Sadia Ali

Comparable operative times with and without surgery resident participation

BACKGROUND Both physicians and patients may perceive that having surgical residents participate in operative procedures may prolong operations and worsen outcomes. We hypothesized that resident participation would prolong operative times and potentially adversely affect postoperative outcomes. OBJECTIVE To evaluate the effect of general surgery resident participation in surgical procedures on operative times and postoperative patient outcomes. DESIGN Retrospective study of general surgery procedures performed during two 1-year time periods, 2007 without residents and 2011 with residents. Procedures included laparoscopic appendectomy and cholecystectomy, thyroidectomy, breast procedure, hernia repair, lower extremity amputation, tunneled venous catheter, and percutaneous endoscopic gastrostomy. The primary outcome was operative time and secondary outcomes included length of stay (LOS) and mortality. SETTING Academic general surgery residency program. RESULTS There were 2280 operative procedures performed during the 2 periods: 1150 with resident involvement (RES group) and 1130 without residents (NORES group). The RES and NORES groups were similar for patient age (42 vs 41, p = 0.14) and male gender (46% vs 45%, p = 0.68), and there was no difference in overall operative time (68min vs 66min, p = 0.58). More specifically there was no difference in operative time (minutes) for specific procedures including laparoscopic appendectomy (67 vs 71, p = 0.8), thyroidectomy (125 vs 109, p = 0.16), breast procedure (38 vs 26, p = 0.79), hernia repair (61 vs 60, p = 0.74), lower extremity amputation (65 vs 77, p = 0.16), tunneled venous catheter (49 vs 47, p = 0.75), and percutaneous endoscopic gastrostomy (49 vs 46, p = 0.76). However, laparoscopic cholecystectomy took slightly longer in the RES group (71 vs 66, p = 0.02). LOS was shorter during the year with resident involvement (2.6 days vs 3.7 days, p = 0.0004) and there was no difference in mortality (0.17% vs 0.35%, p = 0.45). CONCLUSIONS There is no difference in operative time for common general surgery procedures with or without resident involvement. In addition, resident involvement is associated with a decrease in LOS. This information should be used to change physician and patient negative perceptions regarding resident involvement while performing surgical procedures.

Improving organ donation rates by modifying the family approach process.

BACKGROUND The purpose of this study was to identify steps during family approach for organ donation that may be modified to improve consent rates of potential organ donors. METHODS Retrospective study of our local organ procurement organization (OPO) database of potential organ donors. Modifiable variables involved in the family approach of potential organ donors were collected and included race and sex of OPO representative, individual initiating approach discussion with family (RN or MD vs. OPO), length of donation discussion, use of a translator, and time of day of approach. RESULTS Of 1137 potential organ donors, 661 (58%) consented and 476 (42%) declined. Consent rates were higher with matched race of donor and OPO representative (66% vs. 52%, p < 0.001), family approach by female OPO representative (67% vs. 56%, p = 0.002), if approach was initiated by OPO representative (69% vs. 49%, p < 0.001), and if consent rate was dependent on time of day the approach occurred: 6:00 am to noon (56%), noon to 6:00 pm (67%), 6:00 pm to midnight (68%), and midnight to 6:00 am (45%), p = 0.04. Family approach that led to consent lasted longer than those declining (67 vs. 43 minutes, p < 0.001). Independent predictors of consent to donation included female OPO representative (odds ratio [OR], 1.7; p = 0.006), approach discussion initiated by OPO representative (OR, 1.9; p = 0.001), and longer approach discussions (OR, 1.02; p < 0.001). The independent predictor of declined donation was the use of a translator (OR, 0.39; p = 0.01). CONCLUSION Variables such as race and sex of OPO representative and time of day should be considered before approaching a family for organ donation. Avoiding translators during the approach process may improve donation rates. Education for health care providers should reinforce the importance of allowing OPO representatives to initiate the family approach for organ donation. LEVEL OF EVIDENCE Epidemiologic study, level IV. Therapeutic study, level IV.

