Cornelius A. Thiels

Use of Unmanned Aerial Vehicles for Medical Product Transport

Advances in technology and decreasing costs have led to an increased use of unmanned aerial vehicles (UAVs) by the military and civilian sectors. The use of UAVs in commerce is restricted by US Federal Aviation Administration (FAA) regulations, but the FAA is drafting new regulations that are expected to expand commercial applications. Currently, the transportation of medical goods in times of critical need is limited to wheeled motor vehicles and manned aircraft, options that can be costly and slow. This article explores the demand for, feasibility of, and risks associated with the use of UAVs to deliver medical products, including blood derivatives and pharmaceuticals, to hospitals, mass casualty scenes, and offshore vessels in times of critical demand.

Wide Variation and Overprescription of Opioids after Elective Surgery

Objective: We aimed to identify opioid prescribing practices across surgical specialties and institutions. Background: In an effort to minimize the contribution of prescription narcotics to the nationwide opioid epidemic, reductions in postoperative opioid prescribing have been proposed. It has been suggested that a maximum of 7 days, or 200 mg oral morphine equivalents (OME), should be prescribed at discharge in opioid-naïve patients. Methods: Adults undergoing 25 common elective procedures from 2013 to 2015 were identified from American College of Surgeons National Surgical Quality Improvement Program data from 3 academic centers in Minnesota, Arizona, and Florida. Opioids prescribed at discharge were abstracted from pharmacy data and converted into OME. Wilcoxon Rank-Sum and Kruskal-Wallis tests assessed variations. Results: Of 7651 patients, 93.9% received opioid prescriptions at discharge. Of 7181 patients who received opioid prescriptions, a median of 375 OME (interquartile range 225–750) were prescribed. Median OME varied by sex (375 men vs 390 women, P = 0.002) and increased with age (375 age 18–39 to 425 age 80+, P < 0.001). Patients with obesity and patients with non-cancer diagnoses received more opioids (both P < 0.001). Subset analysis of the 5756 (75.2%) opioid-naïve patients showed the majority received >200 OME (80.9%). Significant variations in opioid prescribing practices were seen within each procedure and between the 3 medical centers. Conclusions: The majority of patients were overprescribed opioids. Significant prescribing variation exists that was not explained by patient factors. These data will guide practices to optimize opioid prescribing after surgery.

Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy

INTRODUCTION Current Advanced Trauma Life Support guidelines recommend decompression for thoracic tension physiology using a 5-cm angiocatheter at the second intercostal space (ICS) on the midclavicular line (MCL). High failure rates occur. Through systematic review and meta-analysis, we aimed to determine the chest wall thickness (CWT) of the 2nd ICS-MCL, the 4th/5th ICS at the anterior axillary line (AAL), the 4th/5th ICS mid axillary line (MAL) and needle thoracostomy failure rates using the currently recommended 5-cm angiocatheter. METHODS A comprehensive search of several databases from their inception to July 24, 2014 was conducted. The search was limited to the English language, and all study populations were included. Studies were appraised by two independent reviewers according to a priori defined PRISMA inclusion and exclusion criteria. Continuous outcomes (CWT) were evaluated using weighted mean difference and binary outcomes (failure with 5-cm needle) were assessed using incidence rate. Outcomes were pooled using the random-effects model. RESULTS The search resulted in 34,652 studies of which 15 were included for CWT analysis, 13 for NT effectiveness. Mean CWT was 42.79 mm (95% CI, 38.78-46.81) at 2nd ICS-MCL, 39.85 mm (95% CI, 28.70-51.00) at MAL, and 34.33 mm (95% CI, 28.20-40.47) at AAL (P=.08). Mean failure rate was 38% (95% CI, 24-54) at 2nd ICS-MCL, 31% (95% CI, 10-64) at MAL, and 13% (95% CI, 8-22) at AAL (P=.01). CONCLUSION Evidence from observational studies suggests that the 4th/5th ICS-AAL has the lowest predicted failure rate of needle decompression in multiple populations. LEVEL OF EVIDENCE Level 3 SR/MA with up to two negative criteria. STUDY TYPE Therapeutic.

Effect of Hospital Case Mix on the Hospital Consumer Assessment of Healthcare Providers and Systems Star Scores: Are All Stars the Same?

