Reducing Health Care Burden of Emergency General Surgery with a 24-Hour Dedicated Emergency General Surgery Service

Background Emergency general surgery (EGS) diagnoses account for 11% of surgical admissions and 50% of surgical mortality. In this population, 7 specific operations are associated with 80.3% of deaths, 78.9% of complications, and 80.2% of hospital costs. In 2016, our institution established a comprehensive in-house EGS service. Herein, we hypothesize that formation of a dedicated EGS service is associated with a significant reduction in morbidity for patients undergoing the most common EGS procedures. Methods All patients undergoing one of the most common EGS procedures within 2 days of admission were identified from 1/1/2013 to 5/9/2019 via a retrospective chart review. Patients were cohorted as pre- and post-EGS implementation. The primary outcome measure was the overall complication rate. Secondary endpoints included mortality, individual complication rate, time to operation, overnight operation, and length of stay. Finally, both cohorts were benchmarked to national outcomes. Results 718 patients met inclusion criteria (pre-EGS = 409 and post-EGS = 309). Overall complication rate decreased significantly (19.8% vs 13.9%, P = .0387) and overnight operations increased significantly in the post-EGS group (7.8%-16.5%, P = .0003). Pre-EGS complications were higher than national data in all but 1 procedure group, whereas post-EGS complications rates were lower in all but 2 categories. Discussion Implementation of a dedicated EGS service line was associated with a significant decrease in complication rate among the most complication-prone EGS procedures. Number of operations within 24 hours did not increase significantly; however, overnight operations did increase. Our results indicate that establishing a service-specific EGS line is reasonable and beneficial.

Individual variations of the superior petrosal vein complex and their microsurgical relevance in 50 cases of trigeminal microvascular decompression

Background We investigated the understudied anatomical variations of the superior petrosal vein (SPV) complex (SPVC), which may play some role in dictating the individual complication risk following SPVC injury. Methods Microvascular decompressions of the trigeminal nerve between September 2012 and July 2016. All operations utilized an SPVC preserving technique. Preoperative balanced fast field echo (bFFE) magnetic resonance imaging, or equivalent sequences, and operative videos were studied for individual SPVC anatomical features. Results Applied imaging and operative SPVC anatomy were described for fifty patients (mean age, 67.18 years; female sex and right-sided operations, 58% each). An SPVC component was sacrificed intentionally in 6 and unintentionally in only 7 cases. Twenty-nine different individual variations were observed; 80% of SPVCs had either 2 SPVs with 3 or 1 SPV with 2, 3, or 4 direct tributaries. Most SPVCs had 1 SPV (64%) and 2 SPVs (32%). The SPV drainage point into the superior petrosal sinus was predominantly between the internal auditory meatus and Meckel cave (85.7% of cases). The vein of the cerebellopontine fissure was the most frequent direct tributary (86%), followed by the pontotrigeminal vein in 80% of SPVCs. Petrosal-galenic anastomosis was detected in at least 38% of cases. At least 1 SPV in 54% of the cases and at least 1 direct tributary in 90% disturbed the operative field. The tributaries were more commonly sacrificed. Conclusions The extensive anatomical variation of SPVC is depicted. Most SPVCs fall into 4 common general configurations and can usually be preserved. BFFE or equivalent sequences remarkably facilitated the intraoperative understanding of the individual SPVC in most cases.

Risk Factors for In-Hospital Complications of Fall-Related Fractures among Older Chinese: A Retrospective Study

Purpose. The aim of this study was to investigate the risk factors and the efficacy of the preventive measurements for the in-hospital complications of fall-related fractures. Methods. The data on older Chinese patients with fall-related fractures were collected, including information on the patients, diseases, and preventive measurements. The potential risk factors for the in-hospital complications included health status on admission, comorbidity, fractures, preventive measures of the complications, and drugs use for the comorbidity. After univariate analyses, multivariate logistic regression analyses were applied to investigate the impact of the potential risk factors on the number of the complications and each individual complication, respectively, and the efficacy of the preventive measurements. Results. A total of 525 male and 1367 female were included in this study. After univariate analyses, multiple logistic regression showed that dementia, pneumonia, antidepressant, postural hypotension, and cerebral infarction could increase the incidence and number of comorbidities. Meanwhile, dementia has shown the strongest association with each individual complication. Conclusions. Different combinations of comorbidity, medication use, and preventive measurements were related to the in-hospital complications of fall-related fractures. Dementia emerged as the most important risk factor for these complications, while most of the preventive measurements could not reduce their incidences.

