Christian Jones

Effect of Surgeon and Hospital Volume on Emergency General Surgery Outcomes

BACKGROUNDnEmergency general surgery (EGS) contributes to half of all surgical mortality nationwide, is associated with a 50% complication rate, and has a 15% readmission rate within 30 days. We assessed associations between surgeon and hospital EGS volume with these outcomes.nnnSTUDY DESIGNnUsing Marylands Health Services Cost Review Commission database, we identified nontrauma EGS procedures performed by general surgeons among patients 20 years or older, who were admitted urgently or emergently, from July 2012 to September 2014. We created surgeon and hospital volume categories, stratified EGS procedures into simple (mortality ≤ 0.5%) and complex (>0.5%) procedures, and assessed postoperative mortality, complications, and 30-day readmissions. Multivariable logistic regressions both adjusted for clinical factors and accounted for clustering by individual surgeons.nnnRESULTSnWe identified 14,753 procedures (61.5% simple EGS, 38.5% complex EGS) by 252 (73.3%) low-volume surgeons (≤25 total EGS procedures/year), 63 (18.3%) medium-volume surgeons (26 to 50/year), and 29 (8.4%) high-volume surgeons (>50/year). Low-volume surgeons operated on one-third (33.1%) of all patients. For simple procedures, the very low rate of death (0.2%) prevented a meaningful regression with mortality; however, there were no associations between low-volume surgeons and complications (adjusted odds ratio [aOR] 1.07; 95% CI 0.81 to 1.41) or 30-day readmissions (aOR 0.80; 95% CI 0.64 to 1.01) relative to high-volume surgeons. Among complex procedures, low-volume surgeons were associated with greater mortality (aOR 1.64; 95% CI 1.12 to 2.41) relative to high-volume surgeons, but not complications (aOR 1.06; 95% CI 0.85 to 1.32) or 30-day readmission (aOR 0.99; 95% CI 0.80 to 1.22). Low-volume hospitals (≤125 total EGS procedures/year) relative to high-volume hospitals (>250/year) were not associated with mortality, complications, or 30-day readmissions for simple or complex procedures.nnnCONCLUSIONSnWe found evidence that surgeon EGS volume was associated with outcomes. Developing EGS-specific services, mentorship opportunities, and clinical pathways for less-experienced surgeons may improve outcomes.

Efficacy and Safety of a Colistin Loading Dose, High-Dose Maintenance Regimen in Critically Ill Patients With Multidrug-Resistant Gram-Negative Pneumonia.

Introduction: Emergence of multidrug-resistant (MDR) gram-negative (GN) pathogens and lack of novel antibiotics have increased the use of colistin, despite unknown optimal dosing. This study aimed to evaluate the safety and efficacy of a colistin loading dose, high-dose (LDHD) maintenance regimen in patients with MDR-GN pneumonia. Methods: A retrospective cohort analysis was performed comparing critically ill patients with MDR-GN pneumonia pre- and postimplementation of a colistin LDHD guideline with a primary outcome of clinical cure. Safety was assessed using incidence of acute kidney injury (AKI) based on RIFLE (risk, injury, failure, loss, end-stage renal disease) criteria. Results: Seventy-two patients met the inclusion criteria (42 preimplementation and 30 postimplementation). Clinical cure was achieved in 23 (55%) patients in the preimplementation group and 20 (67%) patients in the postimplementation group (P = .31). AKI occurred in 50% of the patients during the preimplementation period and 58% during the postimplementation period (P = .59) with no difference in initiation rates of renal replacement therapy. Conclusion: The increased clinical cure rate after implementation of the colistin LDHD guideline did not reach statistical significance. The LDHD guideline, however, was not associated with an increased incidence of AKI, despite higher intravenous colistin doses. Opportunity exists to optimize colistin dosage while balancing toxicity, but larger studies are warranted.

Colistin combination therapy improves microbiologic cure in critically ill patients with multi-drug resistant gram-negative pneumonia

Currently, in vitro synergy with colistin has not translated into improved clinical outcomes. This study aimed to compare colistin combination therapy to colistin monotherapy in critically ill patients with multi-drug resistant gram-negative (MDR-GN) pneumonia. This was a retrospective analysis of critically ill adult patients receiving intravenous colistin for MDR-GN pneumonia comparing colistin combination therapy to colistin monotherapy with a primary endpoint of clinical cure. Combination therapy was defined by administration of another antibiotic to which the MDR-GN pathogen was reported as susceptible or intermediate. Ninety patients were included for evaluation (41 combination therapy and 49 monotherapy). Baseline characteristics were similar between groups. No difference in clinical cure was observed between combination therapy and monotherapy in univariate analysis, nor when adjusted for APACHE II score and time to appropriate antibiotic therapy (57.1 vs. 63.4xa0%, adjusted OR 1.15, pu2009=u20090.78). Microbiological cure was significantly higher for combination therapy (87 vs. 35.5xa0%, pu2009<u20090.001). Colistin combination therapy was associated with a significant improvement in microbiological cure, without improvement in clinical cure. Based on the in vitro synergy and improvement in microbiological clearance, colistin combination therapy should be prescribed for MDR-GN pneumonia. Further research is warranted to determine if in vitro synergy with colistin translates into improved clinical outcomes.