Objective: We aimed to evaluate variations in patient experience measures across different surgical specialties and to assess the impact of further case-mix adjustment. Background: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a publicly reported survey of patients’ hospital experiences that directly influence Medicare reimbursement. Methods: All adult surgical inpatients meeting criteria for HCAHPS sampling from 2013 to 2014 at a single academic center were identified. HCAHPS measures were analyzed according to published top-box and Star-rating methodologies, and were dichotomized (“high” vs “low”). Multivariable logistic regression was used to identify independent associations of high patient scores on various HCAHPS measures with specialty, diagnosis-related group complexity, cancer diagnosis, sex, and emergency admission after adjusting for HCAHPS case-mix adjusters (education, overall health status, language, and age). Results: We identified 36,551 eligible patients, of which 30.8% (n = 11,273) completed HCAHPS. Women [odds ratio (OR) 0.78, 95% confidence interval (CI) 0.72–0.85, P < 0.001], complex cases (OR 0.90, 95% CI 0.82–0.99, P = 0.02), and emergency admissions (OR 0.67, 95% CI 0.55–0.82, P < 0.001) had lesser Star scores on adjusted analysis, whereas patients with a cancer diagnosis had greater Star scores (OR 1.15, 95% CI 1.03–1.29, P = 0.01). Using general surgery as the reference, the Star scores varied significantly across 12 specialties (range OR 0.65 for plastics to 1.29 for transplant surgery). Patient responses to individual composite scores (pain, care transition, physician, and nurse) varied by specialty. Conclusions: HCAHPS case-mix adjustment does not include adjustment for specialty or diagnosis, which may result in artificially lower scores for centers that provide a high level of complex care. Further research is needed to ensure that the HCAHPS is an unbiased comparison tool.

Every Surgical Resident Should Know How to Perform a Cricothyrotomy: An Inexpensive Cricothyrotomy Task Trainer for Teaching and Assessing Surgical Trainees

OBJECTIVE Emergency cricothyrotomy is a rare but potentially lifesaving procedure. Training opportunities for surgical residents to learn this skill are limited, and many graduating residents have never performed one during their training. We aimed to develop and validate a novel and inexpensive cricothyrotomy task trainer that can be constructed from household items. DESIGN A model was constructed using a toilet paper roll (trachea and larynx), Styrofoam (soft tissue), cardboard (thyroid cartilage), zip tie (cricoid), and fabric (skin). Participants were asked to complete a simulated cricothyrotomy procedure using the model. They were then evaluated using a 10-point checklist (5 points total) devised by 6 general surgeons. Participants were also asked to complete an anonymous survey rating the educational value and the degree of enjoyment regarding the model. SETTING A tertiary care teaching hospital. PARTICIPANTS A total of 54 students and general surgery residents (11 medical students, 32 interns, and 11 postgraduate year 3 residents). RESULTS All 54 participants completed the training and assessment. The scores ranged from 0 to 5. The mean (range) scores were 1.8 (1-4) for medical students, 3.5 (1-5) for junior residents, and 4.9 (4-5) for senior-level residents. Medical students were significantly outperformed by junior- and senior-level residents (p < 0.001). Trainees felt that the model was educational (4.5) and enjoyable (4.0). CONCLUSIONS A low-fidelity, low-cost cricothyrotomy simulator distinguished the performance of emergency cricothyrotomy between medical students and junior- and senior-level general surgery residents. This task trainer may be ideally suited to providing basic skills to all physicians in training, especially in settings with limited resources and clinical opportunities.

Influence of Social Media on the Dissemination of a Traditional Surgical Research Article

OBJECTIVE Many institutions use social media to share research with the general public. However, the influence of social media on the dissemination of a surgical research article itself is unknown. Our objective was to determine whether a blog post highlighting the findings of a surgical research article would lead to increased dissemination of the article itself. DESIGN We prospectively followed the online page views of an article that was published online in Surgery in May 2015 and published in print in August 2015. The authors subsequently released a blog post in October 2015 to promote the research. The number of article page views from the journals website was obtained before and after the blog post, along with the page views from the blog post itself. Social media influence data were collected, including social activity in the form of mentions on social media sites, scholarly activity in online libraries, and scholarly commentary. RESULTS The articles online activity peaked in the first month after online publication (475 page views). Online activity plateaued by 4 months after publication, with 118 monthly page views, and a blog post was subsequently published. The blog post was viewed by 1566 readers, and readers spent a mean of 2.5 minutes on the page. When compared to the projected trend, the page views increased by 33% in the month after the blog post. The blog post resulted in a 9% increase in the social media influence score and a 5% absolute increase in total article page views. CONCLUSIONS Social media is an important tool for sharing surgical research. Our data suggest that social media can increase distribution of an articles message and also potentially increase dissemination of the article itself. We believe that authors should consider using social media to increase the dissemination of traditionally published articles.

