National surgical, obstetric, anaesthesia and nursing plan, Nigeria.

Recent evidence suggests that strengthening surgical care within existing health systems will strengthen the overall health-care system. However, Nigeria's national strategic health development plan 2018-2022 placed little emphasis on surgical care. To address the gap, we worked with professional societies and other partners to develop the national surgical, obstetric, anaesthesia and nursing plan 2019-2023. The aim was to foster actions to prioritize surgical care for the achievement of universal health coverage. In addition to creating a costed strategy to strengthen surgical care, the plan included children's surgery and nursing: two key aspects that have been neglected in other national surgical plans. Pilot implementation of the plan began in 2020, supported by a nongovernmental organization with experience in surgical care in the region. We have created specific entry points to facilitate the pilot implementation. In the pilot, an electronic surgery registry has been created; personnel are being trained in life support; nurses are being trained in safe perioperative care; biomedical technicians and sterile supplies nurses are being trained in surgical instrument repair and maintenance; and research capacity is being strengthened. In addition, the mainstream media are being mobilized to improve awareness about the plan among policy-makers and the general population. Another development partner is interested in providing support for paediatric surgery, and a children's hospital is being planned. As funding is a key challenge to full implementation, we need innovative domestic funding strategies to support and sustain implementation.

De récentes preuves suggèrent que le renforcement des soins chirurgicaux au sein des systèmes de santé existants entraînera un renforcement du système tout entier. Pourtant, le plan 2018­2022 de développement stratégique de la santé au Nigeria n'accorde que peu d'importance à ces soins. Pour remédier au problème, nous avons travaillé avec des associations professionnelles ainsi que d'autres partenaires afin de mettre au point le plan national de chirurgie, d'obstétrique, d'anesthésie et de soins infirmiers 2019­2023. Objectif: favoriser les mesures privilégiant les soins chirurgicaux, en vue d'offrir une couverture maladie universelle. Outre l'élaboration d'une stratégie chiffrée servant à consolider le secteur, le plan a intégré les unités de soins infirmiers et de chirurgie pédiatrique, deux aspects clés qui ont été négligés dans d'autres plans nationaux relatifs à la chirurgie. La mise en œuvre de la version pilote du plan a démarré en 2020, avec l'aide d'une organisation non gouvernementale possédant de l'expérience en matière d'interventions chirurgicales dans la région. Nous avons établi des points de départ spécifiques pour faciliter cette mise en œuvre. Dans le cadre de la version pilote, un registre de chirurgie électronique a été créé; le personnel a été formé à l'assistance vitale; les infirmiers ont découvert comment administrer des soins périopératoires sûrs; les techniciens biomédicaux et les infirmiers en stérilisation du matériel ont appris à réparer les instruments chirurgicaux; et enfin, les capacités de recherche et de maintenance ont été revues à la hausse. Par ailleurs, les médias traditionnels ont été sollicités afin d'informer les législateurs et la population en général au sujet du plan. Un partenaire de développement supplémentaire a proposé son aide en matière de chirurgie pédiatrique, et un hôpital pour enfants est prévu. Les fonds constituant l'un des principaux défis d'une mise en œuvre complète, nous avons besoin de stratégies de financement innovantes à l'échelle nationale pour la soutenir et la maintenir.

