Child-adolescent emergency psychiatry: addressing false positive admissions.

Current literature emphasizes the necessary and increasing role of the emergency department (ED) psychologist. This perspective paper will illustrate that the recent focus on an ED psychologist is necessary, but insufficient. Equally important, is an understanding of when a patient in a potential crisis does not require an ED admission, but rather an assessment that is made prior to the patient going to the ED. The essential role of an outpatient crisis team is vital in differentiating when an ED admission is indicated for a psychiatric crisis (true positive) and when an ED admission is not indicated for a psychiatric crisis (false positive). Evaluating crises prior to ED admissions accomplishes two critical healthcare objectives in a parallel process: 1) accurately assessing the proper level of care needed when a patient reports they are experiencing acute psychiatric symptoms (which may or may not necessitate emergency department level of care, and 2) reducing burden on an already over-extended ED when emergency care is not indicated. Our findings are uniquely drawn from a highly diverse youth patient population in Northern California, United States.

Surgeon Quality and Patient Survival After Resection for Non-Small-Cell Lung Cancer.

PURPOSE: The quality and outcomes of curative-intent lung cancer surgery vary in populations. Surgeons are key drivers of surgical quality. We examined the association between surgeon-level intermediate outcomes differences, patient survival differences, and potential mitigation by processes of care. PATIENTS AND METHODS: Using a baseline population-based surgical resection cohort, we derived surgeon-level cut points for rates of positive margins, nonexamination of lymph nodes, nonexamination of mediastinal lymph nodes, and wedge resections. Applying the baseline cut points to a subsequent cohort from the same population-based data set, we assign surgeons into three performance categories in reference to each metric: 1 (<25th percentile), 2 (25th-75th percentile), and 3 (>75th percentile). The sum of performance scores created three surgeon quality tiers: 1 (4-6, low), 2 (7-9, intermediate), and 3 (10-12, high). We used chi-squared, Wilcoxon-Mann-Whitney, and Kruskal-Wallis tests to compare patient characteristics between the baseline and subsequent cohorts and across surgeon tiers. We applied Cox proportional hazards models to examine the association between patient survival and surgeon performance tier, sequentially adjusting for clinical stage, patient characteristics, and four specific processes. RESULTS: From 2009 to 2021, 39 surgeons performed 4,082 resections across the baseline and subsequent cohorts. Among 31 subsequent cohort surgeons, five were tier 1, five were tier 2, and 21 were tier 3. Tier 1 and 2 surgeons had significantly worse outcomes than tier 3 surgeons (hazard ratio [HR], 1.37; 95% CI, 1.10 to 1.72 and 1.19; 95% CI, 1.00 to 1.43, respectively). Adjustment for specific processes mitigated the surgeon-tiered survival differences, with adjusted HRs of 1.02 (95% CI, 0.8 to 1.3) and 0.93 (95% CI, 0.7 to 1.25), respectively. CONCLUSION: Readily accessible intermediate outcomes metrics can be used to stratify surgeon performance for targeted process improvement, potentially reducing patient survival disparities.

Survival Before and After Direct Surgical Quality Feedback in a Population-Based Lung Cancer Cohort.

BACKGROUND: Surgical resection is the main curative modality for non-small cell lung cancer (NSCLC), but variation in the quality of care contributes to suboptimal survival rates. Improving surgical outcomes by eliminating quality deficits is a key strategy for improving population-level lung cancer survival. We evaluated the long-term survival effect of providing direct feedback on institutional performance in a population-based cohort. METHODS: The Mid-South Quality of Surgical Resection cohort includes all NSCLC resections at 11 hospitals in four contiguous Dartmouth Hospital Referral Regions in Arkansas, Mississippi, and Tennessee. We evaluated resections from 2004 to 2013, before and after onset of a benchmarked performance feedback campaign to surgery and pathology teams in 2009. RESULTS: We evaluated 2,206 patients: 56% preintervention (pre-era) and 44% postintervention (post-era). Preoperative positron emission tomography/computed tomography (46% vs 82%, p < 0.0001), brain scans (6% vs 21%, p < 0.0001), and bronchoscopy (8% vs 27%, p < 0.0001) were more frequently used in the post-era. Patients had 5-year survival of 47% (44% to 50%) in the pre-era compared with 53% (50% to 56%) in the post-era (p = 0.0028). The post-era had an adjusted hazard ratio of 0.85 (95% confidence interval [CI], 0.75 to 0.97; p = 0.0158) compared with the pre-era. This differed by extent of resection (p = 0.0113): compared with the pre-era, the post-era adjusted hazard ratio was 0.49 (95% CI, 0.33 to 0.72) in pneumonectomy, 0.91 (95% CI, 0.79 to 1.05) in lobectomy/bilobectomy, and 0.85 (95% CI, 0.63 to 1.15) in segmentectomy/wedge resections. CONCLUSIONS: Overall survival after surgical resection improved significantly in a high lung cancer mortality region of the United States. Reasons may include better selection of patients for pneumonectomy and more thorough staging.

Evolution in the Surgical Care of Patients With Non-Small Cell Lung Cancer in the Mid-South Quality of Surgical Resection Cohort.