Prehospital endotracheal intubation vs extraglottic airway device in blunt trauma

OBJECTIVE The objective of the study is to compare outcomes in blunt trauma patients managed with prehospital insertion of an extraglottic airway device (EGD) vs endotracheal intubation (ETI). The null hypothesis was that there would be no difference in mortality for the 2 groups. METHODS This is a retrospective study of blunt trauma patients with Glasgow Coma Scale score less than or equal to 8 transported by ground emergency medical services directly from the scene of injury to a single urban level 1 trauma center. Patients managed with only noninvasive airway techniques were excluded, leaving patients undergoing either EGD placement or ETI. Outcomes included in-emergency department (ED) traumatic arrest and hospital mortality. Multivariable logistic regression was used to control for the potential confounding effects of demographic and clinical variables. For all analyses, P < .05 was used to establish statistical significance. RESULTS In bivariate analysis, patients managed with EGD were more likely than those managed with ETI to have an in-ED traumatic arrest (36.5% vs 17.1%; P = .005), but eventual hospital mortality did not significantly differ between the 2 groups (75.7% vs 67.1%; P = .228). After controlling for demographic and clinical characteristics, patients managed with EGD were no more likely than patients managed with ETI to experience traumatic arrest in the ED (adjusted odds ratio, 1.67; 95% confidence interval, 0.72-3.89), and there was also no difference in overall hospital mortality (adjusted odds ratio, 0.912; 95% confidence interval, 0.36-2.30). CONCLUSION In this preliminary, retrospective analysis, we found no difference in overall survival among trauma patients managed with prehospital EGD and those managed with prehospital ETI.

Thromboelastogram does not detect pre-injury anticoagulation in acute trauma patients

Purpose: Thromboelastography (TEG) has been recommended to characterize post‐traumatic coagulopathy, yet no study has evaluated the impact of pre‐injury anticoagulation (AC) on TEG variables. We hypothesized patients on pre‐injury AC have a greater incidence of coagulopathy on TEG compared to those without AC. Methods: This retrospective chart review evaluated all trauma patients admitted to an urban, level one trauma center from February 2011 to September 2014 who received a TEG within the first 24 h. Patients were classified as receiving pre‐injury AC or no AC if their documented medications prior to admission included warfarin, dabigatran, or anti‐Xa (aXa) inhibitors (apixaban or rivaroxaban). The presence of coagulopathy on TEG or conventional assays was defined by exceeding local laboratory reference standards. Results: A total of 54 patients were included (AC, n = 27 [warfarin n = 13, dabigatran n = 6, aXa inhibitor n = 8] vs. no AC, n = 27). Baseline characteristics were similar between groups, including age (72 ± 13 years vs. 72 ± 15; p = 0.85), male gender (70% vs. 74%; p = 0.76) and blunt mechanism of injury (100% vs. 100%; p = 1). There was no difference in the number of patients determined to have coagulopathy on TEG (no AC 11% vs. AC 15%; p = 0.99). Conventional tests, including the international normalized ratio (INR) and activated partial thromboplastin time (aPTT), identified coagulopathy in a high proportion of anti‐coagulated patients (no AC 22% vs. AC 85%; p < 0.01). Conclusion: TEG has limited clinical utility to evaluate the presence of pre‐injury AC. Traditional markers of drug induced coagulopathy should guide reversal decisions.

Impact of Diabetes Mellitus on the Outcome of Pancreatic Cancer

Introduction Diabetes mellitus (DM) has the potential to impact the pathogenesis, treatment, and outcome of pancreatic cancer. This study evaluates the impact of DM on pancreatic cancer survival. Methods We conducted a retrospective cohort study from the Veterans Affairs (VA) Central Cancer Registry (VACCR) for pancreatic cancer cases between 1995 and 2008. DM and no-DM cases were identified from comorbidity data. Univariate and multivariable analysis was performed. Multiple imputation method was employed to account for missing variables. Results Of 8,466 cases of pancreatic cancer DM status was known in 4728 cases that comprised this analysis. Males accounted for 97.7% cases, and 78% were white. Overall survival was 4.2 months in DM group and 3.6 months in the no-DM group. In multivariable analysis, DM had a HR = 0.91 (0.849–0.974). This finding persisted after accounting for missing variables using multiple imputations method with the HR in DM group of 0.93 (0.867–0.997). Conclusions Our data suggest DM is associated with a reduction in risk of death in pancreatic cancer. Future studies should be directed towards examining this association, specifically impact of DM medications on cancer outcome.

Implementation of a surgical intensive care unit service is associated with improved outcomes for trauma patients.

