net, atop other issues such as transportation and inability to miss work playing a role.
Asunto(s)
Colonoscopía , Accesibilidad a los Servicios de Salud , Pacientes no Asegurados , Pacientes no Presentados , Mejoramiento de la Calidad , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Adulto JovenRESUMEN
BACKGROUND: The acute care surgery (ACS) model has been widely implemented, with single institution studies demonstrating improved outcomes but multicenter studies questioning the efficiency. Acute care surgery programs care for sicker and more economically disadvantaged patients. This study compares outcomes between ACS and traditional models in the management of diverticulitis across an entire state. STUDY DESIGN: The Virginia Health Information administrative database for adults discharged with diverticulitis from January 2008 through September 2015, was reviewed. Patient characteristics were analyzed and compared between ACS and traditional models. Outcome differences were compared using logistic regression. RESULTS: We reviewed 23,943 admissions, with 2,330 (9.7%) patients cared for in ACS programs. The ACS patients were more likely to be uninsured (10.6% vs 6.8%, p < 0.0001) or covered by Medicaid (5.5% vs 3.4%, p < 0.0001), and the ACS hospitals cared for a higher percentage of minority patients than in the traditional programs (30.4% vs 19.8%, p < 0.0001). Operative rates were higher in ACS hospitals (14.7% vs 11.8%, p < 0.0001), as were rates of complicated diverticulitis (24.5% vs 20.3%, p < 0.0001). The ACS patients had significantly higher rates of comorbidities. After adjusting for patient comorbidities and demographics, ACS patients had a higher rate of complications (odds ratio [OR] 1.36, p = 0.0017). However, there was no difference in mortality, length of stay, or costs. When comparing only operative patients, there were no outcome differences after adjusting for patient factors. CONCLUSIONS: Acute care surgery patients present to the hospital with more severe disease, higher rates of medical comorbidities, and lower socioeconomic status. Once patient factors are accounted for, outcomes are equivalent for operative patients in either model. Acute care surgery hospitals provide high quality and efficient care to sicker and more complex patients than traditional programs.
Asunto(s)
Cuidados Críticos , Diverticulitis/cirugía , Enfermedad Aguda , Adulto , Anciano , Diverticulitis/complicaciones , Diverticulitis/mortalidad , Femenino , Hospitalización , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores Socioeconómicos , Resultado del Tratamiento , VirginiaRESUMEN
BACKGROUND: The acute care surgery (ACS) model has been widely implemented with single institution studies demonstrating improved outcomes. Recent multicenter studies have raised questions about the economics and efficacy of ACS. This study compares traditional and ACS outcomes across an entire state. METHODS: A retrospective review of Virginia's Health Information administrative database was completed. Adults admitted with appendicitis or cholecystitis between 2008 and 2014 were included. Hospital administration was contacted to determine surgical model. To compare patient characteristics, t-test and chi-square analyses were used. Total charges and length of stay (LOS) differences between ACS and traditional were examined using generalized linear models, whereas logistic regression was used for the presence of complications and 30-day mortality. RESULTS: Overall, the ACS model showed an increased proportion of uninsured patients with a higher rate of comorbidities. In the appendicitis subgroup, (n = 22,011; ACS n = 1993), ACS patients had higher total charges ($30,060 versus $28,460, P = 0.013), longer LOS (3.31 versus 2.92 d, P < 0.001), and higher chance of complications (odds ratio [OR] = 1.2, P = 0.016) and mortality (OR = 2.4, P = 0.029). After adjustment for comorbidities and insurance, mortality was no longer significantly different. In the cholecystitis group (n = 6936; ACS n = 777), ACS patients had a longer LOS (4.55 versus 4.13 d; P = 0.009) without significant differences in mortality, complications, or cost. There were no significant differences after adjustment for patient characteristics. CONCLUSIONS: ACS patients in Virginia have a higher rate of medical comorbidities and uninsured status, with slightly worse outcomes than the traditional model for appendicitis. Further studies to determine which patients benefit the most from ACS are warranted.
