Ilene Staff

Duration of red blood cell storage is associated with increased incidence of deep vein thrombosis and in hospital mortality in patients with traumatic injuries

IntroductionIn critically ill patients the relationship between the storage age of red blood cells (RBCs) transfused and outcomes are controversial. To determine if duration of RBC storage is associated with adverse outcomes we studied critically ill trauma patients requiring transfusion.MethodsThis retrospective cohort study included patients with traumatic injuries transfused ≥5 RBC units. Patients transfused ≥ 1 unit of RBCs with a maximum storage age of up to 27 days were compared with those transfused 1 or more RBC units with a maximum storage age of ≥ 28 days. These study groups were also matched by RBC amount (+/- 1 unit) transfused. Primary outcomes were deep vein thrombosis and in-hospital mortality.ResultsTwo hundred and two patients were studied with 101 in both decreased and increased RBC age groups. No differences in admission vital signs, laboratory values, use of DVT prophylaxis, blood products or Injury Severity Scores were measured between study groups. In the decreased compared with increased RBC storage age groups, deep vein thrombosis occurred in 16.7% vs 34.5%, (P = 0.006), and mortality was 13.9% vs 26.7%, (P = 0.02), respectively. Patients transfused RBCs of increased storage age had an independent association with mortality, OR (95% CI), 4.0 (1.34 - 11.61), (P = 0.01), and had an increased incidence of death from multi-organ failure compared with the decreased RBC age group, 16% vs 7%, respectively, (P = 0.037).ConclusionsIn trauma patients transfused ≥5 units of RBCs, transfusion of RBCs ≥ 28 days of storage may be associated with deep vein thrombosis and death from multi-organ failure.

da Vinci Skills Simulator Construct Validation Study: Correlation of Prior Robotic Experience With Overall Score and Time Score Simulator Performance

OBJECTIVE To assess the construct validity of the da Vinci Skills Simulator (Intuitive Surgical, Sunnyvale, CA). Ideally, a well-designed simulator should demonstrate construct validity, which is defined in this study as the correlation between robotic surgical experience and performance on the simulator. PATIENTS AND METHODS Thirty-nine surgeons (18 [46%] group I [0-20 robotic cases]; 8 [21%] group II [21-150 robotic cases]; and 13 [33%] group III [>150 robotic cases]) were enrolled from September 2010 to December 2010. Participants completed 24 virtual-reality exercises on the da Vinci Skills Simulator. Data on 12 performance metrics were collected by the software. Overall means for score and time across exercises were analyzed. RESULTS Overall scores (64.7%/79.1%/87.4%) and time scores (39.1%/58.6%/87.3%) were significantly different among surgeons in groups I-III (P <.001) and demonstrated significant linear relationships (P <.001) for all 24 exercises. Comparisons between the 3 groups using a univariate general linear model (GLM) was used to compare groups I and II and II and III. Groups I and II differed using overall score for 15 exercises and time score for 11 exercises. Groups II and III differed using overall score for 6 exercises and time score for 15 exercises. Mean overall score for 1 exercise displayed significance between both groups I and II and II and III; while using time score, 5 exercises displayed significance between surgeons in groups I and II and II and III. CONCLUSION Initial construct validity analysis revealed that both overall scores and time scores showed a significant linear relationship when comparing the surgeons in groups I, II, and III. Overall score seems to be a stronger indicator for differences between surgeons in groups I and II. Time score seems to be a stronger indicator for differences between surgeons in groups II and III.

Peripheral leukocyte counts and outcomes after intracerebral hemorrhage

BackgroundIntracerebral hemorrhage (ICH) is a devastating disease that carries a 30 day mortality of approximately 45%. Only 20% of survivors return to independent function at 6 months. The role of inflammation in the pathophysiology of ICH is increasingly recognized. Several clinical studies have demonstrated an association between inflammatory markers and outcomes after ICH; however the relationship between serum biomarkers and functional outcomes amongst survivors has not been previously evaluated. Activation of the inflammatory response as measured by change in peripheral leukocyte count was examined and assessment of mortality and functional outcomes after ICH was determined.FindingsPatients with spontaneous ICH admitted to a tertiary care center between January 2005 and April 2010 were included. The change in leukocyte count was measured as the difference between the maximum leukocyte count in the first 72 hours and the leukocyte count on admission. Mortality was the primary outcome. Secondary outcomes were mortality at 1 year, discharge disposition and the modified Barthel index (MBI) at 3 months compared to pre-admission MBI. 423 cases were included. The in-hospital mortality was 30.4%. The change in leukocyte count predicted worse discharge disposition (OR = 1.258, p = 0.009). The change in leukocyte count was also significantly correlated with a decline in the MBI at 3 months. These relationships remained even after removal of all patients with evidence of infection.ConclusionsGreater changes in leukocyte count over the first 72 hours after admission predicted both worse short term and long term functional outcomes after ICH.

