Jesus G. Ulloa

Is there a relationship between hospital volume and patient outcomes in gastroschisis repair

PURPOSE Given the well-established relationship between surgical volume and outcomes for many surgical procedures, we examined whether the same relationship exists for gastroschisis closure. METHODS We conducted a retrospective analysis of infants who underwent gastroschisis closure between 1999 and 2007 using a California birth-linked cohort. Hospitals were divided into terciles based on the number of gastroschisis closures performed annually. Using regression techniques, we examined the effects of hospital volume on patient mortality and length of stay while controlling for patient and hospital confounders. RESULTS We identified 1537 infants who underwent gastroschisis repair at 55 hospitals, 4 of which were high-volume and 42 of which were low-volume. The overall in-hospital mortality rate was 4.8% and the median length of stay was 46.5days. After controlling for other factors, patients treated at high-volume hospitals had significantly lower odds of inpatient mortality (OR 0.40; 95% CI 0.21, 0.76). There was a near-significant trend towards shorter hospital length of stay at highvolume hospitals (p=0.066). CONCLUSIONS Patients who undergo gastroschisis closure at high-volume hospitals in California experience lower odds of in-hospital mortality compared to those treated at low-volume hospitals. These findings offer initial evidence to support policies that limit the number of hospitals providing complex newborn surgical care.

Predictors of Primary Care Physician Practice Location in Underserved Urban or Rural Areas in the United States: A Systematic Literature Review

Purpose The authors conducted a systematic review of the medical literature to determine the factors most strongly associated with localizing primary care physicians (PCPs) in underserved urban or rural areas of the United States. Method In November 2015, the authors searched databases (MEDLINE, ERIC, SCOPUS) and Google Scholar to identify published peer-reviewed studies that focused on PCPs and reported practice location outcomes that included U.S. underserved urban or rural areas. Studies focusing on practice intentions, nonphysicians, patient panel composition, or retention/turnover were excluded. They screened 4,130 titles and reviewed 284 full-text articles. Results Seventy-two observational or case–control studies met inclusion criteria. These were categorized into four broad themes aligned with prior literature: 19 studies focused on physician characteristics, 13 on financial factors, 20 on medical school curricula/programs, and 20 on graduate medical education (GME) programs. Studies found significant relationships between physician race/ethnicity and language and practice in underserved areas. Multiple studies demonstrated significant associations between financial factors (e.g., debt or incentives) and underserved or rural practice, independent of preexisting trainee characteristics. There was also evidence that medical school and GME programs were effective in training PCPs who locate in underserved areas. Conclusions Both financial incentives and special training programs could be used to support trainees with the personal characteristics associated with practicing in underserved or rural areas. Expanding and replicating medical school curricula and programs proven to produce clinicians who practice in underserved urban or rural areas should be a strategic investment for medical education and future research.

Appendicitis within Morgagni Hernia and simultaneous Paraesophageal Hernia

BackgroundMorgagni hernia is a congenital diaphragmatic defect that rarely presents with symptomatic findings in adults. The presence of one diaphragmatic defect may decrease the occurrence of a separate diaphragmatic defect. Appendicitis may be a unique presentation of incarcerated bowel in a Morgagni defect.Case presentationReview of recent literature and presentation of a patient with Morgagni defect. Only five cases of simultaneous Morgagni hernia and paraesophageal hernia have been described in the English-language literature since 1958. Here, we report the first case of acute appendicitis within an incarcerated right Morgagni hernia in a 76-year-old patient who also had a paraesophageal hernia.ConclusionThis case illustrates that there is no role for watchful waiting in the management of Morgagni Defects when diagnosed in adult patients.

Microaggressions During Medical Training

Unlike the findings from the study by O’Donnell and colleagues,2 restricted cubic spline analyses of the association between sodium excretion and composite CVD provided no evidence of a nonlinear association (P = .11) and indicated a significant linear association (P < .001) in our study. O’Donnell and colleagues used only 1 morning spot sample to calculate 24-hour urinary sodium excretion, which is subject to bias due to day-to-day variations in sodium intake and systemic differences between morning spot samples and 24-hour samples in sodium excretion among populations with various levels of sodium intake.3 In our study, up to three 24-hour urine samples were obtained, which provided more accurate measurements of usual sodium intake at the individual level. Dr Almirall is concerned about the potential confounding effect of kidney function and proteinuria among patients with CKD. In multivariable models, we adjusted for baseline estimated glomerular filtration rate. Furthermore, we additionally adjusted for 24-hour urinary protein and albumin excretion (Table). The positive and linear association between urinary sodium excretion and risk of CVD remained after these adjustments. These analyses confirmed that higher urinary sodium excretion was associated with increased risk of CVD among patients with CKD.

A cohort study of a general surgery electronic consultation system: safety implications and impact on surgical yield

BackgroundElectronic consultation (eConsult) systems have enhanced access to specialty expertise and enhanced care coordination among primary care and specialty care providers, while maintaining high primary care provider (PCP), specialist and patient satisfaction. Little is known about their impact on the efficiency of specialty care delivery, in particular surgical yield (percent of ambulatory visits resulting in a scheduled surgical case).MethodsRetrospective cohort of a random selection of 150 electronic consults from PCPs to a safety-net general surgery clinic for the three most common general surgery procedures (herniorrhaphy, cholecystectomy, anorectal procedures) in 2014. Electronic consultation requests were reviewed for the presence/absence of consult domains: symptom acuity/severity, diagnostic evaluation, concurrent medical conditions, and attempted diagnosis. Logic regression was used to examine the association between completeness of consult requests and scheduling an ambulatory clinic visit. Surgical yield was also calculated, as was the percentage of patients requiring unanticipated healthcare visits.ResultsIn 2014, 1743 electronic consultations were submitted to general surgery. Among the 150 abstracted, the presence of consult domains ranged from 49% to 99%. Consult completeness was not associated with greater likelihood of scheduling an ambulatory visit. Seventy-six percent of consult requests (114/150) were scheduled for a clinic appointment and surgical yield was 46%; without an eConsult system, surgical yield would have been 35% (p=0.07). Among patients not scheduled for a clinic visit (n=36), 4 had related unanticipated emergency department visits.ConclusionEconsult systems can be used to safely optimize the surgical yield of a safety-net general surgery service.