Jennifer Yu

Missed injuries and unplanned readmissions in pediatric trauma patients

BACKGROUND We sought to determine the incidence and characteristics of missed injuries and unplanned readmissions at a Level-1 pediatric trauma center. METHODS We conducted a retrospective review of all trauma patients who presented to our ACS-verified Level-1 pediatric trauma center from 2009 to 2014. RESULTS Overall, there were 27 readmissions and 27 missed injuries (0.38%). Patients who were unplanned readmissions had a greater Injury Severity Score (ISS) (8.6 vs 5.2, p=0.03), had longer hospitalizations (4.9 vs 2.5days, p=0.02), and were more likely to have required operative intervention (51.9% vs 32.3%, p=0.04). Similarly, patients identified with missed injuries had a higher ISS (15.2 vs 5.2, p<0.0001), greater length of stay (12.7 vs 2.5days, p<0.0001), and were also more likely to be intubated (25.9% vs 3.6%, p<0.0001) or require critical care (48.1% vs 10.3%, p<0.0001). Seven missed injuries were in patients who were deemed nonaccidental trauma (25.9%) and significantly altered their hospital course while 10 patients (37%) required operative intervention. On multivariate analysis, only ISS was found to be an independent risk factor for readmissions and missed injuries. CONCLUSIONS Missed injuries and unplanned readmissions were rare occurrences among our pediatric patient population. These events, however, did result in longer hospitalizations and additional procedures. Patients with multisystem injuries and compromised physical exam are at higher risk. LEVEL OF EVIDENCE IV.

COMPROMISED MARGINS FOLLOWING MASTECTOMY FOR STAGE I - III INVASIVE BREAST CANCER

BACKGROUND We investigated factors associated with positive margins following mastectomy and the impact on outcomes. METHODS We identified 240 patients with stage I-III invasive breast cancer who underwent mastectomy from 1999 to 2009. Data included patient and tumor characteristics, pathologic margin assessment, and outcomes. Margin positivity was defined as the presence of in situ or invasive malignancy at any margin. Descriptive statistics were used for data summary and were compared using χ(2). RESULTS Of the 240 patients, 132 (55%) had a simple mastectomy with sentinel lymph node biopsy and 108 (45%) had a modified radical mastectomy. Overall, 21 patients (9%) had positive margins, including 12 (57%) with one positive margin, 3 (14%) with two positive margins, and 6 (29%) with three or more positive margins. The most commonly affected margin was the deep margin (48% of patients). Eight of the 21 patients (38%) received adjuvant chest wall irradiation. There were no differences between patients who had a positive margin and those who did not with respect to patient age, race, percentage of in situ component, tumor size, tumor grade, lymphovascular invasion, or immunostain profile (P > 0.05 for all). None of the patients with positive margins experienced a local recurrence. CONCLUSIONS Positive margins following mastectomy occurred in nearly 10% of our patients. No specific patient or tumor characteristics predicted a risk for having a positive margin. Despite the finding that only approximately 40% of patients received adjuvant radiation in the setting of a positive margin, no local recurrences have been observed.

Late volvulus of an intrathoracic gastric pull-up

Although volvulus of a gastric pull-up may acutely result from iatrogenic twist at the time of gastric transposition, we have recently encountered a patient in whom a gastric volvulus developed in the late postoperative period, resulting in gastric outlet obstruction. The perioperative evaluation and operative management are discussed.

Defining Issues in the Study of Process or Quality Improvement Versus Implementation Science

n this issue, Loor and colleagues [1] describe the design Iand application of a preprocedure cardiothoracic transplant checklist to standardize organ procurement processes at two academic institutions [1]. Arising from a quality improvement initiative, use of the checklist was found to assist in identifying more than 3 times the number of near-miss events than before the checklist was implemented. Overall, the authors should be commended for their stakeholder team development, iterative checklist design process, and dissemination methodology. Although the small sample size might render the outcome measurement more prone to bias, it is important to distinguish between the effectiveness of the checklist itself and the approach to dissemination and implementation of the intervention. This project highlights several key factors in the contrast between implementation science and quality improvement (QI), and it emphasizes the consideration necessary to develop an evidence-based practice tool that remains relevant and replicable in widespread clinical practice.