Implementation of an intern boot camp curriculum to address clinical competencies under the new Accreditation Council for Graduate Medical Education supervision requirements and duty hour restrictions.

IMPORTANCE Todays general surgery interns are faced with increased duty hour restrictions and stringent competency-based supervision milestone requirements (ie, from direct to indirect supervision). Working within these constraints, we instituted a unique 2-month intern curriculum (boot camp) incorporating knowledge-based, experiential, and practical components. OBJECTIVES To describe our curriculum and the effect on resident performance and teaching faculty and nursing staff perceptions. DESIGN All interns underwent a 2-month (July and August 2011) boot camp curriculum consisting of two 2½-hour knowledge-based and procedural skills (SimMan) didactic sessions per week and completion of 25 core intensive introductory American College of Surgeons Fundamentals of Surgery web-based self-study modules, followed by a standardized patient clinical skills assessment. SETTING Integrated general surgery residency program at the University of Connecticut School of Medicine, Farmington. PARTICIPANTS Postgraduate year 1 general surgery categorical and preliminary residents. MAIN OUTCOMES AND MEASURES We used several assessment tools, including an intern boot camp survey, clinical skills assessment scores, intern American Board of Surgeons In-Training Examination scores, and nursing staff and teaching faculty surveys of intern performance and aptitudes compared with the previous years interns. Data were analyzed by independent group t test, χ2 tests of proportions, and Fisher exact test for small sample cross tables. RESULTS In total, 84% (91 of 108) of intern respondents agreed or strongly agreed with the usefulness, relevance, and execution of the boot camp. Compared with the previous years interns, the nursing staff agreed or strongly agreed that the cohort interns were better at patient assessment, collaboration, and effective communication and provided compassionate and respectful patient care. More than 40% (7 of 17) of surveyed teaching faculty agreed or strongly agreed that the cohort interns demonstrated better patient care and procedural skills and self-confidence compared with the previous years interns. The clinical skills assessment scores after the 2-month boot camp paralleled the scores typically seen at the end of the previous 2 internship years (P > .25 for all). The proportion of nondesignated and categorical interns pursuing careers in general surgery scoring in the top quartile on the American Board of Surgery In-Training Examination increased from 7% (2 of 28) to 50% (5 of 10) compared with the previous 2 internship years (P = .01). CONCLUSIONS AND RELEVANCE Recent changes in intern duty hours and supervision rules mandate that residency training programs must institute a competency-oriented curriculum to provide interns with the necessary knowledge and practical skills to attain clinical competence.

Clinical characteristics and outcomes of neurogenic stress cadiomyopathy in aneurysmal subarachnoid hemorrhage

BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is an often devastating form of stroke. Aside from the initial hemorrhage, cardiac complications can occur resulting in neurogenic stress cardiomyopathy (NCM), leading to impaired cardiac function. We investigated whether aSAH patients with NCM had poorer long term functional outcomes than patients without NCM. Mortality, vasospasm, and delayed ischemic complications were also evaluated. METHODS A retrospective study of all patients admitted for aneurysmal subarachnoid hemorrhage (aSAH) from January 2006 to June 2011 (n=299) was conducted. Those patients who underwent an echocardiogram were identified (n=120) and were assigned to the NCM (n=49) category based on echocardiographic findings defined by a depressed ejection fraction (EF%) along with a regional wall motion abnormality (RWMA) in a non-vascular pattern. Primary outcome measures included in-hospital mortality and functional outcomes as measured by the Modified Barthel Index (mBI) at 3 months and one year. Secondary analysis determined if there was an association between NCM, cerebral vasospasm and delayed cerebral ischemia. RESULTS 16% of aSAH patients developed NCM. Mortality was higher (p<.001) in the NCM group (n=23[46.9%]) than in the non-CM group (n=28[11.2%]). Patients with NCM had poorer functional outcomes as measured by the mBI at both 3 months (p=.002) and 12 months (p=.014). The Hunt-Hess score was predictive of functional outcome as measured by the mBI at both 3 months (p=.002) as well as at 1 year (p=.014). NCM was associated with both death (p=.047 CI, 1.012-7.288) and vasospasm (p=.008 CI, 1.34-6.66) after correction for Hunt-Hess grade. Tobacco use (p<.001) and a history of diabetes mellitus (p<.009) were also associated with vasospasm. NCM was associated with higher in-hospital mortality (p=.047) in multivariate analysis. CONCLUSION NCM is seen in a substantial number of aSAH patients and when present, it is associated with higher mortality and poorer long-term functional outcomes. This finding may guide further prospective studies in order to determine if early recognition of NCM as well as optimization of cardiac output would improve mortality.

Diagnosing blunt hollow viscus injury: is computed tomography the answer?

BACKGROUND Blunt hollow viscus injury (BHVI) is challenging to diagnose. The purpose of this study was to determine the reliability of physical exam and the role of computed tomography (CT) in the diagnosis of BHVI. METHODS All blunt abdominal trauma (BAT) admissions to a level 1 trauma center from January 2009 through December 2011 were identified through the trauma registry. Data collected included demographics and findings on CT and physical exam. RESULTS Of 2,912 patients with blunt trauma, 340 had BAT, and 30 (9%) had BHVIs. The sensitivity and specificity of CT were 86% and 88%, respectively, whereas the sensitivity and specificity of clinical exam were 53% and 69%. Twenty-seven percent of patients with BAT and bladder injuries had concomitant BHVIs. CONCLUSIONS This is the largest single series of BHVI after BAT. CT is superior to clinical exam in establishing the diagnosis of BHVI. Although associated injuries are common, bladder injury may be an important marker for BHVI.

Does Prior Abdominal Surgery Influence Outcomes or Complications of Robotic-assisted Laparoscopic Radical Prostatectomy?

OBJECTIVES To determine whether robotic-assisted laparoscopic radical prostatectomy (RALP) in patients with prior abdominal surgery is associated with increased operating times, positive surgical margins, or complications. METHODS An institutional review board-approved retrospective review of a prospective, prostatectomy database was performed. Patients undergoing surgery between January 1, 2004, and February 29, 2008 were included. Transition from open retropubic prostatectomy to RALP took place through 2004, at which point all surgical candidates were offered RALP, regardless of prior surgical history. Learning curves from all surgeons were included. Patients with prior abdominal surgery were compared with those patients without prior surgery with respect to total operating time, robotic-assist time, surgical margin positivity, and rate of complications. RESULTS A total of 1083 patients underwent RALP between January 1, 2004, and February 29, 2008, at our institution; of these, 839 had sufficient data available for analysis. In all, 251 (29.9%) patients had prior abdominal surgery, whereas 588 (70.1%) had no prior abdominal surgery. Total operating times were 209 and 204 minutes (P = .20), robotic console times were 165 and 163 minutes (P = .59), and surgical margin positivity was 21.1% and 27.2% (P = .08) for patients with and without prior abdominal surgery, respectively. The incidence of complications was 14.3% and 17.3% for patients with and without prior abdominal surgery (P = .33). CONCLUSIONS Prior abdominal surgery was not associated with a statistically significant increase in overall operating time, robotic assist time, margin positivity, or incidence of complications in patients undergoing RALP. Robotic prostatectomy can be safely and satisfactorily performed in patients who have had a wide variety of prior abdominal surgery types.

Disease-Specific Symptoms and General Quality of Life of Patients with Prostate Carcinoma before and after Primary Three-Dimensional Conformal Radiotherapy

Approximately 189,000 men are diagnosed with prostate carcinoma each year and more than 1 million are living with the disease. Good prognoses and undesirable sequelae accompany each of several available primary and adjuvant treatment options. The current study explored the effects of primary three‐dimensional conformal radiotherapy with or without neoadjuvant hormonal therapy on urinary, bowel, and sexual symptoms and health‐related quality of life (HRQOL).

