Predictors of acute incisional hernia incarceration at initial hernia diagnosis on computed tomography.

BACKGROUND: Acute incisional hernia incarceration is associated with high morbidity and mortality yet there is little evidence to guide which patients will benefit most from prophylactic repair. We explored baseline computed tomography (CT) characteristics associated with incarceration. METHODS: A case-control study design was utilized to explore adults (≥18 years) diagnosed with an incisional hernia between 2010 and 2017 at a single institution with a 1-year minimum follow-up. Computed tomography imaging at the time of initial hernia diagnosis was examined. Following propensity score matching for baseline characteristics, multivariable logistic regression was performed to identify independent predictors associated with acute incarceration. RESULTS: A total of 532 patients (27.26% male, mean 61.55 years) were examined, of whom 238 experienced an acute incarceration. Between two well-matched cohorts with and without incarceration, the presence of small bowel in the hernia sac (odds ratio [OR], 7.50; 95% confidence interval [CI], 3.35-16.38), increasing sac height (OR, 1.34; 95% CI, 1.10-1.64), more acute hernia angle (OR, 0.98 per degree; 95% CI, 0.97-0.99), decreased fascial defect width (OR, 0.68; 95% CI, 0.58-0.81), and greater outer abdominal fat (OR, 1.28; 95% CI, 1.02-1.60) were associated with acute incarceration. Using threshold analysis, a hernia angle of <91 degrees and a sac height of >3.25 cm were associated with increased incarceration risk. CONCLUSION: Computed tomography features present at the time of hernia diagnosis provide insight into later acute incarceration risk. Improved understanding of acute incisional hernia incarceration can guide selection for prophylactic repair and thereby may mitigate the excess morbidity associated with incarceration. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Sex, race, and socioeconomic distinctions in incisional hernia management.

BACKGROUND: We sought to explore the impact of sex, race, and insurance status on operative management of incisional hernias. METHODS: A retrospective cohort study was conducted to explore adult patients diagnosed with an incisional hernia. Adjusted odds for non-operative versus operative management and time to repair were queried. RESULTS: Of the 29,475 patients with an incisional hernia, 20,767 (70.5%) underwent non-operative management. In relation to private insurance, Medicaid (aOR 1.40, 95% CI 1.27-1.54), Medicare (aOR 1.53, 95% CI 1.42-1.65), and uninsured status (aOR 1.99, 95% CI 1.71-2.36) were independently associated with non-operative management. African American race (aOR 1.30, 95% CI 1.17-1.47) was associated with non-operative management while female sex (aOR 0.81, 95% CI 0.77-0.86) was predictive of elective repair. For patients who underwent elective repair, both Medicare (aOR 1.40, 95% CI 1.18-1.66) and Medicaid (aOR 1.49, 95% CI 1.29-1.71) insurance, but not race, were predictive of delayed repair (>90 days after diagnosis). CONCLUSIONS: Sex, race, and insurance status influence incisional hernia management. Development of evidence-based management guidelines may help to ensure equitable care.

Association Between Time to Source Control in Sepsis and 90-Day Mortality.

Importance: Rapid source control is recommended to improve patient outcomes in sepsis. Yet there are few data to guide how rapidly source control is required. Objective: To determine the association between time to source control and patient outcomes in community-acquired sepsis. Design, Setting, and Particpants: Multihospital integrated health care system cohort study of hospitalized adults (January 1, 2013, to December 31, 2017) with community-acquired sepsis as defined by Sepsis-3 who underwent source control procedures. Follow-up continued through January 1, 2019, and data analyses were completed March 17, 2022. Exposures: Early (<6 hours) compared with late (6-36 hours) source control as well as each hour of source control delay (1-36 hours) from sepsis onset. Main Outcomes and Measures: Multivariable models were clustered at the level of hospital with adjustment for patient factors, sepsis severity, resource availability, and the physiologic stress of procedures generating adjusted odds ratios (aOR) and 95% CI. Results: Of 4962 patients with sepsis (mean [SD] age, 62 [16] years; 52% male; 85% White; mean [SD] Sequential Organ Failure Assessment score, 3.8 [2.5]), source control occurred at a median (IQR) of 15.4 hours (5.5-21.7) after sepsis onset, with 1315 patients (27%) undergoing source control within 6 hours. The crude 90-day mortality was similar for early and late source control (n = 177 [14%] vs n = 529 [15%]; P = .35). In multivariable models, early source control was associated with decreased risk-adjusted odds of 90-day mortality (aOR, 0.71; 95% CI, 0.63-0.80). This association was greater among gastrointestinal and abdominal (aOR, 0.56; 95% CI, 0.43-0.80) and soft tissue interventions (aOR, 0.72; 95% CI, 0.55-0.95) compared with orthopedic and cranial interventions (aOR, 1.33; 95% CI, 0.96-1.83; P < .001 for interaction). Conclusions and Relevance: Source control within 6 hours of community-acquired sepsis onset was associated with a reduced risk-adjusted odds of 90-day mortality. Prioritizing the rapid identification of septic foci and initiation of source control interventions can reduce the number of avoidable deaths among patients with sepsis.

