Pro-con debate on regionalization of emergency general surgery: controversy or common sense?

More than three million patients every year develop emergency general surgical (EGS) conditions and this number is rising. EGS diseases range from straightforward to potentially life-threatening, and if severe or complex may require extensive resources. Given the looming surgeon shortage and concerns about access to care, regionalization of EGS care, in a manner similar to trauma care, has been proposed. We present a unique pro-con debate highlighting the salient arguments for and against regionalization of EGS care in the USA.

Impact of the Affordable Care Act on trauma and emergency general surgery: An Eastern Association for the Surgery of Trauma systematic review and meta-analysis.

BACKGROUND: Trauma and emergency general surgery (EGS) patients who are uninsured have worse outcomes as compared with insured patients. Partially modeled after the 2006 Massachusetts Healthcare Reform (MHR), the Patient Protection and Affordable Care Act was passed in 2010 with the goal of expanding health insurance coverage, primarily through state-based Medicaid expansion (ME). We evaluated the impact of ME and MHR on outcomes for trauma patients, EGS patients, and trauma systems. METHODS: This study was approved by the Eastern Association for the Surgery of Trauma Guidelines Committee. Using Grading of Recommendations Assessment, Development and Evaluation methodology, we defined three populations of interest (trauma patients, EGS patients, and trauma systems) and identified the critical outcomes (mortality, access to care, change in insurance status, reimbursement, funding). We performed a systematic review of the literature. Random effect meta-analyses and meta-regression analyses were calculated for outcomes with sufficient data. RESULTS: From 4,593 citations, we found 18 studies addressing all seven predefined outcomes of interest for trauma patients, three studies addressing six of seven outcomes for EGS patients, and three studies addressing three of eight outcomes for trauma systems. On meta-analysis, trauma patients were less likely to be uninsured after ME or MHR (odds ratio, 0.49; 95% confidence interval, 0.37-0.66). These coverage expansion policies were not associated with a change in the odds of inpatient mortality for trauma (odds ratio, 0.96; 95% confidence interval, 0.88-1.05). Emergency general surgery patients also experienced a significant insurance coverage gains and no change in inpatient mortality. Insurance expansion was often associated with increased access to postacute care at discharge. The evidence for trauma systems was heterogeneous. CONCLUSION: Given the evidence quality, we conditionally recommend ME/MHR to improve insurance coverage and access to postacute care for trauma and EGS patients. We have no specific recommendation with respect to the impact of ME/MHR on trauma systems. Additional research into these questions is needed. LEVEL OF EVIDENCE: Review, Economic/Decision, level III.

A hybrid hydrazine redox flow battery with a reversible electron acceptor.

Hydrazine is a pollutant with high hydrogen content, offering tremendous possibilities in a direct hydrazine fuel cell (DHFC) as it can be converted into electricity via benign end products. Due to the inner sphere nature of half-cell chemistries, hydrazine cross over triggers parasitic chemistry at the Pt-based air cathode of a state-of-the-art DHFC, overly complicating the already sluggish electrode kinetics at the positive electrode. Here, we illustrate that by altering the interfacial chemistry of the catholyte from inner sphere to outer sphere, the parasitic chemistry can be dissociated from the redox chemistry of the electron acceptor and the hybrid fuel cell can be driven by simple carbon-based cathodes. The reversible nature of an outer sphere catholyte leads to a hybrid fuel cell redox flow battery with performance metrics ∼4 times higher than a Pt-based DHFC-air configuration.

Tailoring the Cathode-Electrolyte Interface with Nanoparticles for Boosting the Solid Oxide Fuel Cell Performance of Chemically Stable Proton-Conducting Electrolytes.

Solid oxide fuel cells (SOFCs) represent the most efficient devices for producing electrical power from fuels. The limit in their application is due to the high operation temperature of conventional SOFC materials. Progress is made toward lower operating temperatures using alternative oxygen-ion conducting electrolytes, but problems of stability and electronic conductivity still remain. A promising alternative is the use of chemically stable proton-conducting Y-doped BaZrO3 (BZY) electrolytes, but their practical applications are limited by the BZY's relatively low performance. Herein, it is reported that deposition by impregnation of cathode nanoparticles on BZY backbones provides a powerful strategy to improve the BZY-based SOFC performance below 600 °C, allowing an outstanding power output for this chemically stable electrolyte. Moreover, it is demonstrated that keeping the nanostructure is more important than keeping the desired chemical composition. The proposed scalable processing method can make BZY a competitive electrolyte for SOFC applications.

