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2022 ◽  
Author(s):  
Dawn M G Rask ◽  
Kimberly A Tansey ◽  
Patrick M Osborn

ABSTRACT Background Sustaining critical wartime skills (CWS) during interwar periods is a recurrent and ongoing challenge for military surgeons. Amputation surgery for major extremity trauma is exceptionally common in wartime, so maintenance of surgical skills is necessary. This study was designed to examine the volume and distribution of amputation surgery performed in the military health system (MHS). Study Design All major amputations performed in military treatment facilities (MTF) for calendar years 2017–2019 were identified by current procedural terminology (CPT) codes. The date of surgery, operating surgeon National Provider Identifier, CPT code(s), amputation etiology (traumatic versus nontraumatic), and beneficiary status (military or civilian) were recorded for each surgical case. Results One thousand one hundred and eighty-four major amputations at 16 of the 49 military’s inpatient facilities were identified, with two MTFs accounting for 46% (548/1,184) of the total. Six MTFs performed 120 major amputations for the treatment of acute traumatic injuries. Seventy-three percent (87/120) of traumatic amputations were performed at MTF1, with the majority of patients (86%; 75/87) being civilians emergently transported there after injury. Orthopedic and vascular surgeons performed 78% of major amputations, but only 9.7% (152/1,570) of all military surgeons performed any major amputation, with only 3% (52) involved in amputations for trauma. Nearly all (87%; 26/30) of the orthopedic surgeons at MTF1 performed major amputations, including those for trauma. Conclusion This study highlights the importance of civilian patient care to increase major amputation surgical case volume and complexity to sustain critical wartime skills. The preservation and strategic expansion of effective military–civilian partnerships is essential for sustaining the knowledge and skills for optimal combat casualty care.


Author(s):  
Eva-Lena Syrén ◽  
Gabriel Sandblom ◽  
Lars Enochsson ◽  
Arne Eklund ◽  
Bengt Isaksson ◽  
...  

Abstract Background and aims In some studies, high endoscopic retrograde cholangiopancreatography (ERCP) case-volume has been shown to correlate to high success rate in terms of successful cannulation and fewer adverse events. The aim of this study was to analyze the association between ERCP success and complications, and endoscopist and centre case-volumes. Methods Data were obtained from the Swedish National Register for Gallstone Surgery and ERCP (GallRiks) on all ERCPs performed for Common Bile Duct Stone (CBDS) (n = 17,873) and suspected or confirmed malignancy (n = 6152) between 2009 and 2018. Successful cannulation rate, procedure time, intra- and postoperative complication rates and post-ERCP pancreatitis (PEP) rate, were compared with endoscopist and centre ERCP case-volumes during the year preceding the procedure as predictor. Results In multivariable analyses of the CBDS group adjusting for age, gender and year, a high endoscopist case-volume was associated with higher successful cannulation rate, lower complication and PEP rates, and shorter procedure time (p < 0.05). Centres with a high annual case-volume were associated with high successful cannulation rate and shorter procedure time (p < 0.05), but not lower complication and PEP rates. When indication for ERCP was malignancy, a high endoscopist case-volume was associated with high successful cannulation rate and low PEP rates (p < 0.05), but not shorter procedure time or low complication rate. Centres with high case-volume were associated with high successful cannulation rate and low complication and PEP rates (p < 0.05), but not shorter procedure time. Conclusions The results suggest that higher endoscopist and centre case-volumes are associated with safer ERCP and successful outcome.


2022 ◽  
Vol 22 (1) ◽  
Author(s):  
Martin Roessler ◽  
Felix Walther ◽  
Maria Eberlein-Gonska ◽  
Peter C. Scriba ◽  
Ralf Kuhlen ◽  
...  

Abstract Background Relationships between in-hospital mortality and case volume were investigated for various patient groups in many empirical studies with mixed results. Typically, those studies relied on (semi-)parametric statistical models like logistic regression. Those models impose strong assumptions on the functional form of the relationship between outcome and case volume. The aim of this study was to determine associations between in-hospital mortality and hospital case volume using random forest as a flexible, nonparametric machine learning method. Methods We analyzed a sample of 753,895 hospital cases with stroke, myocardial infarction, ventilation > 24 h, COPD, pneumonia, and colorectal cancer undergoing colorectal resection treated in 233 German hospitals over the period 2016–2018. We derived partial dependence functions from random forest estimates capturing the relationship between the patient-specific probability of in-hospital death and hospital case volume for each of the six considered patient groups. Results Across all patient groups, the smallest hospital volumes were consistently related to the highest predicted probabilities of in-hospital death. We found strong relationships between in-hospital mortality and hospital case volume for hospitals treating a (very) small number of cases. Slightly higher case volumes were associated with substantially lower mortality. The estimated relationships between in-hospital mortality and case volume were nonlinear and nonmonotonic. Conclusion Our analysis revealed strong relationships between in-hospital mortality and hospital case volume in hospitals treating a small number of cases. The nonlinearity and nonmonotonicity of the estimated relationships indicate that studies applying conventional statistical approaches like logistic regression should consider these relationships adequately.