Accuracy of Risk Estimation for Surgeons Versus Risk Calculators in Emergency General Surgery.

INTRODUCTION: Surgical risk calculators have expanded in both number and sophistication of their predictive approach. These calculators are gaining popularity as validated tools to help surgeons estimate mortality and complications following emergency general surgery (EGS). However, the accuracy of risk estimates generated by these calculators compared to risk estimation by practicing surgeons has not been explored. METHODS: Acute care surgeons at a quaternary care center prospectively estimated 30-d mortality and complications for adult EGS patients (2019-2021). Surgeon predictions were compared to Predictive OpTimal Trees in Emergency Surgery Risk (POTTER) and NSQIP estimates. Observed-to-expected (O:E) ratios of median aggregate estimates were calculated. C-statistics for surgeon and calculator estimations were utilized to quantify predictive accuracy. RESULTS: Among 150 patients (median 61 y, 45% male), 30-d mortality was 15% (n = 23). Observed rates of prolonged mechanical ventilation and acute renal failures were 30% and 10%, respectively. Overall, surgeon predictions were similar to risk calculator estimates for mortality (c-statistics 0.843 [surgeon] versus 0.848 [POTTER] and 0.815 [NSQIP]) and need for prolonged ventilation (c-statistics 0.801 versus 0.722 and 0.689, respectively). Surgeons tended to overestimate complication risks. Surgeon experience was not significantly associated with mortality prediction in an adjusted model. CONCLUSIONS: Acute care surgeons at a quaternary care center predicted postoperative mortality and complications with similar discrimination when compared to surgical risk calculators. Surgeon expertise should be utilized in conjunction with risk calculators when counseling EGS patients regarding anticipated postoperative outcomes. Surgeons should be cognizant of patterns in overestimation or underestimation of complications.

Outcomes of operative and nonoperative management of blunt thoracic aortic injury.

