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Procedimentos Cirúrgicos Ambulatórios , Ideação Suicida , Humanos , Feminino , Masculino , Pessoa de Meia-Idade , Adulto , Tomada de DecisõesRESUMO
Traumatic brain injury (TBI) induces immune dysfunction that can be captured clinically by an increase in the neutrophil-to-lymphocyte ratio (NLR). However, few studies have characterized the temporal dynamics of NLR post-TBI and its relationship with hospital-acquired infections (HAI), resource utilization, or outcome. We assessed NLR and HAI over the first 21 days post-injury in adults with moderate-to-severe TBI (n = 196) using group-based trajectory (TRAJ), changepoint, and mixed-effects multivariable regression analysis to characterize temporal dynamics. We identified two groups with unique NLR profiles: a high (n = 67) versus a low (n = 129) TRAJ group. High NLR TRAJ had higher rates (76.12% vs. 55.04%, p = 0.004) and earlier time to infection (p = 0.003). In changepoint-derived day 0-5 and 6-20 epochs, low lymphocyte TRAJ, early in recovery, resulted in more frequent HAIs (p = 0.042), subsequently increasing later NLR levels (p ≤ 0.0001). Both high NLR TRAJ and HAIs increased hospital length of stay (LOS) and days on ventilation (p ≤ 0.05 all), while only high NLR TRAJ significantly increased odds of unfavorable six-month outcome as measured by the Glasgow Outcome Scale (GOS) (p = 0.046) in multivariable regression. These findings provide insight into the temporal dynamics and interrelatedness of immune factors which collectively impact susceptibility to infection and greater hospital resource utilization, as well as influence recovery.
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BACKGROUND: Opioid analgesics are overprescribed after surgery. In August 2018, the authors replaced routine discharge opioid prescription with a nonsteroidal anti-inflammatory drug (NSAID) for patients who had a lumpectomy or excisional biopsy (lump/ex). This study compared patient-reported post-discharge pain scores for patients treated before and after the change in routine discharge medication. METHODS: Patients were categorized based on treatment before and after a change in discharge medication as follows: study period 1 (routine opioids), study period 2 (routine NSAID). Pain severity was assessed with an electronic survey on postoperative days (PODs) 1 to 5. Multivariable generalized estimating equations tested the association between pain severity and discharge in the first versus the second study period. RESULTS: Lump/ex was performed for 1606 patients between December 2017 and June 2019. Of these patients, 789 (49%) reported pain scores and were analyzed (328 in study period 1, 461 in study period 2). Opioid prescription at discharge decreased from 96% in period 1 to 14% (95% confidence interval [CI], 11-18%) in period 2. Only 1% of the patients discharged with NSAID were later prescribed an opioid. The maximum reported pain score on any POD for all the patients was severe for 30 patients (3.8%), moderate for 217 patients (28%), mild for 430 patients (54%), and none for 112 patients (14%). The estimated risk for moderate or greater pain on POD 1 was 36% for period 1 and 34% for period 2. The proportion of patients reporting moderate or greater pain was nonsignificantly lower for the patients treated in period 2 (odds ratio [OR], 0.91; 95% CI 0.67-1.22; P = 0.5). CONCLUSIONS: For patients undergoing lump/ex, a clinically meaningful difference in reported post-discharge pain scores can be excluded with a change to routine NSAID at discharge. Patients undergoing lump/ex should not be routinely discharged with opioids.
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Analgésicos Opioides , Mastectomia Segmentar , Assistência ao Convalescente , Analgésicos Opioides/uso terapêutico , Biópsia , Humanos , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologia , Alta do Paciente , PrescriçõesRESUMO
BACKGROUND: Invasive surgical procedures occur infrequently in an emergency department setting; however, procedural competence is expected from trauma residents. Emergent procedures are challenging to train in a formal manner because of the urgent nature when they present. To supplement education, new and creative teaching tools such as simulation and multidisciplinary training are being used. Our study organized a multidisciplinary simulated learning workshop with surgery and emergency medicine residents for invasive, emergent procedures. MATERIALS AND METHODS: In total, 14 surgical and 36 emergency medicine residents at our institution participated in a simulated learning experience. Ten workshops were organized, with six to seven residents participating in each session. Using a human cadaveric model, all residents were taught by senior-level residents and attendings from both specialties on how to perform uncommonly or anatomically challenging emergent invasive procedures. A pre- and post-laboratory survey was completed by all the residents to assess confidence in performing each of the 13 procedures. RESULTS: All residents (N = 50), who participated in the study, completed pre- and post-laboratory surveys. Comparison of the pre- and post-laboratory confidence levels indicated significant increases in confidence in performing all procedures. Residents stated that this multidisciplinary approach to education in a controlled setting was helpful and fostered a collaborative relationship between both specialties. CONCLUSIONS: Although some surgical procedures remain uncommon in the emergency department, competency is nevertheless expected for appropriate patient care. Using a collaborative simulation-based cadaver laboratory to teach emergent procedures significantly improved residents' confidence while concurrently fostering professional relationships.