Asunto(s)
Apendicitis/cirugía , Colecistitis/cirugía , Cuidados Críticos/economía , Cuidados Críticos/métodos , Complicaciones Posoperatorias/epidemiología , Enfermedad Aguda , Adulto , Anciano , Apendicectomía/efectos adversos , Apendicectomía/economía , Apendicitis/complicaciones , Apendicitis/mortalidad , Procedimientos Quirúrgicos del Sistema Biliar/efectos adversos , Procedimientos Quirúrgicos del Sistema Biliar/economía , Colecistitis/complicaciones , Colecistitis/mortalidad , Comorbilidad , Cuidados Críticos/organización & administración , Costos de la Atención en Salud , Humanos , Tiempo de Internación , Pacientes no Asegurados , Persona de Mediana Edad , Modelos Teóricos , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , VirginiaRESUMEN
OBJECTIVE: Speed mentoring has recently been used by several medical organizations as a strategy to establish mentoring relationships, which are felt to be critically important in the development of the surgeon. This study assesses a surgical speed-mentoring program at the 2015 American College of Surgeons (ACS) Clinical Congress. DESIGN: A steering committee designed the speed-mentoring program to match 60 ACS Resident and Associate Society mentees with a mix of junior and senior leadership of ACS. Each mentee met with 5 mentors for 10 minutes each during the 1 hour session. After participation in the activity, surveys were provided to assess the event. The survey included forced-choice questions using Likert-scales as well as open-ended questions. Mentor and mentee responses were compared using Medcalc software using comparison of means and comparison of proportion, with p < 0.05 considered significant. SETTING: The study was undertaken at the 2015 ACS Clinical Congress. PARTICIPANTS: A total of 60 mentors and 49 mentees participated in the inaugural ACS Speed-Mentoring activity. The postactivity survey was completed by 54 mentors (90%) and 39 mentees (79.5%). RESULTS: There was a high level of satisfaction with the activity, with 100% of mentors and mentees stating that they would recommend the activity to a colleague. There was overall high satisfaction with the organization of the session by both the mentors and the mentees although the mentors were more likely to feel that they needed more time for each interaction. More mentees (93%) than mentors (68.5%) felt they were likely to develop a mentoring relationship with one of their matches outside of the organized session. CONCLUSIONS: We demonstrated that a speed-mentoring event at a national surgical meeting offers an effective platform for mentoring and is mutually beneficial to both mentors and mentees. Data collected here will be used to modify and improve the design of future speed-mentoring sessions.
Asunto(s)
Competencia Clínica , Cirugía General/educación , Relaciones Interprofesionales , Tutoría/organización & administración , Mentores/estadística & datos numéricos , Adulto , Congresos como Asunto , Estudios Transversales , Femenino , Humanos , Internado y Residencia/organización & administración , Masculino , Evaluación de Programas y Proyectos de Salud , Mejoramiento de la Calidad , Sociedades Médicas , Estados UnidosRESUMEN
INTRO: The mental workload associated with laparoscopic suturing can be assessed with a secondary task that requires the same visual-spatial attentional resources. The purpose of this study was to use a secondary task to measure the incremental workload demands of single-incision laparoscopic surgery (SILS) procedures versus traditional laparoscopic procedures. METHOD: 12 surgery residents and surgical assistants who had met FLS criteria on an FLS and SILS simulator performed one trial each of peg transfer, cutting, and intracorporeal suturing tasks simultaneously with the secondary task and provided subjective workload ratings using the NASA-TLX. RESULTS: SILS procedures resulted in lower primary and secondary task scores, p < 0.001 and higher workload ratings, p < 0.0001. Suturing resulted in lower primary (p < 0.003) and secondary task scores (p < 0.017) and higher workload ratings (p < 0.017) compared to the other tasks. CONCLUSIONS: SILS procedures were significantly more mentally demanding than traditional laparoscopic procedures corroborated by primary and secondary tasks scores and subjective ratings.