Improved capture of adverse events after spinal surgery procedures with a longitudinal administrative database

OBJECT The significant medical and economic tolls of spinal disorders, increasing volume of spine surgeries, and focus on quality metrics have made it imperative to understand postoperative complications. This study demonstrates the utility of a longitudinal administrative database for capturing overall and procedure-specific complication rates after various spine surgery procedures. METHODS The Thomson Reuters MarketScan Commercial Claims and Encounters and the Medicare Supplemental and Coordination of Benefits database was used to conduct a retrospective analysis of longitudinal administrative data from a sample of approximately 189,000 patients. Overall and procedure-specific complication rates at 5 time points ranging from immediately postoperatively (index) to 30 days postoperatively were computed. RESULTS The results indicated that the frequency of individual complication types increased at different rates. The overall complication rate including all spine surgeries was 13.6% at the index time point and increased to 22.8% at 30 days postoperatively. The frequencies of wound dehiscence, infection, and other wound complications exhibited large increases between 10 and 20 days postoperatively, while complication rates for new chronic pain, delirium, and dysrhythmia increased more gradually over the 30-day period studied. When specific surgical procedures were considered, 30-day complication rates ranged from 8.6% in single-level anterior cervical fusions to 27.3% in multilevel combined anterior and posterior lumbar spine fusions. CONCLUSIONS This study demonstrates the usefulness of a longitudinal administrative database in assessing postoperative complication rates after spine surgery. Use of this database gave results that were comparable to those in prospective studies and superior to those obtained with nonlongitudinal administrative databases. Longitudinal administrative data may improve the understanding of overall and procedure-specific complication rates after spine surgery.

TERAPI GIZI MEDIS PADA DIABETES MELITUS

Asbtract: Medical nutrition therapy is a vital component in managing diabetes which aims to prevent the progression of chronic complications of diabetes by modification in nutrient intake and lifestyle. Medical nutrition therapy for people with diabetes should be individualized, with consideration given to the individual’s usual food, eating habits, metabolism, physical activity, and co-morbid conditions. Medical nutrition therapy in special conditions such as acute illness, hypoglycemia, old age, pregnancy, lactation, hypertension, nephropathy, and dyslipidemia should be managed carefully. Key words: Medical nutrition therapy, diabetes, individual, complication Abstrak: Terapi gizi medis merupakan komponen penting dalam pilar penatalaksanaan diabetes yang bertujuan untuk mencegah dan memperlambat laju perkembangan komplikasi kronis dari diabetes dengan memodifikasi asupan gizi dan gaya hidup. Pada setiap penyandang diabetes, terapi gizi medis bersifat individual sebab harus mempertimbangkan kebiasaan makan setempat, metabolisme, aktivitas fisik, dan adanya komorbid. Terapi gizi medis pada penyandang diabetes dengan keadaan khusus, seperti penyakit akut, hipoglikemia, perawatan medis, lanjut usia, kehamilan, laktasi, hipertensi, nefropati dan dislipidemia, amat penting dilaksanakan sebab menentukan keberhasilan terapi. Kata kunci: Terapi gizi medis, diabetes, individu, komplikasi

Vidinės miego arterijos endarterektomija esant nebūdingiems simptomams, angiochirurgo patirties ir meistriškumo įtaka operacijos rezultatam