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Educação de Pós-Graduação em Medicina/métodos , Medicina de Emergência/educação , Cirurgia Geral/educação , Internato e Residência/métodos , Equipe de Assistência ao Paciente , Ferimentos e Lesões/cirurgia , Cadáver , Competência Clínica , Medicina de Emergência/métodos , Humanos , Treinamento por SimulaçãoRESUMO
We report a case of fatal immune checkpoint inhibitor (ICI)-associated myocarditis in a 77-year-old man with metastatic non-small cell lung cancer (NSCLC) who presented for mediport placement at our outpatient surgical center. He denied any cardiac complaints and had a previously normal electrocardiogram (EKG) off treatment. Intraoperatively and postoperatively, he displayed cardiac rhythm abnormalities. The patient was then transferred to a tertiary facility, where he expired within 48 hours. As cancer immunotherapy becomes increasingly prominent, ICI-associated myocarditis should be considered a potentially critical contributor to perioperative cardiac morbidity and mortality.
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Antineoplásicos Imunológicos , Carcinoma Pulmonar de Células não Pequenas , Neoplasias Pulmonares , Miocardite , Idoso , Anticorpos Monoclonais Humanizados , Antineoplásicos Imunológicos/efeitos adversos , Carcinoma Pulmonar de Células não Pequenas/tratamento farmacológico , Humanos , Neoplasias Pulmonares/tratamento farmacológico , Masculino , Miocardite/induzido quimicamente , Miocardite/tratamento farmacológicoRESUMO
PURPOSE: One of the most common procedures in the pediatric population is the placement of a gastrostomy tube. There are significant medical, emotional, and social implications for both patients and caregivers. We hypothesized that socioeconomic status had a significant impact on gastrostomy complications. METHODS: A retrospective chart review was performed. Patient and census data including median household income, unemployment rate, health insurance status, poverty level, and caregiver education level were merged. Statistical tests were conducted against a 2-sided alternative hypothesis with a 0.05 significance level. Outcomes examined were minor and major complications in association with socioeconomic variables. RESULTS: Patients with mechanical complications were younger, weighed less, and had a 72% greater chance of having commercial insurance. Patients with Medicare/self-pay were three times more likely to have a minor complication. The average unemployment rate was 23% greater in families with a major complication. Individuals with a minor complication came from community tracts with a lower percentage of families below the poverty level. CONCLUSION: An association between socioeconomic factors and gastrostomy complications was identified. Insurance status and employment status were more significant predictors than poverty level. Further work with variables for targeted interventions to provide specific family support will allow these children and families to thrive. LEVEL OF EVIDENCE: Level II prognosis study.
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Insuficiência de Crescimento/etiologia , Gastrostomia/efeitos adversos , Fatores Socioeconômicos , Cuidadores , Pré-Escolar , Feminino , Humanos , Renda , Cobertura do Seguro , Masculino , Medicare , Pobreza , Estudos Retrospectivos , Classe Social , Estados UnidosRESUMO
BACKGROUND: Owing to the vulnerable nature of children, parental/caregiver engagement in surgical safety is a crucial aspect of care. Historically, the surgical safety process has been isolated from parent involvement. The digital, tablet-based surgical safety application, SafeStart, requires parent participation and provides multiple instances of verification of patient safety information from preoperative clinic visit, to perioperative care, and into the operating room. METHOD: The SafeStart application was utilized for 100 pediatric general surgery patients in an IRB approved prospective study. Parent assessments of the surgical consent and safety processes were collected in pre- and postoperative surveys with a 100% response rate. Standard consent forms were used and compared as a control. RESULTS: Only 31% of parents had knowledge of the surgical safety checklist process prior to their exposure to the study. 96% of the parents reported that the SafeStart patient portal was easy to use. A majority would prefer SafeStart to the standard consent process. CONCLUSION: The SafeStart program connected the surgical safety process from the preoperative clinic visit through postoperative care. Parent's preferred SafeStart to the standard surgical safety checklist and consent process, felt that they were instrumental in protecting their child's safety, and would recommend SafeStart for the surgical care of others. LEVEL OF EVIDENCE: II.
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Consentimento dos Pais , Participação do Paciente , Segurança do Paciente , Procedimentos Cirúrgicos Operatórios , Lista de Checagem , Criança , Feminino , Educação em Saúde , Humanos , Masculino , Pais/educação , Assistência Perioperatória , Estudos Prospectivos , Inquéritos e QuestionáriosRESUMO
PURPOSE: The purpose of this analysis was to determine if a correlation exists between socioeconomic status (SES) and pyloric stenosis (PS) as well as between PS and feeding method. METHODS: Data was collected retrospectively from the electronic medical record. Patients were included if they resided in a county in Illinois where our institution maintains >10% visit share, wereâ¯<â¯1â¯year in age, and received a pyloromyotomy from January 2011 to May 2018. Patient addresses were geocoded and merged with county and tract-level census data. A control group was matched on gender, race, tract level, median household income (MHI), and age. Feeding method for each group was collected. Univariate analysis and multivariate analyses were employed. RESULTS: SES was explored using MHI. After controlling for gender, age, race, and institution adjusted tract size, the association between MHI and pyloromyotomy remained significant. As MHI decreased, the odds of having a PS case increased. Additionally, the PS incidence rate increased as MHI decreased. Patients who were exclusively formula fed were more likely to have PS. CONCLUSION: Pyloric stenosis had a direct correlation with SES as defined by MHI. As MHI decreased, the rates of PS increased. In addition, breastfeeding was protective, independent of MHI. TYPE OF STUDY: Prognosis study. LEVEL OF EVIDENCE: Level II.