Prehospital HMG Co-A Reductase Inhibitor Use and Reduced Mortality in Ruptured Abdominal Aortic Aneurysm

BACKGROUND The compounds 3-hydroxy-3-methyl-glutaryl-CoA reductase inhibitors (HMG Co-A reductase inhibitors, statins) are popular medications for the control of elevated serum cholesterol. Recent evidence has demonstrated a survival benefit to patients who take statins in the premorbid period with severe sepsis, septic shock, or severe trauma. We hypothesized that a similar benefit would be seen in patients with ruptured abdominal aortic aneurysm. STUDY DESIGN We completed a retrospective review of patients with ruptured abdominal aortic aneurysm in our institution from January 2000 to December 2008. We compared age, gender, mortality rates, and Physiologic and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) scores for all patients who met inclusion and exclusion criteria. We compared hospital and ICU lengths of stay, cardiac morbidity, and number of cardiac events per patient between survivor groups with and without prehospital statin use. We compared mortality, cardiac morbidity, and gender using the Pearson chi-square test, Physiologic and Operative Severity Score for the enumeration of Mortality and Morbidity scores and age using the Students t-test and lengths of stay using the Mann Whitney-U test. RESULTS Mortality in the group without prehospital statin use was 63.8%, and in the group with prehospital statin use was 34.8% (p=0.018, odds ratio 0.30 to 0.11). Physiologic and Operative Severity Score for the enumeration of Mortality and Morbidity scores were similar between survivor groups with and without statin use and nonsurvivor groups with and without statin use. Hospital and ICU lengths of stay, cardiac morbidity, and number of cardiac events per patient were not statistically different among survivors. CONCLUSIONS Prehospital statin use appears to be associated with a significant survival benefit in the ruptured abdominal aortic aneurysm population.

Improved Diabetes Control Through a Provider-Based Disease Management Program

Objective: The primary aim of this study was to evaluate the effectiveness of a newly implemented hospital-based diabetes mellitus disease management program. A secondary aim was to determine if relationships existed among variables.Design and setting: Effectiveness was evaluated in terms of glycemic control, post-program acute care resource utilization, adherence with American Diabetes Association (ADA) standards of care, and health-related quality of life. Participants in the Diabetes LifeCare program (DLC) received all standards of care which included diabetes self-management education, medical management by a primary care provider (PCP) supported by an evaluation and recommendations by an Advanced Practice Registered Nurse (APRN), nutritional counseling and at minimum, quarterly follow-up appointments for 1 year.Patients: Patients who were aged ≥18 years and referred to the DLC program with new a diagnosis or history of type 1 or 2 diabetes mellitus.Main outcome measures and results: Results demonstrated that at 3 months after enrollment in the DLC, participants in the study with available data (n = 142) had a mean decrease in predominant glycosylated hemoglobin (HbA1c) values from 9.31 to 7.21 (p < 0.001). The HbA1c value for participants with data at the 6-month visit (n = 66) decreased from 9.23 to 7.22 at 3 months and to 6.80 at 6 months (p < 0.001). At baseline, 52 of the 142 participants (36.5%) had HbA1c values less than 8.0, compared with 107 patients (75.4%) at 3 months (p < 0.0001). A total of 185 of 227 patients (81.5%) received eye examinations as per ADA guidelines. A total of 225 of 227 patients (99.1%) were in compliance with the ADA guidelines for nutritional counseling as a result of participation in the program. On the Physical Component Summary, their mean scores were 42.75 [standard deviation (SD) = 11.17] at enrollment, compared with 45.12 (SD = 10.52) at 3 months (p < 0.001). The Mental Component Summary score increased from 47.52 (SD = 11.90) to 50.83 (SD = 10.47) [p < 0.001]. Regarding resource utilization, during the follow-up period only 3 of 227 patients had emergency room visits and there were no inpatient visits for acute problems related to diabetes.Conclusions: Our results show that, in the short term, significant improvement in glycemic control can be achieved through a comprehensive program of patient education and management, that includes collaborative efforts with the patient’s primary care provider. High rates of eye and foot examination can also be attained by reinforcing patient involvement and admissions for acute metabolic complications can be minimized.