High-volume hospitals are associated with lower mortality among high-risk emergency general surgery patients.

INTRODUCTION: We have previously demonstrated that Emergency General Surgery (EGS) patients treated at high-volume hospitals experience lower mortality rates than those treated at low-volume hospitals. However, EGS comprises a wide spectrum of diseases. Our goal was to determine which EGS diseases had better outcomes at high-volume hospitals. METHODS: We undertook a retrospective analysis of the National Inpatient Sample database for 2013 (a nationwide representative sample). Patients with EGS diseases were identified using American Association for the Surgery of Trauma definitions. A hierarchical logistic regression model was used to measure risk-adjusted probability of death, adjusting for age, sex, race, ethnicity, insurance type, and comorbidities. Patients were then grouped into 16 risk groups based upon their predicted probability of death. We then compared observed mortality rates at high- versus low-volume hospitals within each risk group. RESULTS: Nationwide, 3,006,615 patients with EGS diseases were treated at 4,083 hospitals in 2013. Patients with predicted risk of death of 4% or higher (275,615 patients, 9.2%) had lower observed mortality rates at high-volume hospitals than at low-volume hospitals (7.7% vs. 10.2%, p < 0.001). We estimated that 1,002 deaths were potentially preventable if high-risk patients who were treated at low-volume hospitals were instead transferred to high-volume hospitals. CONCLUSION: EGS patients with predicted risk of death of 4% or higher experience lower mortality rates at high-volume hospitals than at low-volume hospitals. A regional system of EGS care that enables rapid transfer of high-risk patients to high-volume hospitals may prevent several deaths. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III; Therapeutic/Case Management, level IV.

Association of Opioid-Related Adverse Drug Events With Clinical and Cost Outcomes Among Surgical Patients in a Large Integrated Health Care Delivery System.

Importance: Opioids are commonly used for pain control during and after invasive procedures. However, opioid-related adverse drug events (ORADEs) are common and have been associated with worse patient outcomes. Objectives: To examine the incidence of ORADEs in patients undergoing hospital-based surgical and endoscopic procedures and to evaluate the association of ORADEs with clinical and cost outcomes. Design, Setting, and Participants: In this retrospective study of clinical and administrative data, ORADEs were identified using International Classification of Diseases, Ninth Revision diagnosis codes for known adverse effects of opioids or by opioid antagonist use. Multivariable regression analysis was used to measure the association of ORADEs with outcomes after adjusting for potential confounding factors. The setting was 21 acute care hospitals in a large integrated health care delivery system. Participants were 135 379 patients (aged ≥18 years, admitted from January 1, 2013, to September 30, 2015) who underwent surgical and endoscopic procedures and were given opioids. Exposure: Opioid use, reported as morphine milligram equivalent doses. Main Outcomes and Measures: Opioid-related adverse drug events and their association with inpatient mortality, discharge to another care facility, length of stay, cost of hospitalization, and 30-day readmission. Results: Among 135 379 adult patients in this study (67.5% female), 14 386 (10.6%) experienced at least one ORADE. Patients with ORADEs were more likely to be older, of white race/ethnicity, and male and have more comorbidities. Patients with ORADEs received a higher total dose of opioids (median morphine milligram equivalent dose, 46.8 vs 30.0 mg; P < .001) and for a longer duration (median, 3.0 vs 2.0 days; P < .001). In adjusted analyses, ORADEs were associated with increased inpatient mortality (odds ratio [OR], 28.8; 95% CI, 24.0-34.5), greater likelihood of discharge to another care facility (OR, 2.9; 95% CI, 2.7-3.0), prolonged length of stay (OR, 3.1; 95% CI, 2.8-3.4), high cost of hospitalization (OR, 2.7; 95% CI, 2.4-3.0), and higher rate of 30-day readmission (OR, 1.3; 95% CI, 1.2-1.4). ORADEs were associated with a 2.9% increase in absolute mortality, an $8225 increase in cost for the index hospitalization, and a 1.6-day increase in length of stay for the index hospitalization. Conclusions and Relevance: Opioid-related adverse drug events were common among patients undergoing hospital-based invasive procedures and were associated with significantly worse clinical and cost outcomes. Hospital-acquired harm from ORADEs in the surgical patient population is an important opportunity for health systems to improve patient safety and reduce cost.

A Rechargeable Hydrogen Battery.