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Aleitamento Materno/estatística & dados numéricos , Renda , Fórmulas Infantis/estatística & dados numéricos , Estenose Pilórica Hipertrófica/epidemiologia , Feminino , Humanos , Illinois/epidemiologia , Incidência , Lactente , Recém-Nascido , Masculino , Estadiamento de Neoplasias , Estenose Pilórica Hipertrófica/cirurgia , Piloromiotomia , Estudos RetrospectivosRESUMO
Introduction: Laparoscopic appendectomy is the gold standard for treatment of acute appendicitis. The single-incision laparoscopic surgery (SILS) approach has gained widespread acceptance. This study evaluates the learning curve of contemporarily trained surgeons adopting SILS appendectomy and, more specifically, the safety of the operation during the early phase of this learning curve. Methods: A retrospective review of 974 consecutive pediatric patients younger than 18 years of age, who underwent an appendectomy at a single institution from 2005 to 2018, was performed. Nonperforated and perforated appendicitis cases were included. A subgroup analysis was performed on SILS appendectomy. Outcomes measured included length of operating room and anesthesia time, as well as complication rate. A log-logistics and a Loess smoothing model were used. Results: A total of 438 single-incision laparoscopic appendectomies were reviewed. A trend toward faster operative times was observed for all surgeons as case numbers increased. The odds of still being operated on decreased by 0.997 for each additional case. Based on a 95% confidence band and this experienced time as the standard, we expect adopting surgeons to reach this experienced level after 51 cases. During the early SILS appendectomy learning curve, there was no significant difference in complication rate compared with multiport laparoscopy. Conclusion: As expected, the more single-incision cases were performed, the shorter the operative times. More importantly, there was no increase in complication rate during the learning stage of single-incision appendectomies in either perforated or nonperforated appendicitis.
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Apendicectomia/métodos , Apendicite/cirurgia , Laparoscopia/métodos , Curva de Aprendizado , Segurança do Paciente/estatística & dados numéricos , Doença Aguda , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Modelos Logísticos , Masculino , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: With similar effectiveness of ultrasonography, our institution replaced CT imaging with ultrasound for diagnosing appendicitis in children. An unexpected consequence was the overutilization of ultrasound. Our objective was to establish measures that could help prevent this overuse. METHODS: A retrospective chart review of 327 consecutive pediatric patients evaluated for appendicitis between October 2014 and September 2015â¯at our institution was performed. Data on clinical, radiographic, and histopathologic findings were reviewed. Diagnostic accuracy of US and white blood cell (WBC) values was determined. An algorithm was created. RESULTS: 327 (100%) patients received an ultrasound for suspected appendicitis. WBC of 10,000/µl was determined to be the primary discriminant for management and ultrasound utilization. If a WBC ≥10,000/µL had been utilized as criteria for imaging, 49.5% fewer patients would have received an ultrasound. CONCLUSIONS: Clinical exam, WBC count, and surgery consultation prior to ultrasonography can lessen then need for ultrasound utilization in children with suspected appendicitis.
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Algoritmos , Apendicite/diagnóstico por imagem , Apendicite/cirurgia , Contagem de Leucócitos , Melhoria de Qualidade , Ultrassonografia/estatística & dados numéricos , Procedimentos Desnecessários/estatística & dados numéricos , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Illinois , Lactente , Masculino , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/estatística & dados numéricosRESUMO
PURPOSE: The treatment of gastroschisis (GS) using our collaborative clinical pathway, with immediate attempted abdominal closure and bowel irrigation with a mucolytic agent, was reviewed. METHODS: A retrospective review of the past 20 years of our clinical pathway was performed on neonates with GS repair at our institution. The clinical treatment includes attempted complete reduction of GS defect within 2 h of birth. In the operating room, the bowel is evaluated and irrigated with mucolytic agent to evacuate the meconium and decompress the bowel. No incision is made and a neo-umbilicus is created. Clinical outcomes following closure were assessed. RESULTS: 150 babies with gastroschisis were reviewed: 109 (77%) with a primary repair, 33 (23%) with a spring-loaded silo repair. 8 babies had a delayed closure and were not included in the statistical analysis. Successful primary repair and time to closure had a significant relationship with all outcome variables-time to extubation, days to initiate feeds, days to full feeds, and length of stay. CONCLUSION: Early definitive closure of the abdominal defect with mucolytic bowel irrigation shortens time to first feeds, total TPN use, time to extubation, and length of stay.