Venous thromboembolism prophylaxis in neurosurgical trauma patients.

BACKGROUND: Venous thromboembolisms (VTEs) occur more frequently in patients with traumatic brain injuries (TBIs) and spinal cord injuries, yet the use of chemoprophylaxis is controversial. The purpose of this study was to investigate the relationship between the timing of chemical VTE prophylaxis initiation and the development of VTE events in these patients. METHODS: Prospective data were collected and retrospectively reviewed on 1425 patients sustaining TBIs or spinal injuries from 2010 to 2014. Patients were reviewed with respect to age, gender, injury severity score, Glasgow coma score, and mechanism of injury as well as timing of initiation of chemical VTE prophylaxis and presence or absence of VTE. RESULTS: Patients who developed a VTE had a significantly longer time to initiation of chemical VTE prophylaxis (6.7 ± 4.9 d versus 4.7 ± 4.9 d, P < 0.001) compared with those that did not develop a VTE. Also, for each 1 d increase in time to prophylaxis initiation, the odds of developing a VTE increased significantly (odds ratio = 1.055, P < 0.001). The combination subarachnoid hemorrhage/subdural hemorrhage group was started on VTE prophylaxis significantly later (8.3 ± 6.1 d versus 6.7 ± 3.9 d, P < 0.01) than the overall TBI group and had a higher incidence of VTE (14.4 versus 10.4%, P = NS). In contrast, patients sustaining isolated spinal injuries received chemical VTE prophylaxis significantly earlier (3.4 ± 4.2 d versus 6.7 ± 3.9 d, P < 0.001) and had a significant decrease in their VTE rate (4.4 versus 10.4%, P < 0.0001) compared with the overall TBI group. CONCLUSIONS: Patients with VTEs had a significant delay in time to initiation of chemoprophylaxis compared with patients without VTEs. Patients sustaining a TBI had a 2-fold delay in initiation of chemoprophylaxis and an associated 2-fold increase in VTE events compared with patients who sustained spinal injuries. Of those patients who developed a TBI, patients who sustained a combination subarachnoid hemorrhage and/or subdural hemorrhage had a significant delay in initiation of chemoprophylaxis with a higher rate of VTE events.

The Interventional Arm of the Flexibility In Duty-Hour Requirements for Surgical Trainees Trial: First-Year Data Show Superior Quality In-Training Initiative Outcomes.

PURPOSE: With the implementation of strict 80-hour work week in general surgery training, serious questions have been raised concerning the quality of surgical education and the ability of newly trained general surgeons to independently operate. Programs that were randomized to the interventional arm of the Flexibility In duty-hour Requirements for Surgical Trainees (FIRST) Trial were able to decrease transitions and allow for better continuity by virtue of less constraints on duty-hour rules. Using National Surgical Quality Improvement Program Quality In-Training Initiative data along with duty-hour violations compared with old rules, it was hypothesized that quality of care would be improved and outcomes would be equivalent or better than the traditional duty-hour rules. It was also hypothesized that resident perception of compliance with duty hour would not change with implementation of new regulations based on FIRST trial. METHODS: Flexible work hours were implemented on July 1, 2014. National Surgical Quality Improvement Program Quality In-Training Initiative information was reviewed from July 2014 to January 2015. Patient risk factors and outcomes were compared between institutional resident cases and the national cohort for comparison. Residents' duty-hour logs and violations during this period were compared to the 6-month period before the implementation of the FIRST trial. The annual Accreditation Council for Graduate Medical Education resident survey was used to assess the residents' perception of compliance with duty hours. RESULTS: With respect to the postoperative complications, the only statistically significant measures were higher prevalence of pneumonia (3.4% vs. 1.5%, p < 0.05) and lower prevalence of sepsis (0% vs. 1.5%, p < 0.05) among cases covered by residents with flexible duty hours. All other measures of postoperative surgical complications showed no difference. The total number of duty-hour violations decreased from 54 to 16. Had the institution not been part of the interventional arm of the FIRST trial, this number would have increased to 238. The residents' perception of compliance with 80-hour work week from the Accreditation Council for Graduate Medical Education survey improved from 68% to 91%. CONCLUSIONS: Residents with flexible work hours on the interventional arm of the FIRST trial at our institution took care of a significantly sicker cohort of patients as compared with the national dataset with equivalent outcomes. Flexible duty-hour policy under the FIRST trial has enabled the residents to have fewer work-hour violations while improving continuity of care to the patients. Additionally, the overall perception of resident compliance with the duty-hour requirements was improved.

Geographic disparities in pancreatic cancer survival in a southeastern safety-net academic medical center.

OBJECTIVE: To quantify the effects of race, measures of socioeconomic status and geographic residency status on pancreatic cancer survival time. DESIGN: Retrospective review. SETTING: A southeastern safety-net academic medical centre in the United States. PARTICIPANTS: The study population consisted of all patients who were diagnosed, referred to or treated at the medical centre between 2009 and 2012 (n = 245). To ensure completeness and accuracy of the data, follow-up treatment and survival information about the cases were collected from the Georgia Comprehensive Cancer Registry in 2013. MAIN OUTCOME MEASURES: The odds of receiving first-course treatment (surgery, radiation or chemotherapy) and overall survival following a pancreatic cancer diagnosis. RESULTS: There were no observed differences in receipt of initial treatment; however, patients from low socioeconomic and rural areas had significant increase in risk of death compared to patients from affluent and urban areas. CONCLUSIONS: Results from this single site study suggests the significance of factors other than treatment differences that contribute to geographic disparities in mortality.