Las evidencias recientes sugieren que el fortalecimiento de la atención quirúrgica dentro de los sistemas sanitarios existentes reforzará el sistema general de la atención sanitaria. Sin embargo, el plan nacional estratégico para el desarrollo de la salud 2018-2022 de Nigeria dio poca importancia a la atención quirúrgica. Para abordar esta carencia, trabajamos con sociedades profesionales y otros asociados con el fin de elaborar el plan nacional de intervención quirúrgica, obstetricia, anestesia y enfermería 2019-2023. El objetivo era impulsar acciones para priorizar la atención quirúrgica en pro del logro de la cobertura sanitaria universal. Además de crear una estrategia con costes para reforzar la atención quirúrgica, el plan incluía intervenciones quirúrgicas y cuidados de enfermería para niños, que son dos aspectos clave que se han ignorado en otros planes nacionales de intervención quirúrgica. La implementación piloto del plan comenzó en 2020, con el apoyo de una organización no gubernamental que tiene experiencia en la atención quirúrgica en la región. Se han creado puntos iniciales específicos para facilitar la implementación piloto. En el plan piloto, se ha creado un registro electrónico de intervenciones quirúrgicas; se está capacitando al personal en apoyo vital; se está capacitando al personal de enfermería en cuidados perioperatorios seguros; se está capacitando a los técnicos biomédicos y al personal de enfermería de suministros estériles en la restauración de instrumentos quirúrgicos; y se está fortaleciendo la capacidad de mantenimiento e investigación. Además, se está recurriendo a los principales medios de comunicación para dar a conocer el plan a los responsables de formular las políticas y a la población en general. Otro asociado para el desarrollo está interesado en prestar apoyo a la intervención quirúrgica pediátrica, y se está planificando un hospital infantil. Como el financiamiento es un desafío clave para implementar el plan en su totalidad, se requieren estrategias innovadoras de financiamiento nacional para apoyar y sostener la implementación.

A natural experimental study of improvements along an urban canal: impact on canal usage, physical activity and other wellbeing behaviours.

BACKGROUND: There are few robust natural experimental studies of improving urban green spaces on physical activity and wellbeing. The aim of this controlled natural experimental study was to examine the impact of green space improvements along an urban canal on canal usage, physical activity and two other wellbeing behaviours (social interactions and taking notice of the environment) among adults in Greater Manchester, UK. The intervention included resurfaced footpaths, removal of encroaching vegetation, improved entrances, new benches and signage. METHODS: Two comparison sites were matched to the intervention site using a systematic five-step process, based on eight correlates of physical activity at the neighbourhood (e.g. population density) and site (e.g. lighting) levels. Outcomes were assessed using systematic observations at baseline, and 7, 12 and 24 months post-baseline. The primary outcome was the change in the number of people using the canal path from baseline to 12 months. Other outcomes were changes in physical activity levels (Sedentary, Walking, Vigorous), Connect and Take Notice behaviours. Data were analysed using multilevel mixed-effects negative binomial regression models, comparing outcomes in the intervention group with the matched comparison group, controlling for day, time of day and precipitation. A process evaluation assessed potential displacement of activity from a separate existing canal path using intercept surveys and observations. RESULTS: The total number of people observed using the canal path at the intervention site increased more than the comparison group at 12 months post-baseline (IRR 2.10, 95% CI 1.79-2.48); there were similar observed increases at 7 and 24 months post-baseline. There was some evidence that the intervention brought about increases in walking and vigorous physical activity, social interactions, and people taking notice of the environment. The process evaluation suggested that there was some displacement of activity, but the intervention also encouraged existing users to use the canal more often. CONCLUSIONS: Urban canals are promising settings for interventions to encourage green space usage and potentially increase physical activity and other wellbeing behaviours. Interventions that improve access to green corridors along canals and provide separate routes for different types of physical activities may be particularly effective and warrant further research. STUDY PROTOCOL: Study protocol published in Open Science Framework in July 2018 before the first follow-up data collection finished ( https://osf.io/zcm7v ). Date of registration: 28 June 2018.

Inclusion of Children's Surgery in National Surgical Plans and Child Health Programmes: the need and roadmap from Global Initiative for Children's Surgery.

About 1.7 billion children and adolescents, mostly in low- and middle-income countries (LMICs) lack access to surgical care. While some of these countries have developed surgical plans and others are in the process of developing theirs, children's surgery has not received the much-needed specific emphasis and focus in these plans. With the significant burden of children's surgical conditions especially in low- and middle-income countries, universal health coverage and the United Nations' (UN) Sustainable Development Goals (SDG) will not be achieved without deliberate efforts to scale up access to children's surgical care. Inclusion of children's surgery in National Surgical Obstetric and Anaesthesia Plans (NSOAPs) can be done using the Global Initiative for Children's Surgery (GICS)-modified Children's Surgical Assessment Tool (CSAT) tool for baseline assessment and the Optimal Resources for Children Surgical Care (OReCS) as a foundational tool for implementation.