OBJECTIVE: Although the current guidelines for the management of blunt traumatic aortic injury (BTAI) have recommended intervention for grade 2 injuries or higher, a national trend has occurred for aggressive endovascular treatment of low-grade BTAIs. Little is known about the natural history of grade 1 and 2 injuries treated nonoperatively. We hypothesized that most of these low-grade injuries would remain stable with nonoperative management. METHODS: We performed a review of BTAIs at a large referral level 1 trauma center from 2004 to 2020. The injuries were graded using a standard 1 to 4 scale. The outcomes of the nonoperative and thoracic endovascular aortic repair (TEVAR) management strategies were compared, including post-trauma morbidity, mortality, reinterventions, and lesion stability. RESULTS: A total of 176 patients with BTAIs and sufficient imaging studies and follow-up data available were identified during the study period, including 36 with grade 1, 24 with grade 2, 115 with grade 3, and 1 with a grade 4 injury. Of these 176 patients, 112 had undergone TEVAR and 64 had been treated nonoperatively. Most of the patients (90.2%) who had undergone TEVAR had had grade 3 injuries. Nonoperative management was performed for 97.2% of the grade 1 injuries and 62.5% of the grade 2 injuries. Endovascular reintervention after TEVAR was rare (2.7%). The rates of post-trauma morbidity within 30 days (stroke, 3.6% vs 3.1%; myocardial infarction/arrhythmia, 8.9% vs 1.6%; respiratory failure, 31.2% vs 28.1%; acute kidney injury, 9.8% vs 12.5%; urinary tract infection, 2.7% vs 4.8%; gastrointestinal bleeding, 3.6% vs 0.0%; pulmonary embolism, 10.9% vs 4.5%) and 1-year mortality after discharge (1.8% vs 3.1%) were comparable between the operative and nonoperative groups. The median follow-up was 1501 days (interquartile range [IQR], 475.6-2804 days) for the TEVAR group and 1170.5 days (IQR, 317-2173 days) for the nonoperative group. No lesion progression had occurred in the patients with low-grade (grade 1-2) injuries managed nonoperatively. Resolution of grade 1 and 2 injury had occurred in 20% of the patients at 30 days, which had improved to 44% at long-term follow-up. Fourteen patients with grade 3 injuries (12.2% of the grade 3 injuries in our series) were also observed and did not require future intervention. These patients had generally had smaller pseudoaneurysms with minimal periaortic hematoma. None of these 14 patients had experienced progression or rupture during follow-up (median, 454.5 days; IQR, 81-1199 days) using computed tomography. CONCLUSIONS: Nonoperative management of low-grade BTAIs did not result in long-term aortic complications or the need for reintervention. We found that grade 3 injuries with smaller pseudoaneurysms and minimal periaortic hematoma can be safely observed if the patients can be appropriately followed up. Thus, the indications for treatment of select grade 3 injuries merit further consideration.

Consensus Current Procedural Terminology Code Definition of Source Control for Sepsis.

INTRODUCTION: Unlike antibiotic and perfusion support, guidelines for sepsis source control lack high-quality evidence and are ungraded. Internally valid administrative data methods are needed to identify cases representing source control procedures to evaluate outcomes. METHODS: Over five modified Delphi rounds, two independent reviewers identified Current Procedural Terminology (CPT) codes pertinent to source control. In each round, codes with perfect agreement were retained or excluded, whereas disagreements were reviewed by the panelists. Manual review of 400 patient records meeting Sepsis-3 criteria (2010-2017) clinically adjudicated which encounters included source control procedures (gold standard). The performance of consensus codes was compared with the gold standard to assess sensitivity, specificity, predictive values, and likelihood ratios. RESULTS: Of 5752 CPT codes, 609 consensus codes represented source control procedures. Of 400 hospitalizations for sepsis, 39 (9.8%; 95% confidence interval [CI] 7.0%-13.1%) underwent gold standard source control procedures and 29 (7.3%; 95% CI 4.9-10.3%) consensus code-defined source control procedures. Thirty consensus codes were identified (20.0% gastrointestinal/intraabdominal, 10.0% genitourinary, 13.3% hepatopancreatobiliary, 23.3% orthopedic/cranial, 23.3% soft tissue, and 10.0% intrathoracic), which had 61.5% (95% CI 44.6%-76.6%) sensitivity, 98.6% (95% CI 96.8%-99.6%) specificity, 83.2% (95% CI 66.6%-92.4%) positive, and 95.9% (95% CI 93.9%-97.2%) negative predictive values. With pretest probability at sample prevalence, an identified consensus code had a posttest probability of 83.0% (95% CI 66.0%-92.0%), whereas consensus code absence had a probability of 4.0% (95% CI 3.0-6.0) for undergoing a source control procedure. CONCLUSIONS: Using modified Delphi methodology, we created and validated CPT codes identifying source control procedures, providing a framework for evaluation of the surgical care of patients with sepsis.

The Risk of Incarceration During Nonoperative Management of Incisional Hernias: A Population-based Analysis of 30,998 Patients.