Infected hardware after surgical stabilization of rib fractures: Outcomes and management experience

BACKGROUND Surgical stabilization of rib fracture (SSRF) is increasingly used for treatment of rib fractures. There are few data on the incidence, risk factors, outcomes, and optimal management strategy for hardware infection in these patients. We aimed to develop and propose a management algorithm to help others treat this potentially morbid complication. METHODS We retrospectively searched a prospectively collected rib fracture database for the records of all patients who underwent SSRF from August 2009 through March 2014 at our institution. We then analyzed for the subsequent development of hardware infection among these patients. Standard descriptive analyses were performed. RESULTS Among 122 patients who underwent SSRF, most (73%) were men; the mean (SD) age was 59.5 (16.4) years, and median (interquartile range [IQR]) Injury Severity Score was 17 (13–22). The median number of rib fractures was 7 (5–9) and 48% of the patients had flail chest. Mortality at 30 days was 0.8%. Five patients (4.1%) had a hardware infection on mean (SD) postoperative day 12.0 (6.6). Median Injury Severity Score (17 [range, 13–42]) and hospital length of stay (9 days [6–37 days]) in these patients were similar to the values for those without infection (17 days [range, 13–22 days] and 9 days [6–12 days], respectively). Patients with infection underwent a median (IQR) of 2 (range, 2–3) additional operations, which included wound debridement (n = 5), negative-pressure wound therapy (n = 3), and antibiotic beads (n = 4). Hardware was removed in 3 patients at 140, 190, and 192 days after index operation. Cultures grew only gram-positive organisms. No patients required reintervention after hardware removal, and all achieved bony union and were taking no narcotics or antibiotics at the latest follow-up. CONCLUSIONS Although uncommon, hardware infection after SSRF carries considerable morbidity. With the use of an aggressive multimodal management strategy, however, bony union and favorable long-term outcomes can be achieved. LEVEL OF EVIDENCE Therapeutic study, level V.

Adrenocortical carcinoma with inferior vena cava tumor thrombus

Background. The safety, efficacy, and prognostic implications of resection of adrenocortical carcinoma with inferior vena cava tumor thrombus are poorly described. Methods. A retrospective review was performed during a 30‐year period on patients who underwent resection of locally advanced, nonmetastatic adrenocortical carcinoma. We compared patients with and without inferior vena cava tumor thrombus, examining perioperative characteristics, completeness of resection, mortality, and survival. Results. We identified 65 patients who underwent resection of locally advanced (T4N0 and T4N1) adrenocortical carcinoma (28 patients with inferior vena cava tumor thrombus, 37 noninferior vena cava tumor thrombus). Rate of complete resection, adjuvant chemotherapy, and short‐term postoperative morbidity was similar between groups. Overall survival was similar at 12‐months. At 24 months overall survival was less in the inferior vena cava tumor thrombus group (59% vs 30%, P = .04). Differential survival through 60‐month follow‐up favored the noninferior vena cava tumor thrombus group (36% vs 0%, P = .001). Subgroup analysis including only patients with complete resection demonstrates similar survival at 24‐months but at 36‐months survival favored the noninferior vena cava tumor thrombus patients (65% vs 29%, P = .047) and this continued through 60 months (40% vs 0%, P = .049). Conclusion. Attempt at complete resection of adrenocortical carcinoma with inferior vena cava tumor thrombus seems justified particularly as short‐term safety and survival are similar to patients without inferior vena cava tumor thrombus. However, survival beyond 36‐months is limited in patients with inferior vena cava tumor thrombus. Patients being evaluated for resection in the setting of inferior vena cava tumor thrombus should be selected carefully.

Outcomes with multimodal therapy for elderly patients with rectal cancer.

Treatment guidelines for stage II and III rectal cancer include neoadjuvant chemoradiotherapy, surgery and postoperative adjuvant chemotherapy. Although data support this recommendation in younger patients, it is unclear whether this benefit can be extrapolated to elderly patients (aged 75 years or older).

Medical Malpractice Lawsuits Involving Surgical Residents

Importance Medical malpractice litigation against surgical residents is rarely discussed owing to assumed legal doctrine of respondeat superior, or “let the master answer.” Objective To better understand lawsuits targeting surgical trainees to prevent future litigation. Design, Setting, and Participants Westlaw, an online legal research database containing legal records from across the United States, was retrospectively reviewed for malpractice cases involving surgical interns, residents, or fellows from January 1, 2005, to January 1, 2015. Infant-related obstetric and ophthalmologic procedures were excluded. Exposures Involvement in a medical malpractice case. Main Outcomes and Measures Data were collected on patient demographics, case characteristics, and outcomes and were analyzed using descriptive statistics. Results During a 10-year period, 87 malpractice cases involving surgical trainees were identified. A total of 50 patients were female (57%), and 79 were 18 years of age or older (91%), with a median patient age of 44.5 years (interquartile range, 45-56 years). A total of 67 cases (77%) resulted in death or permanent disability. Most cases involved elective surgery (61 [70%]) and named a junior resident as a defendant (24 of 35 [69%]). Cases more often questioned the perioperative medical knowledge, decision making errors, and injuries (53 [61%]: preoperative, 19 of 53 [36%]) and postoperative, 34 of 53 [64%]) than intraoperative errors and injuries (43 [49%]). Junior residents were involved primarily with lawsuits related to medical decision making (21 of 24 [87%]). Residents’ failure to evaluate the patient was cited in 10 cases (12%) and lack of direct supervision by attending physicians was cited in 48 cases (55%). A total of 42 cases (48%) resulted in a jury verdict or settlement in favor of the plaintiff, with a median payout of