Practice, Practice, Practice! Effect of Resuscitative Endovascular Balloon Occlusion of the Aorta Volume on Outcomes: Data From the AAST AORTA Registry.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an endovascular adjunct to hemorrhage control. Success relies on institutional support and focused training in arterial access. We hypothesized that hospitals with higher REBOA volumes will be more successful than low-volume hospitals at aortic occlusion with REBOA. METHODS: This is a retrospective study from the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery Registry from November 2013 to January 2018. Patients aged ≥18 y who underwent REBOA were included. Successful placement of REBOA catheters (defined as hemodynamic improvement with balloon inflation) was compared between high-volume (≥80 cases; two hospitals), mid-volume (10-20 cases; four hospitals), and low-volume (<10 cases; 14 hospitals) hospitals, adjusting for patient factors. RESULTS: Of 271 patients from 20 hospitals, 210 patients (77.5%) had successful REBOA placement. Most patients were male (76.0%) and sustained blunt trauma (78.1%). cardiopulmonary resuscitation (CPR) was ongoing at the time of REBOA placement in 34.5% of patients. Inpatient mortality was 67.4%, unchanged by hospital volume. Multivariable logistic regression found increased odds of successful REBOA placement at high-volume versus low-volume hospitals (odds ratio [OR], 7.50; 95% confidence interval [CI], 2.10-27.29; P = 0.002) and mid-volume versus low-volume hospitals (OR, 7.82; 95% CI, 1.52-40.31; P = 0.014) and decreased odds among patients undergoing CPR during REBOA placement (OR, 0.10; 95% CI, 0.03-0.34; P < 0.001) when adjusting for age, sex, mechanism of injury, prehospital CPR, CPR on admission, transfer status, hospital location of REBOA placement, Glasgow Coma Scale ≤ 13, and injury severity. CONCLUSIONS: Hospitals with higher REBOA volumes were more likely to achieve hemodynamic improvement with REBOA inflation. However, mortality and complication rates were unchanged. Independent of hospital volume, ongoing CPR is associated with a decreased odds of successful REBOA placement.

Defining recovery neurobiology of injured spinal cord by synthetic matrix-assisted hMSC implantation.

Mesenchymal stromal stem cells (MSCs) isolated from adult tissues offer tangible potential for regenerative medicine, given their feasibility for autologous transplantation. MSC research shows encouraging results in experimental stroke, amyotrophic lateral sclerosis, and neurotrauma models. However, further translational progress has been hampered by poor MSC graft survival, jeopardizing cellular and molecular bases for neural repair in vivo. We have devised an adult human bone marrow MSC (hMSC) delivery formula by investigating molecular events involving hMSCs incorporated in a uniquely designed poly(lactic-co-glycolic) acid scaffold, a clinically safe polymer, following inflammatory exposures in a dorsal root ganglion organotypic coculture system. Also, in rat T9-T10 hemisection spinal cord injury (SCI), we demonstrated that the tailored scaffolding maintained hMSC stemness, engraftment, and led to robust motosensory improvement, neuropathic pain and tissue damage mitigation, and myelin preservation. The scaffolded nontransdifferentiated hMSCs exerted multimodal effects of neurotrophism, angiogenesis, neurogenesis, antiautoimmunity, and antiinflammation. Hindlimb locomotion was restored by reestablished integrity of submidbrain circuits of serotonergic reticulospinal innervation at lumbar levels, the propriospinal projection network, neuromuscular junction, and central pattern generator, providing a platform for investigating molecular events underlying the repair impact of nondifferentiated hMSCs. Our approach enabled investigation of recovery neurobiology components for injured adult mammalian spinal cord that are different from those involved in normal neural function. The uncovered neural circuits and their molecular and cellular targets offer a biological underpinning for development of clinical rehabilitation therapies to treat disabilities and complications of SCI.