2021 ◽  
Author(s):  
Alicia G Sykes ◽  
Jason B Brill ◽  
James D Wallace ◽  
Clara Lee ◽  
Paul R Lewis ◽  
...  

ABSTRACT Introduction Since 2006, the U.S. Navy has conducted six Pacific Partnership (PP) missions throughout Southeast Asia on board the U.S. Naval Ship Mercy (T-AH 19). This study describes trends in overall and surgical specialty operative volumes to better understand the burden of surgical disease treated during these humanitarian and civic assistance (HCA) operations. This information can assist medical planners and surgical leaders involved in future humanitarian missions. Materials and Methods Following approval from the Naval Medical Center San Diego Institutional Review Board, a retrospective review of surgical case data was performed for the six PP missions from 2006 to 2018. Data collected included patient demographics, Current Procedural Terminology codes, and surgical specialty. The primary outcome was surgical case volume per specialty. Secondary outcomes included surgical staffing per mission and overall trends in operative volume. Results A total of 3,826 operative procedures were performed during the study period. Mission years in which case volume for both general surgery and ophthalmology were below their respective medians were associated with the least total surgical services to host nations (HNs). The number of active duty Navy surgeons varied with each mission; however, the staffing for a PP mission generally included at least two general surgeons, one ophthalmologist, one plastic surgeon, one pediatric surgeon, one orthopedic surgeon, one otolaryngologist, one oral surgeon, one urologist, and one obstetrician–gynecologist. Case volume per surgeon was highest in 2006 (50 cases per surgeon) and decreased after 2006, reaching an all-time low during the 2018 PP mission (10 cases per surgeon). Pediatric surgery and plastic surgery had the highest average case volumes per surgeon at 58 and 46 cases per surgeon, respectively, while oromaxillofacial surgery and neurosurgery had the lowest average case volumes per surgeon at 9 and 14 cases per surgeon, respectively. Conclusions Operative volume on military HCA missions is greatly influenced by the priorities of the HN, the mission focus, the number of individuals from the HN that present for screening, and the availability of personnel and resources available on the hospital ship. Future mission planning should optimize general surgery and ophthalmology staffing and essential equipment, as total mission case volumes were highly dependent upon the productivity of these two specialties. Careful determination of the surgical needs of HNs should serve as a guide for the selection of subspecialists to maximize effectiveness in future military HCA missions.


Medicine ◽  
2021 ◽  
Vol 100 (48) ◽  
pp. e27852
Author(s):  
Jian-Yi Huang ◽  
Hong-Yu Lin ◽  
Qing-Qing Wei ◽  
Xing-Hua Pan ◽  
Ning-Chao Liang ◽  
...  

Author(s):  
Jacob A. Doll ◽  
Adam J. Nelson ◽  
Lisa A. Kaltenbach ◽  
Daniel Wojdyla ◽  
Stephen W. Waldo ◽  
...  

Background: Percutaneous coronary intervention is performed by operators with differing experience, technique, and case mix. It is unknown if operator practice patterns impact patient outcomes. We sought to determine if a cluster algorithm can identify distinct profiles of percutaneous coronary intervention operators and if these profiles are associated with patient outcomes. Methods: Operators performing at least 25 annual procedures between 2014 and 2018 were clustered using an agglomerative hierarchical clustering algorithm. Risk-adjusted in-hospital mortality was compared between clusters. Results: We identified 4 practice profiles among 7706 operators performing 2 937 419 procedures. Cluster 1 (n=3345) demonstrated case mix and practice patterns similar to the national median. Cluster 2 (n=1993) treated patients with lower clinical acuity and were less likely to use intracoronary diagnostics, atherectomy, and radial access. Cluster 3 (n=1513) had the lowest case volume, were more likely to work at rural hospitals, and cared for a higher proportion of patients with ST-segment–elevation myocardial infarction and cardiogenic shock. Cluster 4 (n=855) had the highest case volume, were most likely to treat patients with high anatomic complexity and use atherectomy, intracoronary diagnostics, and mechanical support. Compared with cluster 1, adjusted in-hospital mortality was similar for cluster 2 (estimated difference, −0.03 [95% CI, −0.10 to 0.04]), higher for cluster 3 (0.14 [0.07–0.22]), and lower for cluster 4 (−0.15 [−0.24 to −0.06]). Conclusions: Distinct percutaneous coronary intervention operator profiles are differentially associated with patient outcomes. A phenotypic approach to physician assessment may provide actionable feedback for quality improvement.