Professional Use of Social Media Among Surgeons: Results of a Multi-Institutional Study

OBJECTIVEnAmong surgeons, professional use of social media (SM) is varied, and attitudes are ambiguous. We sought to characterize surgeons professional use and perceptions of SM.nnnDESIGNnSurgical faculty and trainees received institutional review board-approved e-mail surveys assessing SM usage and attitudes. Regression analyses identified predictors of SM attitudes and preference for professional contact.nnnSETTINGnSurveys were administered to surgical faculty, fellows, and residents at 4 academic medical centers between January and April 2016.nnnPARTICIPANTSnOf 1037 surgeons, clinical fellows, and residents e-mailed, 208 (20%) responded, including 132 faculty and 76 trainees.nnnRESULTSnAmong 208 respondents, 46 (22%) indicated they preferred some form of SM as their preferred networking and communication modality. A total of 145 (70%) indicated they believe SM benefits professional development. The position of clinical resident predicted preference to maintain professional contact via SM (p = 0.03). Age <55 predicted positive attitude (p = 0.02) and rank of associate professor predicted negative attitude toward SM (p = 0.03). Lack of time as well as personal and patient privacy concerns were cited most commonly as reasons for not using SM.nnnCONCLUSIONSnMost of surgeons responding to our survey used some form of SM for professional purposes. Perceived barriers include lack of value, time constraints, and personal and patient privacy concerns. Generational differences in surgeon attitudes suggest usage of SM among surgeons will expand over time.

Facility disparities in reporting comorbidities to the National Trauma Data Bank

BACKGROUNDnThe National Trauma Data Bank (NTDB) includes patient comorbidities. This study evaluates factors of trauma centers associated with higher rates of missing comorbidity data.nnnMETHODSnProportions of missing comorbidity data from facilities in the NTDB from 2011 to 2014 were evaluated for associations with facility characteristics. Proportional impact analysis was performed to identify potential policy targets.nnnRESULTSnOf 919 included facilities, 85% reported comorbidity data in 95% or more cases; only 31.3% were missing no data. Missing rates were significantly different based on most facility categories, but independently associated only with hospital size, region, and trauma center level. Only 15% of centers were responsible for over 80% of cases missing data.nnnCONCLUSIONSnThere is significant nonrandom variation in reporting trauma patient comorbidities to the NTDB. Missing data needs to be recognized and considered in studies of trauma comorbidities. Targeted intervention may improve data quality.

Discharge destination and readmission rates in older trauma patients

BACKGROUNDnIn older trauma patients, the impact of discharge destination on readmission rates is not known. The objective of this study was to evaluate the association between the discharge destination and the 30-day readmission rate in older trauma patients.nnnMATERIALS AND METHODSnA previously validated database of all patients aged 45xa0years or older undergoing trauma evaluation at our level 1 trauma center between January 1, 2008 and December 31, 2008 was analyzed to retrospectively compare the incidences of 30-day readmission between patients discharged to home, to inpatient rehabilitation facilities, and to other extended care facilities (ECFs). Demographic information including age and gender and potentially confounding factors including injury severity, trauma activation level, comorbidities, medications, and preinjury functional status were included. Univariate analysis was undertaken using chi-square testing. Multiple logistic regression was performed with potential confounding variables to evaluate for independent contribution to readmission risk.nnnRESULTSnA total of 960 patients were evaluated; 81 patients (8.4%) were excluded, leaving 879 patients included in the analysis. Seventy-six patients (8.6%) were readmitted within 30xa0d of discharge. Overall, 6% of those discharged to home, 13% of those discharged to ECF, and 16% of those discharged to rehabilitation were readmitted (Pxa0<xa00.01 on univariate analysis). Overall, 866 (98.5%) patients had data recorded for all variables analyzed using multiple logistic regression; among these, only discharge destination was independently associated with the rate of readmission (Pxa0<xa00.01).nnnCONCLUSIONSnDischarge to ECFs and inpatient rehabilitation facilities appear to be an independent risk factor for hospital readmissions in this population despite controlling for injury severity and comorbidities. Recognition of this risk factor may aid in the disposition planning of these patients and suggests the need for further evaluation of this correlation at other US medical centers.