Asunto(s)
Atención , Cognición , Laparoscopía/educación , Laparoscopía/métodos , Análisis y Desempeño de Tareas , Carga de Trabajo , Competencia Clínica , Humanos , Entrenamiento SimuladoRESUMEN
BACKGROUND: The effects of refraining from practice for different intervals on laparoscopic suturing and mental workload was assessed with a secondary task developed by the authors. We expected the inability to practice to produce a decrease in performance on the suturing, knot tying, and secondary task and skills to rebound after a single refresher session. METHODS: In total, 22 surgical assistant and premedical students trained to Fundamentals of Laparoscopic Surgery proficiency in intracorporeal suturing and knot tying were assessed on that task using a secondary task. Participants refrained from practicing any Fundamentals of Laparoscopic Surgery tasks for 1 or 5 months. At the time of their return, they were assessed immediately on suturing and knot tying with the secondary task, practiced suturing and knot tying for 40 minutes, and then were reassessed. RESULTS: The mean suture times from the initial reassessment were greater than the proficiency times but returned to proficiency levels after one practice session, F(2, 40) = 14.5, P < .001, partial η2 = .420. Secondary task scores mirrored the results of suturing time, F(2, 40) = 6.128, P < .005, partial η2 = .235, and were moderated by retention interval. CONCLUSION: When participants who reached proficiency in suturing and knot tying were reassessed after either 1or 5 months without practice, their performance times increased by 35% and secondary task scores decreased by 30%. These deficits, however, were nearly reversed after a single refresher session.
Asunto(s)
Curriculum , Laparoscopía/educación , Retención en Psicología , Técnicas de Sutura/educación , Adulto , Competencia Clínica , Femenino , Humanos , Masculino , Factores de Tiempo , Carga de Trabajo , Adulto JovenRESUMEN
There are several treatments available for choledocholithiasis, but the optimal treatment is highly debated. Some advocate preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) with cholangiography (IOC). Others advocate initial LC + IOC followed by common bile duct exploration or ERCP. The purpose of this study was to determine whether initial LC + IOC had a shorter length of stay (LOS) compared with preoperative magnetic resonance cholangiopancreatography (MRCP) or ERCP. Patients who underwent cholecystectomy between 2012 and 2013 at two institutions were reviewed. Patients were selected if they had suspected choledocholithiasis, indicated by dilated CBD and/or elevated bilirubin, or confirmed choledocholithiasis. They were excluded if they had pancreatitis or cholangitis. There were 126 patients with suspected choledocholithiasis in this study. Of these, 97 patients underwent initial LC ± IOC with an average LOS of 3.9 days. IOC was negative in 47.4 per cent patients, and they had a shorter LOS compared with positive IOC patients (2.93 vs 4.82, P < 0.001). Laparoscopic common bile duct exploration was successful in 64.7 per cent and had a shorter LOS compared with postoperative ERCP patients (P = 0.01). Preoperative MRCP was performed in 21 patients with an average LOS of 6.48 days. Preoperative ERCP was performed in eight patients with an average LOS of seven days. Initial LC+IOC is associated with a shorter LOS compared to preoperative MRCP or ERCP. It is recommended as the optimal treatment choice for suspected choledocholithiasis.
Asunto(s)
Colangiopancreatografia Retrógrada Endoscópica , Pancreatocolangiografía por Resonancia Magnética , Colecistectomía Laparoscópica , Coledocolitiasis/terapia , Tiempo de Internación , Adulto , Algoritmos , Colangiografía , Femenino , Humanos , Periodo Intraoperatorio , Masculino , Persona de Mediana Edad , Cuidados Preoperatorios , Estudios RetrospectivosRESUMEN
INTRODUCTION: Residencies are required to have a standardized process for transitioning patient care. This study was designed to assess a novel method of training and evaluating handoffs using both a lecture format and standardized patient (SP) interactions. METHODS: Matched group design was used to randomly assign interns to trained versus control groups, with the trained group receiving formal handoff training before SP encounters. The residents evaluated three ER SPs and read four written scenarios and then transitioned patients to an SP acting as a resident. All handoffs were videotaped and scored by two blind raters using a rating scale developed based on specialist's interviews. RESULTS: Thirty-two interns were included in the study. The trained interns performed significantly better with lower scores on patient handoffs (mean = 10.08, SD = 2.46) than the untrained interns (mean = 16.56, SD = 2.79). There was also a significant effect for case, with the ER SP cases (mean = 12.23, SD = 14.41) resulting in better performance than the written cases in both surgery and pediatrics (mean = 14.41, SD = 4.29). CONCLUSIONS: A protocol was designed and implemented for training residents to perform handoffs, with initial results showing that the curriculum is effective.