We utilize proton-coupled electron transfer in hydrogen storage molecules to unlock a rechargeable battery chemistry based on the cleanest chemical energy carrier molecule, hydrogen. Electrochemical, spectroscopic, and spectroelectrochemical analyses evidence the participation of protons during charge-discharge chemistry and extended cycling. In an era of anthropogenic global climate change and paramount pollution, a battery concept based on a virtually nonpolluting energy carrier molecule demonstrates distinct progress in the sustainable energy landscape.

An Electrochemical Wind Velocity Sensor.

Electrochemical interfaces invariably generate unipolar electromotive force because of the unidirectional nature of electrochemical double layers. Herein we show an unprecedented generation of a time varying bipolar electric field between identical half-cell electrodes induced by tailored interfacial migration of magnetic particles. The periodic oscillation of a bipolar electric field is monotonically correlated with velocity-dependent torque, opening new electrochemical pathways targeting velocity monitoring systems.

Fuel Exhaling Fuel Cell.

State-of-the-art proton exchange membrane fuel cells (PEMFCs) anodically inhale H2 fuel and cathodically expel water molecules. We show an unprecedented fuel cell concept exhibiting cathodic fuel exhalation capability of anodically inhaled fuel, driven by the neutralization energy on decoupling the direct acid-base chemistry. The fuel exhaling fuel cell delivered a peak power density of 70 mW/cm2 at a peak current density of 160 mA/cm2 with a cathodic H2 output of ∼80 mL in 1 h. We illustrate that the energy benefits from the same fuel stream can at least be doubled by directing it through proposed neutralization electrochemical cell prior to PEMFC in a tandem configuration.

Racial/Ethnic Disparities in Longer-term Outcomes Among Emergency General Surgery Patients: The Unique Experience of Universally Insured Older Adults.

OBJECTIVES: To determine whether racial/ethnic disparities in 30/90/180-day mortality, major morbidity, and unplanned readmissions exist among universally insured older adult (≥65 years) emergency general surgery patients; vary by diagnostic category; and can be explained by variations in geography, teaching status, age-cohort, and a hospital's percentage of minority patients. SUMMARY OF BACKGROUND DATA: As the US population ages and discussions surrounding the optimal method of insurance provision increasingly enter into national debate, longer-term outcomes are of paramount concern. It remains unclear the extent to which insurance changes disparities throughout patients' postacute recovery period among older adults. METHODS: Survival analysis of 2008 to 2014 Medicare data using risk-adjusted Cox proportional-hazards models. RESULTS: A total of 6,779,649 older adults were included, of whom 82.8% identified as non-Hispanic white (NHW), 9.2% non-Hispanic black (NHB), 5.6% Hispanic, and 1.5% non-Hispanic Asian (NHA). Relative to NHW patients, each group of minority patients was significantly less likely to die [30-day NHB vs NHW hazard ratio (95% confidence interval): 0.88 (0.86-0.89)]. Differences became less apparent as outcomes approached 180 days [180-day NHB vs NHW: 1.00 (0.98-1.02)]. For major morbidity and unplanned readmission, differences among NHW, Hispanic, and NHA patients were comparable. NHB patients did consistently worse. Efforts to explain the occurrence found similar trends across diagnostic categories, but significant differences in disparities attributable to geography and the other included factors that combined accounted for up to 50% of readmission differences between racial/ethnic groups. CONCLUSION: The study found an inversion of racial/ethnic mortality differences and mitigation of non-NHB morbidity/readmission differences among universally insured older adults that decreased with time. Persistent disparities among nonagenarian patients and hospitals managing a regionally large share of minority patients warrant particular concern.

Variations in outcomes of emergency general surgery patients across hospitals: A call to establish emergency general surgery quality improvement program.