Association between intentional ingestion of foreign objects and psychiatric disease among prisoners: A retrospective study

Introduction: Intentional ingestion of foreign objects (IIFO) is prevalent among U.S. prisoners. IIFOs often require surgical or endoscopic interventions, extended hospital stays, and may result in significant morbidity or even mortality. Although psychiatric illness is prevalent among prisoners engaging in IIFO, this association remains poorly defined. The aim of this study is to describe the psychiatric illness profile among prisoners diagnosed with IIFO. We hypothesized that repeated episodes of IIFO are associated with an escalating pattern of documented psychiatric illness. Methods: After approvals were obtained from our Institutional Review Board and the Ohio Department of Rehabilitation and Correction, a retrospective study was conducted of prisoners presenting to our facility with IIFO between 2004 and 2011. All historical and concurrent psychiatric diagnoses were abstracted from the medical record and classified into Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition based categories. In addition, medical history, alcohol/drug use, and prior episodes of IIFO were recorded. Statistical analyses included Chi-square and Kruskal–Wallis tests for categorical and continuous data, respectively. Results: We analyzed 136 IIFO episodes involving 27 patients. Repeat IIFO episodes were associated with an increasing number of psychiatric diagnoses. Patients with their fifth or later IIFO had a larger number of psychiatric diagnoses and the number of objects ingested as compared to patients presenting with a first episode (P < 0.01). Similarly, patients who went on to present with additional episodes of IIFO during the study had more psychiatric diagnoses identified throughout their visits (P < 0.01). The proportion of patients with mood and anxiety disorders (including post-traumatic stress) was progressively greater among prisoners with recurrent episodes of IIFO (P < 0.05). Other psychiatric disorders were not significantly associated with IIFO escalation. Conclusions: We observed a significant association between IIFO recurrences and increases in both the quantity of ingested items and the number of documented psychiatric diagnoses. Of note, psychiatric diagnoses of malingering or secondary gain were not identified in the current patient sample. Consideration of early psychiatric evaluation and intervention in the setting of IIFO, especially recurrent IIFO, is strongly encouraged. The following core competencies are addressed in this article: Medical knowledge, Patient care, Systems-based practice.

History of Social Media in Surgery

&NA; In many ways, the history of surgeons on Twitter echoes the initial resistance and ultimate mass adoption of laparoscopic surgery that led to the field of minimally invasive surgery. At its inception, social media was similarly met with skepticism and concerns of threats to professionalism. Despite these concerns, numerous surgeons and other physicians pioneered the use of social media to establish a virtual medical community and share scientific knowledge regarding a variety of topics including medical conferences, journal publications, and more. After these initial successes, surgeons views have evolved, leading to mass adoption of social media and participation on Twitter as a means of professional networking and dissemination of science. This article chronicles that history.

#ILookLikeASurgeon: embracing diversity to improve patient outcomes

The stereotype of the arrogant, white, male surgeon is a barrier to professionals

Correlations between pulmonary artery pressures and inferior vena cava collapsibility in critically ill surgical patients: An exploratory study.

Introduction: As pulmonary artery catheter (PAC) use declines, search continues for reliable and readily accessible minimally invasive hemodynamic monitoring alternatives. Although the correlation between inferior vena cava collapsibility index (IVC-CI) and central venous pressures (CVP) has been described previously, little information exists regarding the relationship between IVC-CI and pulmonary artery pressures (PAPs). The goal of this study is to bridge this important knowledge gap. We hypothesized that there would be an inverse correlation between IVC-CI and PAPs. Methods: A post hoc analysis of prospectively collected hemodynamic data was performed, examining correlations between IVC-CI and PAPs in a convenience sample of adult Surgical Intensive Care Unit patients. Concurrent measurements of IVC-CI and pulmonary arterial systolic (PAS), pulmonary arterial diastolic (PAD), and pulmonary arterial mean (PAM) pressures were performed. IVC-CI was calculated as ([IVC max − IVC min]/IVC max) × 100%. Vena cava measurements were obtained by ultrasound-credentialed providers. For the purpose of correlative analysis, PAP measurements (PAS, PAD, and PAM) were grouped by terciles while the IVC-CI spectrum was divided into thirds (<33, 33-65, ≥66). Results: Data from 34 patients (12 women, 22 men, with median age of 59.5 years) were analyzed. Median Acute Physiologic Assessment and Chronic Health Evaluation II score was 9. A total of 76 measurement pairs were recorded, with 57% (43/76) obtained in mechanically ventilated patients. Correlations between IVC-CI and PAS (rs = −0.334), PAD (rs = −0.305), and PAM (rs = −0.329) were poor. Correlations were higher between CVP and PAS (R2 = 0.61), PAD (R2 = 0.68), and PAM (R2 = 0.70). High IVC-CI values (≥66%) consistently correlated with measurements in the lowest PAP ranges. Across all PAP groups (PAS, PAD, and PAM), there were no differences between the mean measurement values for the lower and middle IVC-CI ranges (0%-65%). However, all three groups had significantly lower mean measurement values for the ≥66% IVC-CI group. Conclusions: Low PAS, PAD, and PAM measurements show a reasonable correlation with high IVC-CI (≥66%). These findings are consistent with previous descriptions of the relationship between IVC-CI and CVP. Additional research in this area is warranted to better describe the hemodynamic relationship between IVC-CI and PAPs, with the goal of further reduction in the reliance on the use of PACs.