Asunto(s)
Servicio de Urgencia en Hospital/organización & administración , Internado y Residencia/métodos , Pase de Guardia , Cirugía General/educación , Humanos , Errores Médicos/prevención & control , Pediatría/educación , Aprendizaje Basado en ProblemasRESUMEN
INTRODUCTION: A spatial secondary task developed by the authors was used to measure the mental workload of the participant when transferring suturing skills from a box simulator to more realistic surgical conditions using a fresh cadaver. We hypothesized that laparoscopic suturing on genuine bowel would be more challenging than on the Fundamentals of Laparoscopic Surgery (FLS)-simulated bowel as reflected in differences on both suturing and secondary task scores. METHODS: We trained 14 surgical assistant students to FLS proficiency in intracorporeal suturing. Participants practiced suturing on the FLS box for 30 minutes and then were tested on both the FLS box and the bowel of a fresh cadaver using the spatial, secondary dual-task conditions developed by the authors. RESULTS: Suturing times increased by >333% when moving from the FLS platform to the cadaver F(1,13) = 44.04, P < .001. The increased completion times were accompanied by a 70% decrease in secondary task scores, F(1,13) = 21.21, P < .001. CONCLUSION: The mental workload associated with intracorporeal suturing increases dramatically when trainees transfer from the FLS platform to human tissue under more realistic conditions of suturing. The increase in mental workload is indexed by both an increase in suturing times and a decrease in the ability to attend to the secondary task.
Asunto(s)
Atención/fisiología , Laparoscopía/educación , Procesos Mentales/fisiología , Técnicas de Sutura/educación , Transferencia de Experiencia en Psicología/fisiología , Adulto , Cadáver , Competencia Clínica , Femenino , Humanos , Masculino , Modelos Anatómicos , Entrenamiento Simulado , Análisis y Desempeño de Tareas , Adulto JovenRESUMEN
The objective of this study was to investigate the feasibility of using ultrasound (US) in place of portable chest x-ray (CXR) for the rapid detection of a traumatic pneumothorax (PTX) requiring urgent decompression in the trauma bay. All patients who presented as a trauma alert to a single institution from August 2011 to May 2012 underwent an extended focused assessment with sonography for trauma (FAST). The thoracic cavity was examined using four-view US imaging and were interpreted by a chief resident (Postgraduate Year 4) or attending staff. US results were compared with CXR and chest computed tomography (CT) scans, when obtained. The average age was 37.8 years and 68 per cent of the patients were male. Blunt injury occurred in 87 per cent and penetrating injury in 12 per cent of activations. US was able to predict the absence of PTX on CXR with a sensitivity of 93.8 per cent, specificity of 98 per cent, and a negative predictive value of 99.9 per cent compared with CXR. The only missed PTX seen on CXR was a small, low anterior, loculated PTX that was stable for transport to CT. The use of thoracic US during the FAST can rapidly and safely detect the absence of a clinically significant PTX. US can replace routine CXR obtained in the trauma bay and allow more rapid initiation of definitive imaging studies.