Assessment of Capacity to Meet Lancet Commission on Global Surgery Indicators in the Federal Capital Territory, Abuja, Nigeria.

BACKGROUND: This is a baseline assessment of surgical capacity in the Federal Capital Territory (FCT), in preparation for the creation of a National Surgical, Obstetric, Anesthesia, and Nursing Plan. METHODS: In October 2017, all 10 of the 11 secondary hospitals in FCT that provide surgical and/or obstetric care were surveyed using a modified World Health Organization Hospital Assessment Tool and a qualitative semi-structured hospital interview tool of the medical Director (MdD). This project received approval from the Nigeria Federal Ministry of Health and the FCT Department of Health and Human Services. RESULTS: The number of inpatient beds ranged from 35 to 140, and the number of admissions ranged from 1200 to 6400 patients per year. The mean number of surgeries performed in 2016 by these hospitals was 783 (range 235-1601). Cesarean section was the most common surgical procedure at each hospital. Only five hospitals regularly performed laparotomies. Only three hospitals regularly performed fixation of open fractures. Of 152 surgical, obstetric, and anesthesia providers, all hospitals had at least one consultant obstetrician, but only four hospitals had a general surgeon and three hospitals had a consultant anesthesiologist. Deficient physical space for inpatient admissions was the most common concern of MdDs. CONCLUSIONS: The FCT reaches the target for 2-h access, with 80% of patients (on average) reaching the hospital within 2 h. However, SAO provider density, surgical volume, and tracking of the perioperative mortality rate were low. Data were lacking to comment on protection against impoverishing and catastrophic expenditures.

Correction to: Assessment of Capacity to Meet Lancet Commission on Global Surgery Indicators in the Federal Capital Territory, Abuja, Nigeria.

In the original article there is an error in Fig. 2. Following is the corrected figure.

Evaluating the impact of improvements in urban green space on older adults' physical activity and wellbeing: protocol for a natural experimental study.

BACKGROUND: Creating or improving urban green space has the potential to be an effective, sustainable and far-reaching way to increase physical activity and improve other aspects of wellbeing in the population. However, there is a dearth of well-conducted natural experimental studies examining the causal effect of changing urban green space on physical activity and wellbeing. This is especially true in older adults and in the United Kingdom. This paper describes a natural experimental study to evaluate the effect of four small-scale urban street greening interventions on older adults' physical activity and wellbeing over a 1-year period, relative to eight matched comparison sites. All sites are located in deprived urban neighbourhoods in Greater Manchester, United Kingdom. METHODS: Components of the interventions include tree and flower planting, and artificial tree decorations. Eight unimproved comparison sites were selected based on a systematic process of matching using several known objective and subjective environmental correlates of physical activity in older adults. The outcome measures are physical activity and two other behavioural indicators of wellbeing (Connect: connecting with other people; and Take Notice: taking notice of the environment), collected using a newly developed observation tool. The primary outcome is Take Notice behaviour due to largest effects on this behaviour being anticipated from improvements in the aesthetic quality of green space at the intervention sites. Baseline data collection occurred in September 2017 before the interventions were installed in November 2017. Follow-up data collection will be repeated in February/ March 2018 (6 months) and September 2018 (12 months). DISCUSSION: The present study permits a rare opportunity to evaluate the causal effects of small-scale changes in urban green space in an understudied population and setting. Although the interventions are expected to have small effects on the outcomes, the present study contributes to developing natural experiment methodology in this field by addressing key methodological weaknesses causing high risk of bias in previous natural experimental studies. Key improvements to reduce risk of bias in the present study are rigorous matching of multiple comparison sites and appropriate statistical control of key confounders. TRIAL REGISTRATION: Retrospectively registered with study ID NCT03575923 . Date of registration: 3 July 2018.

Epidemiology of Hirschsprung disease in California from 1995 to 2013.