Auksė Meškauskienė, Egidijus Barkauskas, Virginija GaigalaitėVilniaus universiteto Neurologijos ir neurochirurgijos klinikos Neuroangiochirurgijos centras,Šiltnamių g. 29, LT-04130 VilniusEl paštas: [email protected] Įvadas / tikslas Vidinės miego arterijos endarterktomijos rezultatai esant nebūdingiems miego arterijos baseino kraujotakos sutrikimo simptomams yra prieštaringi, o duomenų apie angiochirurgo patirties ir meistriškumo įtaką operacijos rezultatams nėra. Darbo tikslas – įvertinti vidinės miego arterijos endarterektomijos riziką dviejų besimptomių ligonių grupių: viena – be židininės simptomatikos su nebūdingais kraujotakos sutrikimo simptomais miego arterijos baseine, kita – su židinine simptomatika, neturinčia tiesioginio ryšio su operuojamos miego arterijos baseinu, bei nustatyti angiochirurgo patirties ir meistriškumo įtaką šių grupių ligonių operacijos rezultatams. Ligoniai ir metodai Per 12 metų (nuo 1995 iki 2006 metų) vidinės miego arterijos endarterektomija buvo atlikta 192 besimptomiams ligoniams, iš jų 71 ligonis turėjo nebūdingų simptomų (I grupė) ir 121 ligonis sirgo vertebrobaziliniu arba priešingos miego arterijos baseino insultu (II grupė). Operacijos komplikacijomis buvo mirtis ir naujas insultas. Rezultatus išanalizavome kiekvienos grupės atskirai, atsižvelgdami į angiochirurgo patirtį ir angiochirurgo individualų miego arterijos endarterektomijų komplikacijų skaičių. Rezultatai Komplikacijų po operacijos I grupėje buvo 1,4%, II grupėje – 10,7% (p < 0,02). Kai I grupės ligonius operavo chirurgai, kurių patirtis buvo vidutiniškai 10 ir daugiau miego arterijos endarterektomijų per metus, komplikacijų nebuvo, tačiau kai operavo mažesnės patirties chirurgai, komplikacijų pasitaikė 6,7% ligonių. Antroje grupėje komplikacijų taip pat kilo mažiau, kai ligonius operavo labiau patyrę angiochirurgai, tačiau skirtumas abiem atvejais nebuvo statistiškai reikšmingas. Operuojant angiochirurgams, kurių individualus VMAE komplikacijų skaičius nesiekė 3%, komplikacijų skirtumas tarp I ir II grupės buvo statistiškai nereikšmingas. Kai II grupės ligonius operavo angiochirurgai, kurių individualus komplikacijų skaičius viršijo 3%, komplikacijų pasitaikė gerokai daugiau (3,0% vs 15,8%, p < 0,02). Išvados Miego arterijos endarterektomijos rizika ligoniams, turintiems nebūdingų simptomų, yra minimali, jei operuoja patyręs ir aukštos kvalifikacijos angiochirurgas. Operacijos rezultatai yra blogesni, jei ligoniai sirgo vertebrobaziliniu arba priešingos miego arterijos baseino insultu. Besimptomių ligonių mirties ir insulto rizika priklauso ne tik nuo vidinės miego arterijos endarterektomijos indikacijų, bet ir nuo angiochirurgo kvalifikacijos. Pagrindiniai žodžiai: miego arterijos endarterektomija, nebūdingi simptomai, rezultatai, chirurgo patirtis, kvalifikacija Carotid endarterectomy in patients with nonspecific symptoms and the impact of vascular surgeon experience and skills on the operative results Auksė Meškauskienė, Egidijus Barkauskas, Virginija GaigalaitėVilnius University, Clinic of Neurology and Neurosurgery, Center of Neuroangiosurgery,Šiltnamių str. 29, LT-04130 Vilnius, LithuaniaE-mail: [email protected] Background / objective There is uncertainty about the relative risk of carotid endarterectomy in patients with nonspecific symptoms and no data on the relationships between the vascular surgeon’s individual experience and skill and the results of operation. The purpose of this study was to examine the risk of carotid endarterectomy in two asymptomatic patients‘, groups – with nonspecific symptoms and with vertebrobasiliar or contralateral stroke – and the impact of the vascular surgeon’s experience and skill on the results of carotid endarterectomy in both groups. Patients and methods Over a 12-year time interval (1995 to 2006), 71 patients with nonspecific symptoms (group I) and 121 patients with contralateral or verterbrobasilar stroke (group II) underwent carotid endarterectomy. Postoperative rates of death and stroke were analysed in both groups with respect to each surgeon’s average annual of carotid endarterectomies and rate of complications. Results The perioperative mortality and stroke rate was 1.4% in group I and 10.7% in group II (p < 0.02). In group I, there were no complications for more active (> 10 CEAs per year) surgeons and 6.7% complications for less (< 10 CEAs per year) active (p > 0.05). The rate of mortality and morbidity in group II for more active surgeons was lower than for surgeons who performed less than 10 CEAs/y, but the difference did not reach statistical significance, either. Surgeons with an individual complication rate < 3% had excellent results in group I and worse in group II, but the difference was not significant. When patients were operated on by surgeons with the individual complication rate > 3%, the results of carotid endarterectomy between groups I and II differed significantly (3.0% vs 15.8%, p < 0.02). Conclusions Operative risk for patients with nonspecific symptoms is very low if carotid endarterectomy is performed by an experienced and skilled vascular surgeon. Patients with verterbrobasiliar or contralateral stroke have worse results than patients with nonspecific symptoms. The risk of operative death and stroke after carotid endarterectomy in asymptomatic patients depends on indications and also on surgeon’s individual skill. Keywords: carotid endarterectomy, nonspecific symptoms, results, surgeon’s experience and skills

Assessment of Complication Types and Rates Related to Diagnostic Angiography and Interventional Neuroradiologic Procedures

We determined the types and rates of complications related to diagnostic angiography and neuroradiologic interventional procedures at a centre that carries out the full spectrum of angiographic procedures. The occurrence of immediate and delayed complications in 1929 neuroangiographic procedures (1358 diagnostic and 571 interventional) performed between the years 1993–1996 was prospectively identified and recorded on a daily basis. A retrospective review of all charts of patients having procedures conducted during the study period was also carried out to ensure that no complications were missed. The overall complication rate for diagnostic cerebral angiography was 2.2%. Puncture site complications ranged from 0 – 0.1%. Vessel injury distal to the puncture site ranged from 0.2 – 0.6%. The temporary neurologic complication rate was 0.3%, while the permanent rate was 0.4%. There were no contrast reactions. The death rate was 0.1%. Interventional procedures had higher incidences of complications with overall rates ranging from 5.3 – 33%. Temporary and permanent neurologic deficits occurred at a rate of 0 – 10.5% depending upon the procedure involved. Individual complication and death rates and complication categories are provided for arteriovenous malformation embolisation, tumour embolisation, temporary balloon occlusion tests, detachable balloon vessel sacrifice, urokinase infusion, angioplasty, papavarine infusion, GDC embolisation, and carotid cavernous fistula embolisation. When carried out in experienced hands, neuroangiography and neurointervention are relatively safe with low incidences of neurologic and non-neurologic complications. Knowledge of these rates is important when counselling patients prior to treatments or deciding upon the risk-benefit ratio of preoperative procedures.