Asunto(s)
Neumotórax/diagnóstico , Radiografía Torácica/métodos , Tomografía Computarizada por Rayos X , Centros Traumatológicos , Heridas y Lesiones/diagnóstico por imagen , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Factibilidad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Neumotórax/etiología , Valor Predictivo de las Pruebas , Curva ROC , Reproducibilidad de los Resultados , Estudios Retrospectivos , Índices de Gravedad del Trauma , Ultrasonografía , Heridas y Lesiones/complicaciones , Adulto JovenRESUMEN
Procalcitonin is used as a marker for sepsis but there is little known about the correlation of the procalcitonin elevation with the causative organism in sepsis. All patients aged 18 to 80 years who were admitted to the surgery service from June 2010 to May 2012 and who had a procalcitonin drawn were evaluated. Culture data were reviewed to determine the causative organism. Infections analyzed included pneumonia, urinary tract infection (UTI), bloodstream infection, and Clostridium difficile. Other parameters assessed included reason for admission, body mass index, pressor use, antibiotic duration, and disposition. Two hundred thirty-two patient records were reviewed. Patients without a known infection/source of sepsis had a mean procalcitonin of 3.95. Those with pneumonia had a procalcitonin of 20.59 (P = 0.03). Those with a UTI had a mean procalcitonin of 66.84 (P = 0.0005). Patients with a bloodstream infection had a mean procalcitonin of 33.30 (P = 0.003). Those with C. difficile had a procalcitonin of 47.20 (P = 0.004). When broken down by causative organisms, those with Gram-positive sepsis had a procalcitonin of 23.10 (P = 0.02) compared with those with Gram-negative sepsis at 32.75 (P = 0.02). Those with fungal infections had a procalcitonin of 42.90 (P = 0.001). These data suggest that procalcitonin elevation can help guide treatment by indicating likely causative organism and infection type. These data may provide a good marker for initiation of antifungal therapy.
Asunto(s)
Infecciones Bacterianas/sangre , Infecciones Bacterianas/diagnóstico , Calcitonina/sangre , Precursores de Proteínas/sangre , Sepsis/sangre , Sepsis/diagnóstico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Infecciones Bacterianas/microbiología , Biomarcadores/sangre , Péptido Relacionado con Gen de Calcitonina , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neumonía/sangre , Neumonía/diagnóstico , Sepsis/microbiología , Adulto JovenRESUMEN
Withdrawal of care has increased in recent years as the population older than 65 years of age has increased. We sought to investigate the impact of this decision on our mortality rate. We retrospectively reviewed a prospectively collected database to determine the percentage of cases in which care was actively withdrawn. Neurologic injury as the cause for withdrawal, age of the patient, number of days to death, number of cases thought to be treatment failures, and the reason for failure were analyzed. Between January 2008 and December 2012, there were 536 trauma service deaths; 158 (29.5%) had care withdrawn. These patients were 67 (± 18.5) years old and neurologic injury was responsible in 63 per cent (± 5.29%). Fifty-two per cent of the patients died by Day 3; 65 per cent by Day 5; and 74 per cent Day 7. A total of 22.7 per cent (± 7.9%) could be considered a treatment failure. Accounting for cases in which care was withdrawn for futility would decrease the overall mortality rate by approximately 23 per cent. Trauma center mortality calculation does not account for care withdrawn. Treating an active, aging population, with advance directives, requires methodologies that account for such decision-making when determining mortality rates.
Asunto(s)
Mortalidad Hospitalaria , Privación de Tratamiento , Heridas y Lesiones/mortalidad , Factores de Edad , Anciano , Toma de Decisiones , Femenino , Humanos , Unidades de Cuidados Intensivos , Masculino , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Centros Traumatológicos , Virginia/epidemiologíaRESUMEN
Reduction of hospital-acquired infections is a patient safety goal and regularly monitored by Performance Improvement committees. There is discordance between the ventilator-associated pneumonia (VAP) rate reported by the Infection Control Committee (ICC) and that observed by our Trauma Service. To investigate this difference, a retrospective evaluation of cases of VAP diagnosed on a single service was undertaken. A prospectively collected database was queried for VAP in intensive care unit patients between January 2010 and June 2011. This was compared with the list of mechanically ventilated patients provided by the ICC. Comparison for criteria used to diagnose pneumonia, ventilator day of the diagnosis, was recorded. The ICC identified two VAPs from 136 potential patients compared with the Trauma Service identifying 36 VAPs. A difference in diagnostic criteria between the ICC and the Trauma Service focused on use of the National Nosocomial Infection Survey (NNIS) algorithm versus quantitative microbiology from bronchoalveolar lavage specimens. Thirty-five of 36 Trauma Service VAPs were not identified as VAPs by the NNIS algorithm as a result of the chest radiographs. Application of differing definitions of VAP results in markedly different VAP rates. The difference has significant implications as infection rates are increasingly reported as a quality metric.