BACKGROUND: National Surgical Quality Improvement Program and Trauma Quality Improvement Program have shown variations in risk-adjusted outcomes across hospitals. Our study hypothesis was that there would be similar variation in risk-adjusted outcomes of emergency general surgery (EGS) patients. METHODS: We undertook a retrospective analysis of the National Inpatient Sample database for 2010. Patients with EGS diseases were identified using American Association for the Surgery of Trauma definitions. A hierarchical logistic regression model was used to model in-hospital mortality, accounting for patient characteristics, including age, sex, race, ethnicity, insurance type, and comorbidities. Predicted-to-expected mortality ratios with 90% confidence intervals were used to identify hospitals as low mortality (ratio significantly lower than 1), high mortality (ratio significantly higher than 1), or average mortality (ratio overlapping 1). RESULTS: Nationwide, 2,640,725 patients with EGS diseases were treated at 943 hospitals in 2010. About one-sixth of the hospitals (139, 15%) were low mortality, a quarter were high mortality (221, 23%), and the rest were average mortality. Mortality ratio at low mortality hospitals was almost four times lower than that of high mortality hospitals (0.57 vs. 2.03, p < 0.0001). If high and average mortality hospitals performed at the same level as low mortality hospitals, we estimate 16,812 (55%) more deaths than expected. CONCLUSION: There are significant variations in risk-adjusted outcomes of EGS patients across hospitals, with several thousand higher than expected number of deaths nationwide. Based on the success of National Surgical Quality Improvement Program and Trauma Quality Improvement Program, we recommend establishing EGS quality improvement program for risk-adjusted benchmarking of hospitals for EGS patients. LEVEL OF EVIDENCE: Care management, level III.

Redox Active Binary Logic Gate Circuit for Homeland Security.

Bipolar junction transistors are at the frontiers of modern electronics owing to their discrete voltage regulated operational levels. Here we report a redox active binary logic gate (RLG) which can store a "0" and "1" with distinct operational levels, albeit without an external voltage stimuli. In the RLG, a shorted configuration of half-cell electrodes provided the logic low level and decoupled configuration relaxed the system to the logic high level due to self-charge injection into the redox active polymeric system. Galvanostatic intermittent titration and electrochemical quartz crystal microbalance studies indicate the kinetics of self-charge injection are quite faster and sustainable in polypyrrole based RLG, recovering more than 70% signal in just 14 s with minor signal reduction at the end of 10000 cycles. These remarkable properties of RLGs are extended to design a security sensor which can detect and count intruders in a locality with decent precision and switching speed.

A Direct Alcohol Fuel Cell Driven by an Outer Sphere Positive Electrode.

Molecular oxygen, the conventional electron acceptor in fuel cells poses challenges specific to direct alcohol fuel cells (DAFCs). Due to the coupling of alcohol dehydrogenation with the scission of oxygen on the positive electrode during the alcohol crossover, the benchmark Pt-based air cathode experiences severe competition and depolarization losses. The necessity of heavy precious metal loading with domains for alcohol tolerance in the state of the art DAFC cathode is a direct consequence of this. Although efforts are dedicated to selectively cleave oxygen, the root of the problem being the inner sphere nature of either half-cell chemistry is often overlooked. Using an outer sphere electron acceptor that does not form a bond with the cathode during redox energy transformation, we effectively decoupled the interfacial chemistry from parasitic chemistry leading to a DAFC driven by alcohol passive carbon nanoparticles, with performance metrics ∼8 times higher than Pt-based DAFC-O2.

Factors Associated With Rehabilitation Outcomes After Traumatic Brain Injury: Comparing Functional Outcomes Between TBIMS Centers Using Hierarchical Linear Modeling.

OBJECTIVE: To examine differences in patient outcomes across Traumatic Brain Injury Model Systems (TBIMS) rehabilitation centers and factors that influence these differences using hierarchical linear modeling (HLM). SETTING: Sixteen TBIMS centers. PARTICIPANTS: A total of 2056 individuals 16 years or older with moderate to severe traumatic brain injury (TBI) who received inpatient rehabilitation. DESIGN: Multicenter observational cohort study using HLM to analyze prospectively collected data. MAIN OUTCOME MEASURES: Functional Independence Measure and Disability Rating Scale total scores at discharge and 1 year post-TBI. RESULTS: Duration of posttraumatic amnesia (PTA) demonstrated a significant inverse relationship with functional outcomes. However, the magnitude of this relationship (change in functional status for each additional day in PTA) varied among centers. Functional status at discharge from rehabilitation and at 1 year post-TBI could be predicted using the slope and intercept of each TBIMS center for the duration of PTA, by comparing it against the average slope and intercept. CONCLUSIONS: HLM demonstrated center effect due to variability in the relationship between PTA and functional outcomes of patients. This variability is not accounted for in traditional linear regression modeling. Future studies examining variations in patient outcomes between centers should utilize HLM to measure the impact of additional factors that influence patient rehabilitation functional outcomes.

Process for developing rehabilitation practice recommendations for individuals with traumatic brain injury.