PURPOSE: This study seeks to update current epidemiology of Hirschsprung disease (HD) in California. METHODS: Using data from the California Office of Statewide Health Planning and Development Linked Birth (1995-2012) and Patient Discharge Databases (1995-2013), patients from either dataset with an ICD-9 diagnosis code of HD (751.3) or procedure code of Soave (48.41), Duhamel (48.65), or Swenson/other pull-through (48.49) were included. Patients > age 18 during their first admission were excluded. RESULTS: Of 9.3 million births, 2,464 patients were identified. Incidence was 2.2 cases/10,000 live births, with rates peaking at 2.9/10,000 births in 2002. Incidence was highest among African American (4.1/10,000) and Asian/Pacific Islander (2.5/10,000) births. Most were male (n = 1652, 67.1%). Sixty patients (2.4%) had Down syndrome. The median gestational age at birth was 38 weeks 6 days (interquartile range [IQR] 37 weeks 1 day-40 weeks 1 day). Mortality during the first year of life was 1.7%. Median age at death was 14.5 days (IQR 0-113 days). CONCLUSION: This is one of the largest population-based studies of HD. In California, the incidence of HD is stable, risk is highest among African American children, and the mortality rate is < 2%.

Symmetry-breaking in branching epithelia: cells on micro-patterns under flow challenge the hypothesis of positive feedback by a secreted autocrine inhibitor of motility.

Branching morphogenesis of epithelia involves division of cells into leader (tip) and follower (stalk) cells. Published work on cell lines in culture has suggested that symmetry-breaking takes place via a secreted autocrine inhibitor of motility, the inhibitor accumulating more in concave regions of the culture boundary, slowing advance of cells there, and less in convex areas, allowing advance and a further exaggeration of the concave/convex difference. Here we test this hypothesis using a two-dimensional culture system that includes strong flow conditions to remove accumulating diffusible secretions. We find that, while motility does indeed follow boundary curvature in this system, flow makes no difference: this challenges the hypothesis of control by a diffusible secreted autocrine inhibitor.

Restrictions on surgical resident shift length does not impact type of medical errors.

BACKGROUND: In 2011, resident duty hours were restricted in an attempt to improve patient safety and resident education. With the goal of reducing fatigue, shorter shift length leads to more patient handoffs, raising concerns about adverse effects on patient safety. This study seeks to determine whether differences in duty-hour restrictions influence types of errors made by residents. MATERIALS AND METHODS: This is a nested retrospective cohort study at a surgery department in an academic medical center. During 2013-14, standard 2011 duty hours were in place for residents. In 2014-15, duty-hour restrictions at the study site were relaxed ("flexible") with no restrictions on shift length. We reviewed all morbidity and mortality submissions from July 1, 2013-June 30, 2015 and compared differences in types of errors between these periods. RESULTS: A total of 383 patients experienced adverse events, including 59 deaths (15.4%). Comparing standard versus flexible periods, there was no difference in mortality (15.7% versus 12.6%, P = 0.479) or complication rates (2.6% versus 2.5%, P = 0.696). There was no difference in types of errors between periods (P = 0.050-0.808). The most number of errors were due to cognitive failures (229, 59.6%), whereas the fewest number of errors were due to team failure (127, 33.2%). By subset, technical errors resulted in the highest number of errors (169, 44.1%). There were no differences between types of errors of cases that were nonelective, at night, or involving residents. CONCLUSIONS: Among adverse events reported in this departmental surgical morbidity and mortality, there were no differences in types of errors when resident duty hours were less restrictive.

The State of Veterinary Dental Education in North America, Canada, and the Caribbean: A Descriptive Study.