OBJECTIVE: The aim of the study was to quantify the risk of incarceration of incisional hernias. BACKGROUND: Operative repair is the definitive treatment for incisional ventral hernias but is often deferred if the perceived risk of elective operation is elevated secondary to comorbid conditions. The risk of incarceration during nonoperative management (NOM) factors into shared decision making by patient and surgeon; however, the incidence of acute incarceration remains largely unknown. METHODS: A retrospective analysis of adult patients with an International Classification of Diseases, Ninth Revision or Tenth Revision diagnosis of incisional hernia was conducted from 2010 to 2017 in 15 hospitals of a single healthcare system. The primary outcome was incarceration necessitating emergent operation. The secondary outcome was 30-, 90-, and 365-day mortality. Univariate and multivariate analyses were used to determine independent predictors of incarceration. RESULTS: Among 30,998 patients with an incisional hernia (mean age 58.1 ±â€Š15.9 years; 52.7% female), 23,022 (78.1%) underwent NOM of whom 540 (2.3%) experienced incarceration, yielding a 1- and 5-year cumulative incidence of 1.24% and 2.59%, respectively. Independent variables associated with incarceration included: age older than 40 years, female sex, current smoker, body mass index 30 or greater, and a hernia-related inpatient admission. All-cause mortality rates at 30, 90, and 365 days were significantly higher in the incarceration group at 7.2%, 10%, and 14% versus 1.1%, 2.3%, and 5.3% in patients undergoing successful NOM, respectively. CONCLUSIONS: Incarceration is an uncommon complication of NOM but is associated with a significant risk of death. Tailored decision making for elective repair and considering the aforementioned risk factors for incarceration provides an initial step toward mitigating the excess morbidity and mortality of an incarceration event.

Postprocedural Cognitive Load Measurement With Immediate Feedback to Guide Curriculum Development.

BACKGROUND: Methods to assess competency in cardiothoracic training are essential. Here, we report a system that allows us to better assess competency from the perspective of both the trainee and educator. We hypothesized that postprocedural cognitive burden measurement (by the trainee) with immediate feedback (from the educator) could aid in identifying barriers to the acquisition of skills and knowledge so that training curricula can be individualized. METHODS: The National Aeronautics and Space Administration Task Load Index (NASA-TLX), a validated instrument to measure cognitive load, was administered with an online platform after bronchoscopy, esophagogastroduodenoscopy, and video-assisted thoracoscopic surgery for 11 residents. Immediate postprocedure feedback and standardized debriefing occurred for each procedure. RESULTS: Mean NASA-TLX scores were highest (indicating greater cognitive load) for esophagogastroduodenoscopy and video-assisted thoracoscopic surgery (P < .001). When comparing subscale measures, mental demand was significantly higher for video-assisted thoracoscopic surgery (P = .026) compared with the other procedures, whereas physical demand was highest for esophagogastroduodenoscopy (P = .018). Self-reported frustration was similar for all case types (P = .247). Cognitive burden decreased with a greater number of procedures for bronchoscopy (P = .027). Significant improvement was noted by the trainee at the end of the rotation in self-assessed procedural competency and preparedness for thoracic board topics (all P < .05). Postprocedure feedback by the attending surgeon correlated with more frequent completion of self-evaluations by the residents. CONCLUSIONS: Longitudinal assessment of cognitive load in combination with postprocedural feedback identified barriers to skill acquisition for both residents and educators. This information allows for individualized rotation development as a step toward a competency-based curriculum.

Automatic Detection of Thyroid and Adrenal Incidentals Using Radiology Reports and Deep Learning.

BACKGROUND: Computed tomography (CT) is commonly performed when evaluating trauma patients with up to 55% showing incidental findings. Current workflows to identify and inform patients are time-consuming and prone to error. Our objective was to automatically identify thyroid and adrenal lesions in radiology reports using deep learning. MATERIALS AND METHODS: All trauma patients who presented to an accredited Level 1 Trauma Center between January 2008 and January 2019 were included. Radiology reports of CT scans that included either a thyroid or adrenal gland were obtained. Preprocessing included word tokenization, removal of stop words, removal of punctuation, and replacement of misspellings. A word2vec model was trained using 1.4 million radiology reports. Both training and testing reports were selected at random, manually reviewed, and were considered the gold standard. True positive cases were defined as any lesions in the thyroid or adrenal gland, respectively. Training data was used to create models that would identify reports that contained either thyroid or adrenal lesions. Our primary outcomes were sensitivity and specificity of the models using predetermined thresholds on a separate testing dataset. RESULTS: A total of 51,771 reports were identified on 35,859 trauma patients. A total of 1,789 reports were annotated for training and 500 for testing. The thyroid model predictions resulted in a 90.0% sensitivity and 95.3% specificity. The adrenal model predictions resulted in a 92.3% sensitivity and a 91.1% specificity. A total of 240 reports were confirmed to have thyroid incidentals (mean age 69.1 yrs ± 18.9, 35% M) and 214 reports with adrenal incidentals (mean age 68.7 yrs ± 16.9, 50.5% M). CONCLUSIONS: Both the thyroid and adrenal models have excellent performance with sensitivities and specificities in the 90s. Our deep learning model has the potential to reduce administrative costs and improve the process of informing patients.