BACKGROUND Our trauma service recently transitioned from a pulmonary intensive care unit (ICU) service to a surgical ICU (SICU) service. We hypothesized that a newly formed SICU service could provide comparable outcomes to the existing pulmonary ICU service. A specific aim of this study was to compare outcomes of trauma patients admitted to the ICU before and after implementation of a SICU service. METHODS We performed a retrospective study of trauma patients admitted to the ICU of our urban, American College of Surgeons– verified, Level 1 trauma center during a 4-year period (2009–2012). Patients managed by the pulmonary ICU service (2009–2010) were compared with patients managed by a SICU service (2011–2012). The primary outcome was mortality, while secondary outcomes included complications (pulmonary, infectious, cardiac, and thromboembolic), hospital and ICU length of stay, ventilator days, and need for reintubation. RESULTS There were 2,253 trauma patients admitted to the ICU during the study period, 1,124 and 1,129 managed by the pulmonary ICU and SICU services, respectively. When comparing outcomes for SICU and pulmonary ICU patients, there was no difference in mortality (11% vs. 13%, p = 0.41), but patients managed by the SICU service had fewer pulmonary complications (3% vs. 6%, p < 0.001), fewer days on the ventilator (3 vs. 4, p = 0.002), and less often required reintubation after extubation (4% vs. 9%, p < 0.001). CONCLUSION Transition from a pulmonary ICU service to a SICU service at our institution was associated with no change in mortality but an improvement in pulmonary complications, ventilator days, and reintubation rates. Trauma centers currently staffed with a pulmonary ICU service should feel comfortable converting to SICU service and should expect comparable or improved outcomes for trauma patients admitted to the ICU. LEVEL OF EVIDENCE Therapeutic/care management study, level IV.

PTSD in those who care for the injured

BACKGROUND Post Traumatic Stress Disorder (PTSD) has become a focus for the care of trauma victims, but the incidence of PTSD in those who care for injured patients has not been well studied. Our hypothesis was that a significant proportion of health care providers involved with trauma care are at risk of developing PTSD. METHODS A system-wide survey was applied using a modified version of the Primary Care PTSD Screen [PC-PTSD], a validated PTSD screening tool currently being used by the VA to screen veterans for PTSD. Pre-hospital and in-hospital care providers including paramedics, nurses, trauma surgeons, emergency medicine physicians, and residents were invited to participate in the survey. The survey questionnaire was anonymously and voluntarily performed online using the Qualtrix system. Providers screened positive if they affirmatively answered any three or more of the four screening questions and negative if they answered less than three questions with a positive answer. Respondents were grouped by age, gender, region, and profession. RESULTS 546 providers answered all of the survey questions. The screening was positive in 180 (33%) and negative in 366 (67%) of the responders. There were no differences observed in screen positivity for gender, region, or age. Pre-hospital providers were significantly more likely to screen positive for PTSD compared to the in-hospital providers (42% vs. 21%, P<0.001). Only 55% of respondents had ever received any information or education about PTSD and only 13% of respondents ever sought treatment for PTSD. CONCLUSION The results of this survey are alarming, with high proportions of healthcare workers at risk for PTSD across all professional groups. PTSD is a vastly underreported entity in those who care for the injured and could potentially represent a major problem for both pre-hospital and in-hospital providers. A larger, national study is warranted to verify these regional results.

Transmission-based contact precautions for multidrug-resistant organisms in trauma patients: fewer days in isolation with no increase in hospital-associated infections.

BACKGROUND Our hospital transitioned from routine to selective contact isolation of patients based not on history or diagnosis of multidrug-resistant organisms (MDROs) but rather on the likelihood the patient was soiling their environment. We hypothesized that the change to true transmission-based contact isolation would not be associated with an increase in hospital-associated infections with MDROs. METHODS We performed a retrospective study of trauma admissions during two periods: the first period (March to August 2011, PRE group) before and the second period (March to August 2012, POST group) after implementation of the new transmission-based contact isolation guidelines. We compared the PRE and POST groups for admission demographics and physiology as well as mechanism and severity of injury. The primary outcome was the number of patients placed in contact isolation. RESULTS There were 1,465 and 1,617 trauma admissions during the PRE and POST periods, respectively. The PRE and POST groups were similar for age, sex, admission physiology, mechanism of injury, and injury severity. Overall, 3.3% (n = 49) of the patients in the PRE group were placed in contact isolation as compared with 1.7% (n = 25) in the POST group (p = 0.001). More than double the number of patient days were spent in isolation in the PRE period than the POST period (3.8% [n = 246 days] vs. 1.7% [n = 131 days], p < 0.001). There was no difference between the PRE and POST groups in the rates of developing hospital-acquired MDRO infections (0.2% [n = 3] vs. 0.2% [n = 4], p = 0.99). CONCLUSION Transitioning from routine MDRO contact precautions to transmission-based MDRO contact precautions can reduce the number of trauma patients requiring isolation without an increase in hospital-acquired MDRO infections. LEVEL OF EVIDENCE Therapeutic/care management, level IV.