Ethical considerations in the use of Pernkopf's Atlas of Anatomy: A surgical case study

The use of Eduard Pernkopfs anatomic atlas presents ethical challenges for modern surgery concerning the use of data resulting from abusive scientific work. In the 1980s and 1990s, historic investigations revealed that Pernkopf was an active National Socialist (Nazi) functionary at the University of Vienna and that among the bodies depicted in the atlas were those of Nazi victims. Since then, discussions persist concerning the ethicality of the continued use of the atlas, because some surgeons still rely on information from this anatomic resource for procedural planning. The ethical implications relevant to the use of this atlas in the care of surgical patients have not been discussed in detail. Based on a recapitulation of the main arguments from the historic controversy surrounding the use of Pernkopfs atlas, this study presents an actual patient case to illustrate some of the ethical considerations relevant to the decision of whether to use the atlas in surgery. This investigation aims to provide a historic and ethical framework for questions concerning the use of the Pernkopf atlas in the management of anatomically complex and difficult surgical cases, with special attention to implications for medical ethics drawn from Jewish law.

Opioid Medication Use in the Surgical Patient: An Assessment of Prescribing Patterns and Use

BACKGROUND With the epidemic of prescription opioid abuse in the US, rates of opioid-related unintentional deaths have risen dramatically. However, few data exist comparing postoperative opioid prescriptions with patient use. We sought to better elucidate this relationship in surgical patients. STUDY DESIGN A prospective cohort study was conducted of narcotic-naïve patients undergoing open and laparoscopic abdominal procedures on a minimally invasive surgery service. During the first 14 post-discharge days and at their first postoperative clinic visit, patients recorded pain scores and number of opioid pills taken. Clinical data were extracted from the medical record. Descriptive statistics were used in data analysis. RESULTS From 2014 through 2017, one hundred and seventy-six patients completed postoperative pain surveys. Mean age was 60.4 ± 14.9 years and sex was distributed equally. Most patients (69.9%) underwent laparoscopic procedures. Hydrocodone-acetaminophen was the most commonly prescribed postoperative pain medication (118 patients [67.0%]), followed by oxycodone-acetaminophen (26 patients [14.8%]). Patients were prescribed a median of 150 morphine milligram equivalents (MME) (interquartile range [IQR] 150 to 225 MME), equivalent to twenty 5-mg oral oxycodone pills (IQR 20 to 30 pills). However, by their first postoperative visit, they had only taken a median 30 MME (IQR 10 to 90 MME), or 4 pills (IQR 1.3 to 12 pills). Eight (4.5%) patients received a refill or an additional prescription for pain medications. At the first postoperative visit, 76.7% of respondents were satisfied or very satisfied with their overall postoperative pain management. CONCLUSIONS Postoperative patients might consume less than half of the opioid pills they are prescribed. More research is needed to standardize opioid prescriptions for postoperative pain management while reducing opioid diversion.

Alpha Synuclein Fibrils Contain Multiple Binding Sites for Small Molecules

The fibrillary aggregation of the protein alpha synuclein (Asyn) is a hallmark of Parkinsons disease, and the identification of small molecule binding sites on fibrils is essential to the development of diagnostic imaging probes. A series of molecular modeling, photoaffinity labeling, mass spectrometry, and radioligand binding studies were conducted on Asyn fibrils. The results of these studies revealed the presence of three different binding sites within fibrillar Asyn capable of binding small molecules with moderate to high affinity. A knowledge of the amino acid residues in these binding sites will be important in the design of high affinity probes capable of imaging fibrillary species of Asyn.