Center-level Utilization of Hepatitis C Virus-positive Donors for Orthotopic Heart Transplantation.

BACKGROUND: The use of hepatitis C virus-positive (HCV+) donors has expanded the donor pool for orthotopic heart transplantation (OHT). This study evaluated center-level trends and utilization of HCV+ donors for OHT. METHODS: Data were extracted from the Scientific Registry of Transplant Recipients on adults (≥18 y) undergoing OHT between January 1, 2016 and December 31, 2019. Centers performing <10 OHTs during the study period were excluded. Donor utilization rates were evaluated at the center level. Center-level characteristics were compared between centers performing HCV+ donor hepatitis C virus-negative (HCV-) recipient OHTs and those not utilizing HCV+ donors for HCV- recipients. RESULTS: A total of 10 134 patients underwent OHT, including 613 (6.05%) HCV+ donors transplanted into HCV- recipients. The number of HCV+ OHTs increased from 15 of 2512 (0.60%) in 2016 to 285 of 2490 (11.45%) in 2019 (P < 0.001). In 2016, among 105 centers performing OHTs, 7 (6.67%) utilized HCV+ donors compared to 2019 during which 55 (52.89%) of 104 centers utilized HCV+ donors (P < 0.001). In total, 57 of 107 (53.27%) centers utilized HCV+ donors during the study period. Centers utilizing HCV+ donors had higher overall donor utilization rates (7376/24 378 [30.26%] versus 3463/15 335 [22.58%], P < 0.001) and were higher volume as compared to nonutilizing centers (mean annual OHT volume 30.72 ± 1.21 versus 16.2 ± 1.40, P < 0.001). CONCLUSIONS: Although the use of HCV+ donors for OHT is rapidly expanding in the United States, almost half of transplant centers remain nonutilizers. Broader education and implementation of HCV+ donor protocols may be important in expanding OHT to more patients with end-stage heart failure.

Machine learning for the prediction of pathologic pneumatosis intestinalis.

BACKGROUND: The radiographic finding of pneumatosis intestinalis can indicate a spectrum of underlying processes ranging from a benign finding to a life-threatening condition. Although radiographic pneumatosis intestinalis is relatively common, there is no validated clinical tool to guide surgical management. METHODS: Using a retrospective cohort of 300 pneumatosis intestinalis cases from a single institution, we developed 3 machine learning models for 2 clinical tasks: (1) the distinction of benign from pathologic pneumatosis intestinalis cases and (2) the determination of patients who would benefit from an operation. The 3 models are (1) an imaging model based on radiomic features extracted from computed tomography scans, (2) a clinical model based on clinical variables, and (3) a combination model using both the imaging and clinical variables. RESULTS: The combination model achieves an area under the curve of 0.91 (confidence interval: 0.87-0.94) for task I and an area under the curve of 0.84 (confidence interval: 0.79-0.88) for task II. The combination model significantly (P < .05) outperforms the imaging model and the clinical model for both tasks. The imaging model achieves an area under the curve of 0.72 (confidence interval: 0.57-0.87) for task I and 0.68 (confidence interval: 0.61-0.74) for task II. The clinical model achieves an area under the curve of 0.87 (confidence interval: 0.83-0.91) for task I and 0.76 (confidence interval: 0.70-0.81) for task II. CONCLUSION: This study suggests that combined radiographic and clinical features can identify pathologic pneumatosis intestinalis and aid in patient selection for surgery. This tool may better inform the surgical decision-making process for patients with pneumatosis intestinalis.