2021 ◽  
pp. 1-10

OBJECTIVE Experts can assess surgeon skill using surgical video, but a limited number of expert surgeons are available. Automated performance metrics (APMs) are a promising alternative but have not been created from operative videos in neurosurgery to date. The authors aimed to evaluate whether video-based APMs can predict task success and blood loss during endonasal endoscopic surgery in a validated cadaveric simulator of vascular injury of the internal carotid artery. METHODS Videos of cadaveric simulation trials by 73 neurosurgeons and otorhinolaryngologists were analyzed and manually annotated with bounding boxes to identify the surgical instruments in the frame. APMs in five domains were defined—instrument usage, time-to-phase, instrument disappearance, instrument movement, and instrument interactions—on the basis of expert analysis and task-specific surgical progressions. Bounding-box data of instrument position were then used to generate APMs for each trial. Multivariate linear regression was used to test for the associations between APMs and blood loss and task success (hemorrhage control in less than 5 minutes). The APMs of 93 successful trials were compared with the APMs of 49 unsuccessful trials. RESULTS In total, 29,151 frames of surgical video were annotated. Successful simulation trials had superior APMs in each domain, including proportionately more time spent with the key instruments in view (p < 0.001) and less time without hemorrhage control (p = 0.002). APMs in all domains improved in subsequent trials after the participants received personalized expert instruction. Attending surgeons had superior instrument usage, time-to-phase, and instrument disappearance metrics compared with resident surgeons (p < 0.01). APMs predicted surgeon performance better than surgeon training level or prior experience. A regression model that included APMs predicted blood loss with an R2 value of 0.87 (p < 0.001). CONCLUSIONS Video-based APMs were superior predictors of simulation trial success and blood loss than surgeon characteristics such as case volume and attending status. Surgeon educators can use APMs to assess competency, quantify performance, and provide actionable, structured feedback in order to improve patient outcomes. Validation of APMs provides a benchmark for further development of fully automated video assessment pipelines that utilize machine learning and computer vision.


2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Shou-Yen Chen ◽  
Hsiang-Yun Lo ◽  
Shang-Kai Hung

Abstract Background The coronavirus disease 2019 (COVID-19) pandemic has greatly affected medical education in addition to clinical systems. Residency training has probably been the most affected aspect of medical education during the pandemic, and research on this topic is crucial for educators and clinical teachers. The aim of this study was to understand the effect of the COVID-19 pandemic comprehensively through a systematic review and analysis of related published articles. Methods A systematic review was conducted based on a predesigned protocol. We searched MEDLINE and EMBASE databases until November 30, 2020, for eligible articles. Two independent reviewers extracted data by using a customized form to record crucial information, and any conflicts between the two reviewers were resolved through discussion with another independent reviewer. The aggregated data were summarized and analyzed. Results In total, 53 original articles that investigated the effect of the COVID-19 pandemic on residency training were included. Studies from various regions were included in the research, with the largest percentage from the United States (n = 25, 47.2%). Most of these original articles were questionnaire-based studies (n = 44, 83%), and the research target groups included residents (79.55%), program directors (13.64%), or both (6.82%). The majority of the articles (n = 37, 84.0%) were published in countries severely affected by the pandemic. Surgery (n = 36, 67.92%) was the most commonly studied field. Conclusions The COVID-19 pandemic has greatly affected residency training globally, particularly surgical and interventional medical fields. Decreased clinical experience, reduced case volume, and disrupted education activities are major concerns. Further studies should be conducted with a focus on the learning outcomes of residency training during the pandemic and the effectiveness of assisted teaching methods.


Arthroplasty ◽  
2021 ◽  
Vol 3 (1) ◽  
Author(s):  
Chelsea Matzko ◽  
Zachary P. Berliner ◽  
Gregg Husk ◽  
Bushra Mina ◽  
Barton Nisonson ◽  
...  

