Emergency Department-based Intensive Care Unit Use Peaks Near Emergency Department Shift Turnover.

INTRODUCTION: The Emergency Critical Care Center (EC3) is an emergency department-based intensive care unit (ED-ICU) designed to improve timely access to critical care for ED patients. ED patients requiring intensive care are initially evaluated and managed in the main ED prior to transfer to a separate group of ED-ICU clinicians. The timing of patient transfers to the ED-ICU may decrease the number of handoffs between main ED teams and have an impact on both patient outcomes and optimal provider staffing models, but has not previously been studied. We aimed to analyze patterns of transfer to the ED-ICU and the relationship with shift turnover times in the main ED. We hypothesized that the number of transfers to the ED-ICU increases near main ED shift turnover times. METHODS: An electronic health record search identified all patients managed in the ED and ED-ICU in 2016 and 2017. We analyzed the number of ED arrivals per hour, the number of ED-ICU consults per hour, the time interval from ED arrival to ED-ICU consult, the distribution throughout the day, and the relationship with shift turnover times in the main ED. RESULTS: A total of 160,198 ED visits were queried, of which 5308 (3.3%) were managed in the ED-ICU. ED shift turnover times were 7 am, 3 pm, and 11 pm. The mean number of ED-ICU consults placed per hour was 221 (85 standard deviation), with relative maximums occurring near ED turnover times: 10:31 pm-11:30 pm (372) and 2:31 pm-3:30 pm (365). The minimum was placed between 7:31 am - 8:30 am (88), shortly after the morning ED turnover time. The median interval from ED arrival time to ED-ICU consult order was 161 minutes (range 6-1,434; interquartile range 144-174). Relative minimums were observed for patients arriving shortly prior to ED turnover times: 4:31 am - 5:30 am (120 minutes [min]), 12:31 pm - 1:30 pm (145 min), and 9:31 pm - 10:30 pm (135 min). Relative maximums were observed for patients arriving shortly after ED turnover times: 7:31 am - 8:30 am (177 min), 4:31 pm - 5:30 pm (218 min), and 11:31 pm - 12:30 am (179 min). CONCLUSION: ED-ICU utilization was highest near ED shift turnover times, and utilization was dissimilar to overall ED arrival patterns. Patients arriving immediately prior to ED shift turnover received earlier consults to the ED-ICU, suggesting these patients may have been preferentially transferred to the ED-ICU rather than signed out to the next team of emergency clinicians. These findings may guide operational planning, staffing models, and timing of shift turnover for other institutions implementing ED-ICUs. Future studies could investigate whether an ED-ICU model improves critically ill patients' outcomes by minimizing ED provider handoffs.

Reconstruction of the chin using an expanded deltopectoral flap following multiple recurrences of oral cancer.

An important alternative to free tissue transfer in patients requiring correction of soft tissue chin defects are local and regional flaps, such as the pectoralis major myocutaneous flap and deltopectoral flap. With predictable vascular supply, potential for large size, and good aesthetic match for facial and cervical skin, the deltopectoral flap can offer the reconstructive surgeon additional options in patients who lack vessels suitable for free tissue transfer. The use of an expanded deltopectoral flap for a staged reconstruction of the chin in a patient with cancer recurrences, concomitant resections, radiation and multiple reconstructions is reported.

Les lambeaux locaux et régionaux, tels que le lambeau myocutané du grand pectoral et le lambeau deltopectoral, constituent une solution de rechange importante au transfert de tissus libres chez les patients qui ont besoin de faire corriger des anomalies des tissus mous du menton. Étant donné son alimentation vasculaire prévisible, sa grande dimension potentielle et sa correspondance esthétique avec la peau du visage et du cou, le lambeau deltopectoral peut offrir au chirurgien en reconstruction des possibilités supplémentaires auprès des patients dont les vaisseaux ne conviennent pas au transfert de tissus libres. Les auteurs décrivent le recours à un lambeau deltopectoralé largi dans le cadre d'une reconstruction graduelle du menton chez un patient subissant des récurrences de cancer, des résections concomitantes, une radiation et des reconstructions multiples.

Prophylactic laparoscopic gastrectomy for hereditary diffuse gastric cancer: a case series in a single family.

BACKGROUND: Hereditary diffuse gastric carcinomas (HDGCs) are particularly troubling because of autosomal dominant heritance, high penetrance, early age of onset, and a lack of effective treatment once symptomatic. HDGC is further complicated by difficulty of effective screening. Gastrectomy provides definitive treatment for CDH1 mutation-positive patients. Attempting to minimize the morbidity and mortality of this procedure via a laparoscopic approach is appropriate. METHODS: Six consanguineous patients, 21 to 51 years of age, were identified as carriers of the CDH1 gene mutation. All of the patients' gastric mucosa was normal by endoscopic appearance and biopsy. After appropriate multispecialty counseling, all patients elected to undergo a laparoscopic total gastrectomy. Demographics, genealogy, operative approach, outcomes, and pathology were reviewed. RESULTS: All gastrectomies were completed using a laparoscopic approach. Gross examination of resected stomachs was unremarkable. Histological examination demonstrated multiple foci of invasive signet ring adenocarcinoma in all patients. There were no anastomotic leaks, one small bowel obstruction requiring reoperation, and one esophageal stricture requiring dilation. CONCLUSIONS: This series demonstrates the utility and safety of the laparoscopic approach for prophylactic total gastrectomy for carriers of the CDH1 gene mutation. It serves to highlight that patients with CDH1 mutations may be more likely to undergo gastrectomy if they are offered the lower risk laparoscopic approach.