Leveraging Decision Curve Analysis to Improve Clinical Application of Surgical Risk Calculators.

BACKGROUND: Surgical risk calculators (SRCs) have been developed for estimation of postoperative complications but do not directly inform decision-making. Decision curve analysis (DCA) is a method for evaluating prediction models, measuring their utility in guiding decisions. We aimed to analyze the utility of SRCs to guide both preoperative and postoperative management of patients undergoing hepatopancreaticobiliary surgery by using DCA. METHODS: A single-institution, retrospective review of patients undergoing hepatopancreaticobiliary operations between 2015 and 2017 was performed. Estimation of postoperative complications was conducted using the American College of Surgeons SRC [ACS-SRC] and the Predictive OpTimal Trees in Emergency Surgery Risk (POTTER) calculator; risks were compared with observed outcomes. DCA was used to model optimal patient selection for risk prevention strategies and to compare the relative performance of the ACS-SRC and POTTER calculators. RESULTS: A total of 994 patients were included in the analysis. C-statistics for the ACS-SRC prediction of 12 postoperative complications ranged from 0.546 to 0.782. DCA revealed that an ACS-SRC-guided readmission prevention intervention, when compared with an all-or-none approach, yielded a superior net benefit for patients with estimated risk between 5% and 20%. Comparison of SRCs for venous thromboembolism intervention demonstrated superiority of the ACS-SRC for thresholds for intervention between 2% and 4% with the POTTER calculator performing superiorly between 4% and 8% estimated risk. CONCLUSIONS: SRCs can be used not only to predict complication risk but also to guide risk prevention strategies. This methodology should be incorporated into external validations of future risk calculators and can be applied for institution-specific quality improvement initiatives to improve patient outcomes.

Development and validation of a five-factor score for prediction of pathologic pneumatosis.

BACKGROUND: The significance of pneumatosis intestinalis (PI) remains challenging. While certain clinical scenarios are predictive of transmural ischemia, risk models to assess the presence of pathologic PI are needed. The aim of this study was to determine what patient factors at the time of radiographic diagnosis of PI predict the risk for pathologic PI. METHODS: We conducted a retrospective cohort study examining patients with PI from 2010 to 2016 at a multicenter hospital network. Multivariate logistic regression was used to develop a predictive model for pathologic PI in a derivation cohort. Using regression-coefficient-based methods, the final multivariate model was converted into a five-factor-based score. Calibration and discrimination of the score were then assessed in a validation cohort. RESULTS: Of 305 patients analyzed, 102 (33.4%) had pathologic PI. We identified five factors associated with pathologic PI at the time of radiographic diagnosis: small bowel PI, age 70 years or older, heart rate 110 bpm or greater, lactate of 2 mmol/L or greater, and neutrophil-lymphocyte ratio 10 or greater. Using this model, patients in the validation cohort were assigned risk scores ranging from 0 to 11. Low-risk patients were categorized when scores are 0 to 4; intermediate, score of 5 to 6; high, score of 7 to 8; and very high risk, 9+. In the validation cohort, very high-risk patients (n = 17; 18.1%) had predicted rates of pathologic pneumatosis of 88.9% and an observed rate of 82.4%. In contrast, patients labeled as low risk (n = 37; 39.4%) had expected rates of pathologic pneumatosis of 1.3% and an observed rate of 0%. The model showed excellent discrimination (area under the curve, 0.90) and good calibration (Hosmer-Lemeshow goodness-of-fit, p = 0.37). CONCLUSION: Our score accurately stratifies patient risk of pathologic pneumatosis. This score has the potential to target high-risk individuals for expedient operation and spare low-risk individuals invasive interventions. LEVEL OF EVIDENCE: Prognostic Study, Level III.

Improved Understanding of Acute Incisional Hernia Incarceration: Implications for Addressing the Excess Mortality of Emergent Repair.

