John C. Kubasiak

The impact of operative timing on outcomes of appendicitis: a National Surgical Quality Improvement Project analysis

BACKGROUND Surgery is indicated for acute uncomplicated appendicitis but the optimal timing is controversial. Recent literature is conflicting on the effect of time to intervention. METHODS We queried the American College of Surgeons National Surgical Quality Improvement Project dataset for patients undergoing laparoscopic and open appendectomy between 2007 and 2012. Logistic regression was used to evaluate 30-day morbidity and mortality of intervention at different time periods, adjusting for preoperative risk factors. RESULTS A total of 69,926 patients undergoing appendectomy were identified. Groups were divided by time to intervention: group 1, less than 24 hours (n = 55,839; 79.9%); group 2, 24 to 48 hours (n = 13,409; 18.6%); and group 3, greater than 48 hours (n = 1,038; 1.5%). After adjustment, the risk of complication remained increased for group 3 versus group 1 or 2 (odds ratio 1.66, 95% confidence interval 1.34 to 2.07). CONCLUSIONS These data demonstrate equivalent outcomes between time to appendectomy of less than 24 and 24 to 48 hours. There was a 2-fold increase in complication rate for patients delayed longer than 48 hours.

Value of circulating insulin-like growth factor-associated proteins for the detection of stage I non-small cell lung cancer.

OBJECTIVE Circulating biomarkers related to insulin-like growth factor (IGF) signaling are associated with disease progression in multiple carcinomas, but their potential diagnostic value for lung cancer screening has been inadequately examined. We evaluated 9 circulating IGF-related factors for their ability to assign clinical significance to indeterminate pulmonary nodules identified via computed tomography-based radiologic studies. METHODS Patients (n = 224 stage I non-small cell lung cancer; n = 123 benign) were enrolled by Rush University and the Mayo Clinic and had pretreatment serum evaluated for levels of IGF-1, IGF-2, and insulin-like growth factor binding proteins (IGFBPs) 1-7. The Mann-Whitney rank-sum test and receiver-operator characteristics curves were used to assess differences in biomarker concentrations relevant to malignant versus benign pathology. These targets were used to help refine our companion blood test for assigning clinical significance to computed tomography-detected solitary nodules (discovery cohort, n = 94) and were validated against an independent cohort from the Mayo Clinic (n = 81). RESULTS Patients with benign pulmonary nodules were found to have serum concentrations of IGFBP-3, IGFBP-5, IGF-1, and IGF-2 that were higher (P = .001, P < .001, P = .002, and P = .011, respectively) than those with non-small cell lung cancer, with distinct associations with histologic subtypes observed. Refinement of our multianalyte classification algorithm using IGF-related factors provided a new panel consisting of interleukin-6, interleukin-1 receptor antagonist, interleukin-10, stromal cell-derived factor-1(α + β), IGFBP-4, IGFBP-5, and IGF-2 with improved assay performance-achieving a (validated) negative predictive value of 100%. CONCLUSIONS Our findings suggest a divergent role for IGF signaling in the biology of benign and malignant pulmonary nodules. Upon further validation, these observations may help identify cases of false positives resulting from computed tomography-based screening studies.

Patient Safety Indicators for Judging Hospital Performance: Still Not Ready for Prime Time.

Patient Safety Indicators (PSIs) were originally intended for use as a screen for quality of care but are now being used to rank hospitals and to modify hospital reimbursement. PSI data are dependent on accuracy of clinical documentation and coding. Information on whether a PSI event is inherent to the nature of the operation or posed a significant impact on the outcome is lacking. Cases for one year at a single academic center were queried. Cases with target PSIs were included (n = 136). Cases were evaluated for both the inherent nature and significance of injury. Both patient safety officers agreed that the PSI event was inherent to the disease process, and thus, the procedure and was not a marker of patient safety (false positive) in 11.8% to 33.3% of cases. Both reviewers agreed that the events were not clinically significant in 11.8% to 30.4% of cases. This study found high false-positive rates and only moderate interrater reliability for 3 PSIs. PSIs as currently reported are not reliable enough to be utilized for ranking.

Outcomes and Use of Laparoscopic Versus Open Gastric Resection.

Background and Objectives: The advantages of laparoscopy over open surgery are well established. Laparoscopic resection for gastric cancer is safe and results in equivalent oncologic outcomes when compared with open resection. The purpose of this study was to assess the use of laparoscopy to treat gastric cancer and the associated outcomes. Methods: The American College of Surgeons National Surgical Quality Improvement Project (NSQIP) dataset was queried for patients with gastric cancer (ICD-9 Code 151.0–151.9) from January 2005 through December 2012. Logistic regression was used to evaluate the 30-day morbidity and mortality of open gastrectomy (CPT code 43620-2, 43631-4) versus that of the laparoscopic procedure on the stomach (CPT code 43650), while adjusting for preoperative risk factors. Results: A total of 4116 patients with gastric cancer were identified and divided by surgical approach into 2 groups: open gastrectomy (n = 3725; 90.5%) and laparoscopic procedure on the stomach (n = 391; 9.5%). After adjustment for preoperative risk factors, complications were significantly fewer in laparoscopic versus open gastric resection (odds ratio [OR] 0.61, 95% confidence interval [CI] = 0.45–0.82; P = .001). After adjusting for preoperative risk factors, there was no statistically significant difference in mortality with laparoscopic compared to open gastric resection (OR 0.74; 95% CI = 0.32–1.72; P = .481). Conclusions: Laparoscopy is underused in the treatment of gastric cancer. Given that laparoscopic gastric resection has a lower morbidity in comparison to open resection, steps should be made toward advancing the use of laparoscopy for gastric cancer.

Delayed cerebrospinal fluid leak after penetrating cervical trauma

Stab wound injury to the cervical spinal cord is a rare occurrence and usually presents with immediate, disastrous, and permanent neurological consequences. Rarer, and potentially as severe, is the complication of a delayed cerebrospinal fluid leak following a stab wound to the cervical spine. In this case, magnetic resonance imaging demonstrates a cerebrospinal fluid leak that extends to the skin with injury to the posterior dura at the C1/C2 level. Epidemiology and management of penetrating cervical spinal cord injury and delayed cerebrospinal fluid leaks are discussed.