BACKGROUND: Attempts at measuring quality of rehabilitation care are hampered by a gap in knowledge translation of evidence-based approaches and lack of consensus on best practices. However, adoption of evidence-based best practices is needed to minimize variations and improve quality of care. Therefore, the objective of this project was to describe a process for assessing the quality of evidence of clinical practices in traumatic brain injury (TBI) rehabilitative care. METHODS: A multidisciplinary team of clinicians developed discipline-specific clinical questions using the Population, Intervention, Control, Outcome process. A systematic review of the literature was conducted for each question using Pubmed, CINAHL, PsychInfo, and Allied Health Evidence databases. Team members assessed the quality, level, and applicability of evidence utilizing a modified Oxford scale, the Agency for Healthcare Research and Quality Methods Guide, and a modified version of the Grading of Recommendations, Assessment, Development, and Evaluation scale. RESULTS: Draft recommendations for best-practice were formulated and shared with a Delphi panel of clinical representatives and stakeholders to obtain consensus. CONCLUSION: Evidence-based practice guidelines are essential to improve the quality of TBI rehabilitation care. By using a modified quality of evidence assessment tool, we established a process to gain consensus on practice recommendations for individuals with TBI undergoing rehabilitation.

Polarity governed selective amplification of through plane proton shuttling in proton exchange membrane fuel cells.

Graphene oxide (GO) anisotropically conducts protons with directional dominance of in plane ionic transport (σ IP) over the through plane (σ TP). In a typical H2-O2 fuel cell, since the proton conduction occurs through the plane during its generation at the fuel electrode, it is indeed inevitable to selectively accelerate GO's σ TP for advancement towards a potential fuel cell membrane. We successfully achieved ∼7 times selective amplification of GO's σ TP by tuning the polarity of the dopant molecule in its nanoporous matrix. The coexistence of strongly non-polar and polar domains in the dopant demonstrated a synergistic effect towards σ TP with the former decreasing the number of water molecules coordinated to protons by ∼3 times, diminishing the effects of electroosmotic drag exerted on ionic movements, and the latter selectively accelerating σ TP across the catalytic layers by bridging the individual GO planes via extensive host guest H-bonding interactions. When they are decoupled, the dopant with mainly non-polar or polar features only marginally enhances the σ TP, revealing that polarity factors contribute to fuel cell relevant transport properties of GO membranes only when they coexist. Fuel cell polarization and kinetic analyses revealed that these multitask dopants increased the fuel cell performance metrics of the power and current densities by ∼3 times compared to the pure GO membranes, suggesting that the functional group factors of the dopants are of utmost importance in GO-based proton exchange membrane fuel cells.

The Need to Consider Longer-term Outcomes of Care: Racial/Ethnic Disparities Among Adult and Older Adult Emergency General Surgery Patients at 30, 90, and 180 Days.

OBJECTIVES: Following calls from the National Institutes of Health and American College of Surgeons for "urgently needed" research, the objectives of the present study were to (1) ascertain whether differences in 30/90/180-day mortality, major morbidity, and unplanned readmissions exist among adult (18-64 yr) and older adult (≥65 yr) emergency general surgery (EGS) patients; (2) vary by diagnostic category; and (3) are explained by variations in insurance, income, teaching status, hospital EGS volume, and a hospital's proportion of minority patients. BACKGROUND: Racial/ethnic disparities have been described in in-hospital and 30-day settings. How longer-term outcomes compare-a critical consideration for the lived experience of patients-has, however, only been limitedly considered. METHODS: Survival analysis of 2007 to 2011 California State Inpatient Database using Cox proportional hazards models. RESULTS: A total of 737,092 adults and 552,845 older adults were included. In both cohorts, significant differences in 30/90/180-day mortality, major morbidity, and unplanned readmissions were found, pointing to persistently worse outcomes between non-Hispanic Black and White patients [180-d readmission hazard ratio (95% confidence interval):1.04 (1.03-1.06)] and paradoxically better outcomes among Hispanic adults [0.85 (0.84-0.86)] that were not encountered among Hispanic older adults [1.06 (1.04-1.07)]. Stratified results demonstrated robust morbidity and readmission trends between non-Hispanic Black and White patients for the majority of diagnostic categories, whereas variations in insurance/income/teaching status/EGS volume/proportion of minority patients all significantly altered the effect-combined accounting for up to 80% of risk-adjusted differences between racial/ethnic groups. CONCLUSIONS: Racial/ethnic disparities exist in longer-term outcomes of EGS patients and are, in part, determined by differences in factors associated with emergency care. Efforts such as these are needed to understand the interplay of influences-both in-hospital and during the equally critical, postacute phase-that underlie disparities' occurrence among surgical patients.