Michael R. Cassidy

I COUGH: Reducing Postoperative Pulmonary Complications With a Multidisciplinary Patient Care Program

IMPORTANCEnPostoperative pulmonary complications can be a devastating consequence of surgery. Validated strategies to reduce these adverse outcomes are needed.nnnOBJECTIVESnTo design, implement, and determine the efficacy of a suite of interventions for reducing postoperative pulmonary complications.nnnDESIGNnA before-after trial comparing our National Surgical Quality Improvement Program (NSQIP) pulmonary outcomes before and after implementing I COUGH, a multidisciplinary pulmonary care program.nnnSETTINGnAn urban, academic, safety-net hospital.nnnPARTICIPANTSnAll patients who underwent general or vascular surgery at our institution during a 1-year period before and after implementation of I COUGH.nnnINTERVENTIONSnA multidisciplinary team developed a strategy to reduce pulmonary complications based on comprehensive patient and family education and a set of standardized electronic physician orders to specify early postoperative mobilization and pulmonary care. Designated by the acronym I COUGH, the program emphasizes incentive spirometry, coughing and deep breathing, oral care (brushing teeth and using mouthwash twice daily), understanding (patient and family education), getting out of bed at least 3 times daily, and head-of-bed elevation. Nursing and physician education promoted a culture of mobilization and I COUGH interventions. I COUGH was implemented for all general surgery and vascular surgery patients at our institution in August 2010.nnnMAIN OUTCOMES AND MEASURESnThe NSQIP-reported incidence and risk-adjusted ratios of postoperative pneumonia and unplanned intubation, which NSQIP reports as observed-expected (OE) ratios for the 1-year period before implementing I COUGH and as odds ratios (ORs, statistically comparable to OE ratios) for the period after its implementation.nnnRESULTSnBefore implementation of I COUGH, our incidence of postoperative pneumonia was 2.6%, falling to 1.6% after its implementation, and risk-adjusted outcomes fell from an OE ratio of 2.13 to an OR of 1.58. The incidence of unplanned intubations was 2.0% before I COUGH and 1.2% after I COUGH, with risk-adjusted outcomes decreasing from an OE ratio of 2.10 to an OR of 1.31.nnnCONCLUSIONS AND RELEVANCEnI COUGH, a standardized postoperative care program emphasizing patient education, early mobilization, and pulmonary interventions, reduced the incidence of postoperative pneumonia and unplanned intubation among our patients.

A Sprayable Hyaluronate/Carboxymethylcellulose Adhesion Barrier Exhibits Regional Adhesion Reduction Efficacy and Does Not Impair Intestinal Healing

BackgroundWhile bioresorbable solid barriers such as Seprafilm® prevent adhesions, their efficacy is limited to sites of application. The aim of this study was to assess the effectiveness of the sprayable adhesion barrier Sepraspray® in preventing adhesions to sites of direct application and to remote sites.MethodsIntraabdominal adhesions were induced in 30 rats by creating three ischemic buttons on each side of a midline incision. To assess efficacy, Sepraspray (5xa0mg/button) or Seprafilm (1xa0cm2/button) was applied over three buttons on one side of the peritoneum. Operated control animals received no treatment. On dayxa07, adhesions were scored as percent of buttons with adhesions. To assess safety, 81 rats underwent a colonic transection repaired with an end-to-end anastomosis. Both barriers were applied circumferentially to anastomoses. Controls received no product. The integrity of healing anastomosed colonic wounds was assessed by burst pressure and tensile strength at daysxa03, 5, and 7 postoperatively.ResultsThe direct application of both Sepraspray and Seprafilm significantly (pu2009<u20090.001) reduced adhesion formation compared to controls. While Seprafilm had no remote effect on adhesion formation, Sepraspray significantly (pu2009<u20090.001) reduced adhesion formation to contralateral ischemic buttons. Neither barrier affected anastomotic integrity at any time point.ConclusionsSepraspray has widespread efficacy throughout the peritoneum in reducing adhesions without compromising intestinal healing. Furthermore, this sprayable alternative offers the potential for easier intraabdominal application.

Presentation and Survival of Gastric Cancer Patients at an Urban Academic Safety-Net Hospital

IntroductionGastric cancer is decreasing nationally but remains pervasive globally. We evaluated our experience with gastric cancer at a safety-net hospital with a substantial immigrant population.MethodsDemographics, pathology, and treatment were analyzed for gastric adenocarcinoma at our institution (2004–2017). Chi-square analyses were performed for dependence of staging on demographics. Survival was evaluated with Kaplan-Meier and Cox regression analyses.ResultsWe identified 249 patients (median age 65xa0years). Patients were predominantly born outside the USA or Canada (74.3%), non-white (70.7%), and federally insured (71.4%), and presented with late-stage disease (52.2%). Hispanic ethnicity, Central American birthplace, Medicaid insurance, and zip code poverty >u200920% were associated with late-stage presentation (all pu2009<u20090.05). Univariate analyses showed decreased survival for patients with late-stage disease, highest zip code poverty, and ageu2009≥u200965 (all pu2009<u20090.05). On multivariate analysis, survival was negatively associated with late-stage presentation (HR 4.45, pu2009<u20090.001), ageu2009≥u200965 (1.80, pu2009=u20090.018), and H. pylori infection (2.02, pu2009=u20090.036).ConclusionHispanic ethnicity, Central American birthplace, Medicaid insurance, and increased neighborhood poverty were associated with late-stage presentation of gastric cancer with poor outcomes. Further study of these populations may lead to screening protocols in order to increase earlier detection and improve survival.