Dental disease is important in the population of pets seen by veterinarians. Knowledge and skills related to oral disease and dentistry are critical entry-level skills expected of graduating veterinarians. A descriptive survey on the state of veterinary dental education was sent to respondents from 35 veterinary schools in the United States, Canada, and the Caribbean. Using the online SurveyMonkey application, respondents answered up to 26 questions. Questions were primarily designed to determine the breadth and depth of veterinary dental education from didactic instruction in years 1-3 to the clinical year programs. There was an excellent response to the survey with 86% compliance. Learning opportunities for veterinary students in years 1-3 in both the lecture and laboratory environments were limited, as were the experiences in the clinical year 4, which were divided between community-type practices and veterinary dentistry and oral surgery services. The former provided more hands-on clinical experience, including tooth extraction, while the latter focused on dental charting and periodontal debridement. Data on degrees and certifications of faculty revealed only 12 programs with board-certified veterinary dentists. Of these, seven veterinary schools had residency programs in veterinary dentistry at the time of the survey. Data from this study demonstrate the lack of curricular time dedicated to dental content in the veterinary schools participating in the survey, thereby suggesting the need for veterinary schools to address the issue of veterinary dental education. By graduation, new veterinarians should have acquired the needed knowledge and skills to meet both societal demands and professional expectations.

Adrenergic activation attenuates astrocyte swelling induced by hypotonicity and neurotrauma.

Edema in the central nervous system can rapidly result in life-threatening complications. Vasogenic edema is clinically manageable, but there is no established medical treatment for cytotoxic edema, which affects astrocytes and is a primary trigger of acute post-traumatic neuronal death. To test the hypothesis that adrenergic receptor agonists, including the stress stimulus epinephrine protects neural parenchyma from damage, we characterized its effects on hypotonicity-induced cellular edema in cortical astrocytes by in vivo and in vitro imaging. After epinephrine administration, hypotonicity-induced swelling of astrocytes was markedly reduced and cytosolic 3'-5'-cyclic adenosine monophosphate (cAMP) was increased, as shown by a fluorescence resonance energy transfer nanosensor. Although, the kinetics of epinephrine-induced cAMP signaling was slowed in primary cortical astrocytes exposed to hypotonicity, the swelling reduction by epinephrine was associated with an attenuated hypotonicity-induced cytosolic Ca(2+) excitability, which may be the key to prevent astrocyte swelling. Furthermore, in a rat model of spinal cord injury, epinephrine applied locally markedly reduced neural edema around the contusion epicenter. These findings reveal new targets for the treatment of cellular edema in the central nervous system.

The effect of changing the built environment on physical activity: a quantitative review of the risk of bias in natural experiments.

BACKGROUND: Evidence regarding the association of the built environment with physical activity is influencing policy recommendations that advocate changing the built environment to increase population-level physical activity. However, to date there has been no rigorous appraisal of the quality of the evidence on the effects of changing the built environment. The aim of this review was to conduct a thorough quantitative appraisal of the risk of bias present in those natural experiments with the strongest experimental designs for assessing the causal effects of the built environment on physical activity. METHODS: Eligible studies had to evaluate the effects of changing the built environment on physical activity, include at least one measurement before and one measurement of physical activity after changes in the environment, and have at least one intervention site and non-intervention comparison site. Given the large number of systematic reviews in this area, studies were identified from three exemplar systematic reviews; these were published in the past five years and were selected to provide a range of different built environment interventions. The risk of bias in these studies was analysed using the Cochrane Risk of Bias Assessment Tool: for Non-Randomized Studies of Interventions (ACROBAT-NRSI). RESULTS: Twelve eligible natural experiments were identified. Risk of bias assessments were conducted for each physical activity outcome from all studies, resulting in a total of fifteen outcomes being analysed. Intervention sites included parks, urban greenways/trails, bicycle lanes, paths, vacant lots, and a senior citizen's centre. All outcomes had an overall critical (n = 12) or serious (n = 3) risk of bias. Domains with the highest risk of bias were confounding (due to inadequate control sites and poor control of confounding variables), measurement of outcomes, and selection of the reported result. CONCLUSIONS: The present review focused on the strongest natural experiments conducted to date. Given this, the failure of existing studies to adequately control for potential sources of bias highlights the need for more rigorous research to underpin policy recommendations for changing the built environment to increase physical activity. Suggestions are proposed for how future natural experiments in this area can be improved.

ECD kidney transplantation outcomes are improved when matching donors to recipients using a novel creatinine clearance match ratio (CCMR).