BACKGROUND: Incisional hernia develops in up to 20% of patients undergoing abdominal operations. We sought to identify characteristics associated with poor outcomes after acute incisional hernia incarceration. STUDY DESIGN: We performed a retrospective cohort study of adult patients with incisional hernias undergoing elective repair or with acute incarceration between 2010 and 2017. The primary end point was 30-day mortality. Logistic regression was used to determine adjusted odds associated with 30-day mortality. The American College of Surgeons Surgical Risk Calculator was used to estimate outcomes had these patients undergone elective repair. RESULTS: A total of 483 patients experienced acute incarceration; 30-day mortality was 9.52%. Increasing age (adjusted odds ratio 1.05; 95% CI, 1.02 to 1.08) and bowel resection (adjusted odds ratio 3.18; 95% CI, 1.45 to 6.95) were associated with mortality. Among those with acute incarceration, 231 patients (47.9%) had no documentation of an earlier surgical evaluation and 252 (52.2%) had been evaluated but had not undergone elective repair. Among patients 80 years and older, 30-day mortality after emergent repair was high (22.9%) compared with estimated 30-day mortality for elective repair (0.73%), based on the American College of Surgeons Surgical Risk Calculator. Estimated mortality was comparable with observed elective repair mortality (0.82%) in an age-matched cohort. Similar mortality trends were noted for patients younger than 60 years and aged 60 to 79 years. CONCLUSIONS: Comparison of predicted elective repair and observed emergent repair mortality in patients with acute incarceration suggests that acceptable outcomes could have been achieved with elective repair. Almost one-half of acute incarceration patients had no earlier surgical evaluation, therefore, targeted interventions to address surgical referral can potentially result in fewer incarceration-related deaths.

Prolapse Recurrence After Sacrocolpopexy Mesh Removal: A Retrospective Cohort Study.

OBJECTIVES: There is limited literature regarding outcomes after sacrocolpopexy mesh removal. We sought to compare the proportion of prolapse recurrence in women after sacrocolpopexy mesh removal with women who underwent sacrocolpopexy without subsequent mesh removal. We hypothesize that more women will experience prolapse recurrence after mesh removal. METHODS: This is a retrospective cohort study of women who underwent sacrocolpopexy mesh removal between 2010 and 2019. These patients were time matched with women who had a sacrocolpopexy but did not undergo mesh removal. Prolapse recurrence was defined as the leading edge past the hymen or retreatment. Analysis was done using χ, Wilcoxon rank-sum, or t test with a Cox proportional hazard model to assess the association between mesh removal and time to recurrence. RESULTS: We identified 26 mesh removals, which were matched with 78 patients without mesh removal. The most common indications for mesh removal were exposure (69.2%) and pain (57.7%). Women who underwent mesh removal were more likely to have Mersilene mesh (19.2% vs 1.3%, P = 0.006). Recurrence occurred in 46% of women who had mesh removal compared with 7.7% in those without (P < 0.001). When adjusted for age, parity, menopause, smoking, and diabetes status, those who had mesh removal had a 15 times higher hazard of prolapse recurrence (adjusted hazard ratio = 15.4, 95% confidence interval = 4.3-54.8, P = <.0001). CONCLUSIONS: When compared with time-matched controls, women who underwent sacrocolpopexy mesh removal had a significantly higher proportion of prolapse recurrence. Prospective studies are needed to further explore the utility of concomitant prolapse repair at the time of mesh removal.

Interactive NLP in Clinical Care: Identifying Incidental Findings in Radiology Reports.

