Direct to Operating Room for Decompressive Craniotomy/Craniectomy in Patients With Traumatic Brain Injury.

BACKGROUND: Emergent decompressive craniotomy/craniectomy can be a lifesaving surgical intervention for select patients with traumatic brain injury. Prompt management is critical as early decompression can impact traumatic brain injury outcomes. OBJECTIVE: This study aims to describe the feasibility and clinical impact of a new pathway for transporting patients with severe traumatic brain injury directly to the operating room from the trauma bay for decompressive craniotomy/craniectomy. METHODS: This is a retrospective cohort preintervention and postintervention study of severe traumatic brain injury patients undergoing decompressive craniectomy/craniotomy at a Midwestern U.S. Level I trauma center between 2016 and 2022. In the new pathway, the in-house trauma surgeon takes the patient directly to the operating room with the neurosurgery advanced practice provider to drape and prepare the patient for surgery while the neurosurgeon is en route to the hospital. RESULTS: A total of 44 patients were studied, five (5/44, 11.4%) of which were in the preintervention group and 39 (39/44, 88.6%) in the postintervention group. The median arrival-to-operating room time was shorter in the postintervention cohort (1.4 hr) than in the preintervention cohort (1.5 hr). In examining night shifts only, the preintervention cohort had shorter arrival-to-operating room times (1.2 hr) than the postintervention cohort (1.5 hr). CONCLUSION: The study demonstrated that the new pathway is feasible and expedites patient transport to the operating room while awaiting the arrival of the on-call neurosurgeon.

A collaborative model for inpatient training in a small pediatric residency program.

BACKGROUND: The nationwide decline in pediatric admissions to community hospitals threatens the sustainability of small pediatric residency programs. Little is known about the response of small programs to this challenge. OBJECTIVES: We report on the design and evaluation of an innovative, collaborative model for pediatric inpatient training between an academic community medical center and a children's hospital. METHODS: We describe the operational, academic, and financial features of the model. Outcome measures include patient volume and subspecialty mix, resident and faculty perceptions as reported in an anonymous survey, and Accreditation Council for Graduate Medical Education Residency Review Committee (RRC) review. RESULTS: In 2003, Albert Einstein Medical Center (Einstein) closed its pediatric inpatient unit and established an independent teaching service at St Christopher's Hospital for Children (St Christopher's) in Philadelphia, Pennsylvania. Under the new model, patient volume and subspecialty mix more than tripled. Einstein residents and faculty identified 5 major strengths: level of responsibility and decision making, caring for medically complex children, quality of teaching, teamwork, and opportunity to participate in academic activities at a children's hospital. St Christopher's leadership reported increased volume, no disruption of their residency program, and no dilution of clinical teaching material. The Einstein program was reaccredited by the RRC in 2006 for 2 years and in 2009 for 4 years. CONCLUSION: A collaborative model for inpatient training was successful in maintaining a community hospital-based pediatric residency program. Positive outcomes were documented for the residency program, the parent community hospital, and the collaborating children's hospital.

Anti-BSA antibodies are a major cause of non-specific binding in insulin autoantibody radiobinding assays.

Insulin autoantibodies (IAA) are usually the first risk-markers detected during the type 1 diabetes prodrome, but precise measurement is difficult as insulin binding is often low. Non-specific binding (NSB) of (125)I-labelled insulin necessitates competitive displacement with unlabelled insulin to demonstrate specificity. NSB varies with different batches of label, suggesting that it is caused by impurities in the label. Addition of bovine serum albumin (BSA) can reduce NSB, so we investigated whether BSA antibodies cause lack of specificity in IAA assays. Samples from patients with newly-diagnosed type 1 diabetes, healthy schoolchildren previously found to have raised (125)I-insulin binding (≥ 0.4 units) and IAA-negative schoolchildren were re-assayed for IAA by radiobinding microassay using commercial (125)I-insulin with and without 1g/dl BSA added to the buffer. Of 100 patients, 68 were IAA-positive on re-assay with BSA compared to 72 without BSA (p=0.125). Of 154 schoolchildren who previously had raised (125)I-insulin binding, only 45 had (125)I-insulin binding ≥ 0.4 units on re-assay with BSA compared to 90 without BSA (p<0.001). Following competitive displacement with unlabelled insulin, 40 were IAA-positive with BSA compared to 48 without BSA (p=0.02). No IAA-negative schoolchildren were IAA-positive on re-assay. Levels of NSB were associated with antibodies binding (125)I-BSA and purification of labelled insulin reduced NSB. Addition of BSA to assay buffer improves the screening efficiency of the IAA assay without reducing disease sensitivity in patients. High titre BSA antibodies interfere with IAA measurement because of (125)I-BSA present in some insulin labels. Improved purification of insulin labels should obviate the need for competitive displacement.