Asunto(s)
Neumonía Asociada al Ventilador/diagnóstico , Neumonía Asociada al Ventilador/epidemiología , Algoritmos , Lavado Broncoalveolar , Femenino , Humanos , Incidencia , Masculino , Valor Predictivo de las Pruebas , Radiografía Torácica , Estudios Retrospectivos , Sensibilidad y Especificidad , Centros Traumatológicos , Virginia/epidemiologíaRESUMEN
Squamous cell carcinoma of the anus is rare, but more common in men with human immunodeficiency virus (HIV). We describe our findings in 50 biopsies done on 37 HIV-positive men over 5 years. The men were referred from our HIV clinic for abnormal cytology on anal pap or anal condyloma. Thirty-seven patients were referred from the HIV clinic for abnormal cytology on anal pap or the presence of anal condyloma. Biopsies were done in the operating room using acetic acid to visually localize areas of dysplasia. If no abnormalities were seen, biopsies were taken from each quadrant of the anus. A retrospective review was done for biopsy indication, pathology, recurrence, and correlation with anal pap results. On initial biopsy, anal condyloma conferred the presence of anal intraepithelial neoplasia (AIN) in 64.7 per cent (11 of 17), abnormal paps in 83.3 per cent (10 of 12), and both in 50 per cent (3 of 6). Patients with anal condyloma had AIN in an average of 2.5 quadrants whereas those with abnormal cytology had AIN in 2.3 quadrants. Thirty-four of 50 biopsies showed abnormalities (68%), with AIN present in 32 cases, one case of carcinoma in situ, and one case of invasive carcinoma. Aldara was used nine times with improvement in four cases. In HIV-positive men, the presence of condyloma warrants surgical biopsy. Performing anal cytology on patients with anal condyloma did not increase the rate of positive results. Patients with AIN often had disease in more than two quadrants, making surgical excision problematic.
Asunto(s)
Neoplasias del Ano/patología , Carcinoma in Situ/patología , Carcinoma de Células Escamosas/patología , Seropositividad para VIH , Biopsia , Humanos , Masculino , Tamizaje Masivo , Recurrencia Local de Neoplasia , Infecciones por Papillomavirus/patología , Estudios RetrospectivosRESUMEN
Cervical spine (CS) injury occurs in 1 to 3 per cent of blunt trauma patients. The goal of this study is to evaluate the use of magnetic resonance imaging (MRI) as an adjunct to CS computed tomography (CT) in the presence of persistent pain with a normal physical examination or obtundation. A retrospective chart review was performed on 389 blunt trauma patients undergoing both CS CT and MRI between 2007 and 2010. Abnormal CT findings were found in 199. The remaining 190 patients with normal CT scans underwent MRI for persistent pain (109), neurologic symptoms (57), or obtundation (24). Motor vehicle crashes predominated (50%) followed by falls (19%) and motorcycle crashes (12%). In the patients with persistent pain, CT showed no acute injury (89%) with subsequent MRI demonstrating ligamentous edema or injury not seen on CT in 12 per cent of patients. No patient required an operation for CS instability. All the obtunded patients demonstrated localizing motion of four extremities. MRI of these patients demonstrated ligamentous edema or injury not seen on CT in 20 per cent of patients. No obtunded patient had CS instability or needed operative intervention. A localizing physical examination in conjunction with normal CS CT safely precludes a CS injury requiring cervical fixation. MRI does not add substantially to this decision-making and the cervical collar can be safely removed.