BACKGROUND: Despite advances in natural language processing (NLP), extracting information from clinical text is expensive. Interactive tools that are capable of easing the construction, review, and revision of NLP models can reduce this cost and improve the utility of clinical reports for clinical and secondary use. OBJECTIVES: We present the design and implementation of an interactive NLP tool for identifying incidental findings in radiology reports, along with a user study evaluating the performance and usability of the tool. METHODS: Expert reviewers provided gold standard annotations for 130 patient encounters (694 reports) at sentence, section, and report levels. We performed a user study with 15 physicians to evaluate the accuracy and usability of our tool. Participants reviewed encounters split into intervention (with predictions) and control conditions (no predictions). We measured changes in model performance, the time spent, and the number of user actions needed. The System Usability Scale (SUS) and an open-ended questionnaire were used to assess usability. RESULTS: Starting from bootstrapped models trained on 6 patient encounters, we observed an average increase in F1 score from 0.31 to 0.75 for reports, from 0.32 to 0.68 for sections, and from 0.22 to 0.60 for sentences on a held-out test data set, over an hour-long study session. We found that tool helped significantly reduce the time spent in reviewing encounters (134.30 vs. 148.44 seconds in intervention and control, respectively), while maintaining overall quality of labels as measured against the gold standard. The tool was well received by the study participants with a very good overall SUS score of 78.67. CONCLUSION: The user study demonstrated successful use of the tool by physicians for identifying incidental findings. These results support the viability of adopting interactive NLP tools in clinical care settings for a wider range of clinical applications.

Identifying incidental findings from radiology reports of trauma patients: An evaluation of automated feature representation methods.

BACKGROUND: Radiologic imaging of trauma patients often uncovers findings that are unrelated to the trauma. These are termed as incidental findings and identifying them in radiology examination reports is necessary for appropriate follow-up. We developed and evaluated an automated pipeline to identify incidental findings at sentence and section levels in radiology reports of trauma patients. METHODS: We created an annotated dataset of 4,181 reports and investigated automated feature representations including traditional word and clinical concept (such as SNOMED CT) representations, as well as word and concept embeddings. We evaluated these representations by using them with traditional classifiers such as logistic regression and with deep learning methods such as convolutional neural networks (CNNs). RESULTS: The best performance was observed using word embeddings with CNNs with F1 scores of 0.66 and 0.52 at section and sentence levels respectively. The F1 score was statistically significantly higher for sections compared to sentences (Wilcoxon; Z < 0.001, p < 0.05). Compared to using words alone, the addition of SNOMED CT concepts did not improve performance. At the sentence level, the F1 score improved significantly from 0.46 to 0.52 when using pre-trained embeddings (Wilcoxon; Z < 0.001, p < 0.05). CONCLUSION: The results show that the best performance was achieved by using embeddings with CNNs at both sentence and section levels. This provides evidence that such a pipeline is capable of accurately identifying incidental findings in radiology reports in an automated manner.

Predisposed to failure? The challenge of rescue in the medical intensive care unit.

BACKGROUND: Medical intensive care unit (MICU) patients develop acute surgical processes that require operative intervention. There are limited data addressing outcomes of emergency general surgery (EGS) in this population. The aim of our study was to characterize the breadth of surgical consults from the MICU and assess mortality after abdominal EGS cases. METHODS: All MICU patients with an EGS consult in an academic medical center between January 2010 and 2016 were identified from an electronic medical record-based registry. Charts were reviewed to determine reason for consult, procedures performed, and to obtain additional clinical data. A multivariate logistic regression was used to determine patient factors associated with patient mortality. RESULTS: Of 911 MICU patients seen by our service, 411(45%) required operative intervention, with 186 patients undergoing an abdominal operation. The postoperative mortality rate after abdominal operations was 37% (69/186), significantly higher than the mortality of 16% (1833/11192) for all patients admitted to the MICU over the same period (p < 0.05). Damage-control procedures were performed in 64 (34%) patients, with 46% mortality in this group. The most common procedures were bowel resections, with mortality of 42% (28/66) and procedures for severe clostridium difficile, mortality of 38% (9/24). Twenty-seven patients met our definition of surgical rescue, requiring intervention for complications of prior procedures, with mortality of 48%. Need for surgical rescue was associated with increased admission mortality (odds ratio, 13.07; 95% confidence interval, 2.86-59.77). Twenty-six patients had pathology amenable to surgical intervention but did not undergo operation, with 100% mortality. In patients with abdominal pathology at the time of operation, in-hospital delay was associated with increased mortality (odds ratio, 5.13; 95% confidence interval, 1.11-23.77). CONCLUSION: Twenty percent of EGS consults from the MICU had an abdominal process requiring an operative intervention. While the MICU population as a whole has a high baseline mortality, patients requiring abdominal surgical intervention are an even higher risk. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.