Surgery is the most important curative treatment modality for patients with early-stage non-small cell lung cancer (NSCLC). We examined the pattern of surgical resection for NSCLC in a high incidence and mortality region of the United States over a 10-year period (2004-2013) in the context of a regional surgical quality improvement initiative. We abstracted patient-level data on all resections at 11 hospitals in 4 contiguous Dartmouth Hospital Referral Regions in North Mississippi, East Arkansas, and West Tennessee. Surgical quality measures focused on intraoperative practice, with emphasis on pathologic nodal staging. We used descriptive statistics and trend analyses to assess changes in practice over time. To measure the effect of an ongoing regional quality improvement intervention with a lymph node specimen collection kit, we used period effect analysis to compare trends between the preintervention and postintervention periods. Of 2566 patients, 18% had no preoperative biopsy, only 15% had a preoperative invasive staging test, and 11% underwent mediastinoscopy. The rate of resections with no mediastinal lymph nodes examined decreased from 48%-32% (P < 0.0001), whereas the rate of resections examining 3 or more mediastinal stations increased from 5%-49% (P < 0.0001). There was a significant period effect in the increase in the number of N1, mediastinal, and total lymph nodes examined (all P < 0.0001). A quality improvement intervention including a lymph node specimen collection kit shows early signs of having a significant positive effect on pathologic nodal examination in this population-based cohort. However, gaps in surgical quality remain.

Dual intervention to improve pathologic staging of resectable lung cancer.

BACKGROUND: Detection of lymph node metastasis is of immense prognostic value in patients with resectable non-small cell lung cancer (NSCLC), but routine pathologic nodal staging is suboptimal. To determine the impact on the rate of detection of nodal metastasis, we tested dual intervention with a prelabeled lymph node specimen collection kit to improve intraoperative node dissection and a fastidious gross dissection of the lung resection specimen for intrapulmonary lymph nodes. METHODS: We matched dual-intervention cases with controls staged using standard surgical specimen collection and pathologic examination protocols. Controls were hierarchically matched for extent of resection, laterality, surgeon, pathologist, and T stage. All statistical comparisons were made with exact conditional logistic regression, to account for the matched case-control design. RESULTS: One hundred dual-intervention cases were matched with 100 controls. The dual interventions resulted in approximately a 3-fold increase in the number of lymph nodes examined and the number of lymph nodes with metastasis detected; they also increased the proportion of patients with lymph node metastasis from 21% to 35% (p = 0.02). There were strong trends toward higher aggregate stage distribution, and eligibility for postoperative adjuvant chemotherapy in the dual-intervention cases. CONCLUSIONS: The combination of interventions improved the thoroughness and accuracy of pathologic nodal staging. A prospective randomized trial to test the survival impact of the dual interventions is warranted.

Alveolar hydatid disease (Echinococcus multilocularis) in the liver of a Canadian dog in British Columbia, a newly endemic region.

An adult dog that lived in central British Columbia was examined because of a history of lethargy and vomiting. Histology, immunohistochemistry, and polymerase chain reaction (PCR) examination of a hepatic mass confirmed the presence of an alveolar hydatid cyst, the first description of Echinococcus multilocularis in British Columbia. We provide recommendations for case management and remind practitioners in endemic areas of western Canada that dogs can serve as definitive and, rarely, intermediate hosts for E. multilocularis.

RésuméHydatidose alvéolaire(Echinococcus multilocularis)dans le foie d'un chien canadien en Colombie-Britannique, une région nouvellement endémique. Un chien adulte habitant dans le centre de la Colombie-Britannique a été examiné en raison d'une anamnèse d'abattement et de vomissements. L'histologie, l'immunohistochimie et l'amplification en chaîne par la polymérase d'une masse hépatique ont tous confirmé la présence d'un kyste hydatique, la première description d'Echinococcus multilocularis en Colombie-Britannique. Nous présentons des recommandations pour la gestion des cas et rappelons aux praticiens dans les régions endémiques de l'Ouest canadien que les chiens peuvent servir d'hôtes définitifs, et rarement, d'hôtes intermédiaires, pour E. multilocularis.(Traduit par Isabelle Vallières).

Staged total exclusion of the aorta for chronic type B aortic dissection.

Hybrid techniques using extra-anatomic bypass of critical aortic branches to enable endovascular treatment of complex aortic pathology have been previously described. A staged endograft repair of a complex, chronic Stanford type B aortic dissection with aneurysmal degeneration is reported in a 50-year-old man. The aneurysmal portion of the dissection extended from the distal arch to both common iliac arteries and was covered with an endograft from the ascending aorta to both external iliac arteries. Aortic arch branches, visceral, and renal arteries were bypassed using open technique. The patient had no neurologic complications. This case report illustrates the feasibility of the hybrid technique in selected high-risk patients when confronted with complex aortic pathology.

Management of acute infrarenal aortic occlusion secondary to type A dissection.

Infrarenal aortic occlusion is a well described complication of type A aortic dissection that carries a significant mortality rate. A technique of immediate reperfusion of the lower extremities through an axillo-bi-femoral graft is described in 2 patients with good results.