Abstract Background Guidelines support aspirin thromboprophylaxis for primary total hip and knee arthroplasty (THA and TKA) but supporting evidence has come from high volume centers and the practice remains controversial. Methods We studied 4562 Medicare patients who underwent elective primary THA (1736, 38.1%) or TKA (2826, 61.9%) at 9 diverse hospitals. Thirty-day claims data were combined with data from the health system’s electronic medical records to compare rates of venous thromboembolism (VTE) between patients who received prophylaxis with: (1) aspirin alone (47.3%), (2) a single, potent anticoagulant (29%), (3) antiplatelet agents other than aspirin or multiple anticoagulants (21.5%), or (4) low-dose subcutaneous unfractionated heparin or no anticoagulation (2.2%). Sub-analyses separately evaluating THA, TKA and cases from lower volume hospitals (n = 975) were performed. Results The 30-day VTE incidence was 0.6% (29/4562). VTE rates were equal in patients receiving aspirin and those receiving a single potent anticoagulant (0.5% in both groups). Patients with VTE were significantly older than patients without VTE (mean 76.5 vs. 73.1 years, P = 0.04). VTE rate did not associate with sex or hospital case volume. On bivariate analysis considering age, aspirin did not associate with greater VTE risk compared to a single potent anticoagulant (OR = 2.1, CI = 0.7–6.3) with the numbers available. Odds of VTE were increased with use of subcutaneous heparin or no anticoagulant (OR = 6.4, CI = 1.2–35.6) and with multiple anticoagulants (OR = 3.6, CI = 1.1–11.2). THA and TKA demonstrated similar rates of VTE (0.5% vs. 0.7%, respectively, P = 0.43). Of 975 cases done at lower volume hospitals, 387 received aspirin, none of whom developed VTE. Conclusions This study provides further support for aspirin as an effective form of pharmacological VTE prophylaxis after total joint arthroplasty in the setting of a multi-modal regimen using 30-day outcomes. VTE occurred in 0.7% of primary joint arthroplasties. Aspirin prophylaxis did not associate with greater VTE risk compared to potent anticoagulants in the total population or at lower volume hospitals.


2021 ◽  
Vol 13 (4) ◽  
pp. 993-1008
Author(s):  
Patrida Rangchaikul ◽  
Vishwanath Venketaraman

As of September 2021, there has been a total of 123,633 confirmed cases of pregnant women with SARS-CoV-2 infection in the US according to the CDC, with maternal death being 2.85 times more likely, pre-eclampsia 1.33 times more likely, preterm birth 1.47 times more likely, still birth 2.84 times more likely, and NICU admission 4.89 times more likely when compared to pregnant women without COVID-19 infection. In our literature review, we have identified eight key changes in the immunological functioning of the pregnant body that may predispose the pregnant patient to both a greater susceptibility to SARS-CoV-2, as well as a more severe disease course. Factors that may impede immune clearance of SARS-CoV-2 include decreased levels of natural killer (NK) cells, Th1 CD4+ T cells, plasmacytoid dendritic cells (pDC), a decreased phagocytic index of neutrophil granulocytes and monocytes, as well as the immunomodulatory properties of progesterone, which is elevated in pregnancy. Factors that may exacerbate SARS-CoV-2 morbidity through hyperinflammatory states include increases in the complement system, which are linked to greater lung injury, as well as increases in TLR-1 and TLR-7, which are known to bind to the virus, leading to increased proinflammatory cytokines such as IL-6 and TNF-α, which are already elevated in normal pregnant physiology. Other considerations include an increase in angiotensin converting enzyme 2 (ACE2) in the maternal circulation, leading to increased viral binding on the host cell, as well as increased IL-6 and decreased regulatory T cells in pre-eclampsia. We also focus on how the Delta variant has had a concerning impact on SARS-CoV-2 cases in pregnancy, with an increased case volume and proportion of ICU admissions among the infected expecting mothers. We propose that the effects of the Delta variant are due to a combination of (1) the Delta variant itself being more transmissible, contagious, and efficient at infecting host cells, (2) initial evidence pointing to the Delta variant causing a significantly greater viral load that accumulates more rapidly in the respiratory system, (3) the pregnancy state being more susceptible to SARS-CoV-2 infection, as discussed in-depth, and (4) the lower rates of vaccination in pregnant women compared to the general population. In the face of continually evolving strains and the relatively low awareness of COVID-19 vaccination for pregnant women, it is imperative that we continue to push for global vaccine equity.


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