Improved outcomes have been associated with various methods of size matching between expanded criteria (ECD) donors and recipients. A novel method for improved functional based matching was developed utilizing manipulation of Cockcroft-Gault estimated creatinine clearances for donor and recipient. We hypothesized that optimal clearance-based matches would have superior outcomes for both immediate graft function and long-term graft survival. For the analysis, recipients of ECD kidneys in the Scientific Registry of Transplant Recipients (SRTR) transplanted between October 1, 1987 and August 31, 2011 were included. Univariate and multivariate analyses predicted the hazard ratio of graft failure and the odds ratio of requiring dialysis within the first week. A total of 25,640 ECD kidney transplants were analyzed. On multivariate analysis, higher creatinine clearance match ratio (CCMR) was associated with increased graft failure and odds of requiring dialysis within the first week (comparing highest ratio quintile versus lowest ratio quintile: HR 1.43, p < 0.001; OR 2.08, p < 0.001). This study suggests that ECD kidneys have improved outcomes when the recipient/donor CCMR is optimized.

Cholecystostomy offers no survival benefit in patients with acute acalculous cholecystitis and severe sepsis and shock.

BACKGROUND: Acute acalculous cholecystitis is often managed with cholecystectomy or cholecystostomy, but data guiding surgical practice are lacking. MATERIALS AND METHODS: Longitudinal analysis of the California Office of Statewide Health Planning and Development Patient Discharge Data was performed from 1995-2009. Patients with acute acalculous cholecystitis were identified by International Classification of Diseases 9 code. Cox proportional hazard analysis found predictors of time to death, adjusting for patient demographics, sepsis, shock, frailty, Charlson comorbidity index, length of stay, insurance status, teaching hospital status, and year. RESULTS: Of 43,341 patients, 63.5% received a cholecystectomy, 2.8% received a cholecystostomy, and 1.2% received both. Overall, 30.4% of patients died, with higher mortality among patients with cholecystostomy (61.7%) or no procedure (42.0%) than cholecystectomy (23.0%). In patients with severe sepsis and shock, there was no difference in survival of patients with cholecystostomy versus no intervention (hazard ratio [HR] 1.13, P = 0.256), although patients with cholecystectomy (with or without prior cholecystostomy) had improved survival (HR 0.29, P < 0.001; HR 0.56, P < 0.001). Results were similar among patients on the ventilator >96 h. CONCLUSIONS: Although cholecystostomy offered no survival benefit for patients with severe sepsis and shock, cholecystectomy offered improved survival compared with patients without surgical management. Cholecystostomy may not benefit the sickest patients in whom cholecystectomy may never be considered.

An efficient risk adjustment model to predict inpatient adverse events after surgery.

BACKGROUND: Risk adjustment is an important component of surgical outcomes and quality analyses. Current models include numerous preoperative variables; however, the relative contribution of these variables may be limited. This research seeks to identify a model with the fewest number of variables necessary to perform an adequate risk adjustment to predict any inpatient adverse event for use in resource-limited settings. METHODS: All patients from the National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2010 were included. Outcomes were inpatient mortality or any surgical complication captured by NSQIP. Models were built by sequential addition of preoperative risk variables selected by their area under the receiver operator characteristic curve (AUC). RESULTS: Among 863,349 patients, the single variable with the highest AUC was American Society of Anesthesiologists (ASA) classification (AUC = 0.7127). AUC values reached 0.7923 with five variables (ASA classification, wound classification, functional status prior to surgery, albumin, and age) and 0.7945 with six variables. The sixth variable was one of the following: alkaline phosphatase, weight loss, principal anesthesia technique, gender, or emergency status. The model with the highest discrimination that did not require laboratories included ASA classification, functional status prior to surgery, wound classification, and age (AUC = 0.7810). Including all 66 preoperative variables produced little additional gain (AUC = 0.8006). CONCLUSIONS: Six variables are sufficient to develop a risk adjustment tool for inpatient surgical mortality and morbidity. This research has important implications for the field of surgical outcomes research by improving efficiency of data collection. This limited model can aid the expansion of risk-adjusted analyses to resource-limited settings worldwide.