Impact of Concurrent Medication Use on Pancreatic Cancer Survival-SEER-Medicare Analysis.

Objectives: Preclinical studies have suggested that non-antineoplastic medication use may impact pancreatic cancer biology. We examined the association of several medication classes on pancreatic cancer survival in a large medical claims database. Materials and Methods: Histologically confirmed pancreatic adenocarcinoma diagnosed between 2006 and 2009 were analyzed from the Surveillance, Epidemiology, and End Results-Medicare database with available part D data. Drug use was defined as having 2 prescriptions filled within 12 months of pancreatic cancer diagnosis. The following medication classes/combinations were analyzed: &bgr;-blocker, statin, insulin, metformin, thiazolidinedione, warfarin, heparin, &bgr;-blocker/statin, metformin/statin, and &bgr;-blocker/metformin. Multivariable Cox proportional hazard models adjusting for age, sex, race, stage at diagnosis, site of cancer, and Charlson comorbidity index were constructed to test the association between medication classes and overall survival. Results: A total of 13,702 patients were included in the study; median age 76 years, 42.5% males, 77.1% white. The most common anatomic site and stage at diagnosis were head of the pancreas (49.9%) and stage 4 (49.6%), respectively. Ninety-four percent of patients died in the follow-up period (median overall survival 5.3 mo). Multivariable Cox regression analysis showed that use of &bgr;-blockers, heparin, insulin, and warfarin were significantly associated with improved survival (P<0.05 for each one), whereas metformin, thiazolidinedione, statin, and combination therapies were not. Conclusions: In this study, use of &bgr;-blockers, heparin, insulin, and warfarin were associated with improved survival in patients with pancreatic cancer. Additional studies are needed to validate these findings in the clinical setting.

Evidence for chikungunya and dengue transmission in Quelimane, Mozambique: Results from an investigation of a potential outbreak of chikungunya virus

Background In January 2016, health authorities from Zambézia province, Mozambique reported the detection of some patients presenting with fever, arthralgia, and a positive result for chikungunya in an IgM-based Rapid Diagnostic Test (RDT). We initiated a study to investigate a potential chikungunya outbreak in the city of Quelimane. Methods/Principal findings From February to June 2016, we conducted a cross-sectional study enrolling febrile patients attending five outpatient health units in Quelimane. Serum from each patient was tested for CHIKV and DENV, using IgM and IgG ELISA and qRT-PCR. Patients were also tested for malaria by RDT. Entomological surveys were performed around patients’ households, and we calculated the proportion of positive ovitraps and the egg density per trap. A total of 163 patients were recruited, of which 99 (60.7%) were female. The median age was 28 years. IgM and IgG anti-CHIKV antibodies were identified in 17 (10.4%) and 103 (63.2%) patients, respectively. Plaque reduction neutralization assay confirmed the presence of anti-CHIKV antibodies in a subset of 11 tested patients with positive IgG results. IgM anti-DENV antibodies were found in 1 (0.9%) of 104 tested patients. Malaria was diagnosed in 35 (21.5%) patients, 2 of whom were also IgM-positive for CHIKV. Older age and lower education level were independently associated with the prevalence of IgG anti-CHIKV antibodies. Immature forms of Aedes aegypti were collected in 16 (20.3%) of 79 surveyed households. We also found that 25.0% (16/64) of the traps were positive, with an average of 90.8 eggs per pallet. Conclusions Our investigation demonstrated that no CHIKV outbreak was ongoing in Quelimane; rather, endemic transmission of the virus has been ongoing. Aedes aegypti mosquitoes are abundant, but dengue cases occurred only sporadically. Further population-based cohort studies are needed to improve our understanding of aspects related to the dynamics of arboviral transmission in Mozambique, as well as in other parts of Sub-Saharan Africa.