Same day discharge in colorectal surgery: Who requires unplanned overnight monitoring?

BACKGROUND: Enhanced Recovery After Surgery protocols and minimally invasive surgery have decreased colorectal length of stay. Our institution implemented a Same Day Discharge (SDD) colorectal protocol, and this study evaluates factors associated with unplanned admission. METHODS: . Retrospective review was performed from February 2019 to January 2022. Admitted SDD candidates were identified, and their course evaluated. Demographics, clinical characteristics, and outcomes were compared between cohorts. RESULTS: Review identified 152 potential SDD patients, 47 successfully discharged. Of the 105 admitted patients, the most common reasons were operative complexity (47.6 â€‹%) and social reasons (23.8 â€‹%). No differences were seen in operative times, gender, BMI, anticoagulation, or diabetes. The admission cohort was more likely to undergo low anterior resection or right colectomy and was older in age. Case complexity was the highest factor for affecting discharge. CONCLUSION: SDD can be feasible after colectomy, but in certain patients may require deviation. The most common factors requiring admission were complexity and social factors.

Hypothermia and the Global War on Terror: 18 Years of Minimal Progress.

INTRODUCTION: The association between hypothermia, coagulopathy, and acidosis in trauma is well described. Hypothermia mitigation starts in the prehospital setting; however, it is often a secondary focus after other life-saving interventions. The deployed environment further compounds the problem due to prolonged evacuation times in rotary wing aircraft, resource limitations, and competing priorities. This analysis evaluates hypothermia in combat casualties and the relationship to resuscitation strategy with blood products. METHODS: Using the data from the Department of Defense Joint Trauma Registry from 2003 to 2021, a retrospective analysis was conducted on adult trauma patients. Inclusion criteria was arrival at the first military treatment facility (MTF) hypothermic (<95ºF). Study variables included: mortality, year, demographics, battle vs non-battle injury, mechanism, theater of operation, vitals, and labs. Subgroup analysis was performed on severely injured (15 < ISS < 75) hypothermic trauma patients resuscitated with whole blood (WB) vs only component therapy. RESULTS: Of the 69,364 patients included, 908 (1.3%) arrived hypothermic; the vast majority of whom (N = 847, 93.3%) arrived mildly hypothermic (90-94.9°F). Overall mortality rate was 14.8%. Rates of hypothermia varied by year from 0.7% in 2003 to 3.9% in 2014 (P <0.005). On subgroup analysis, mortality rates were similar between patients resuscitated with WB vs only component therapy; though base deficit values were higher in the WB cohort (-10 vs -6, P < 0.001). CONCLUSION: Despite nearly 20 years of combat operations, hypothermia continues to be a challenge in military trauma and is associated with a high mortality rate. Mortality was similar between hypothermic trauma patients resuscitated with WB vs component therapy, despite greater physiologic derangements on arrival in patients who received WB. As the military has the potential to conduct missions in environments where the risk of hypothermia is high, further research into hypothermia mitigation techniques and resuscitation strategies in the deployed setting is warranted.

Effects of Gynecomastia Surgery on Readiness and Return to Duty in an Active Duty Military Population.

INTRODUCTION: Simple mastectomies are routinely performed in the military health care system as gynecomastia can cause significant pain and discomfort when wearing body armor. Postoperative recovery negatively impacts personnel readiness. In this study, we sought to study time to return to duty in active duty service members who undergo surgery for gynecomastia. METHODS AND MATERIALS: We conducted a single-center retrospective review of active duty patients undergoing a surgical operation for gynecomastia from July 2020-June 2022. A total of 96 patients were included. Our primary outcome of interest was time from surgery to return to duty. A multivariate analysis was performed to assess for factors independently associated with surgical complications including patient demographics and operative techniques. RESULTS: The median number of days to return to duty after surgery was 28 days (IQR 13-37). The median loss of duty days because of gynecomastia without surgery was 19 days (IQR 10-21), which was different on the Mann-Whitney U test. Surgical complications were observed in 19 patients (19.7%) with the most common complications being seroma (11), hematoma (4), nipple-areolar complex necrosis (2), and infection (2). Patients with a complication have significantly more time to return to duty (28 vs. 49 days, P < .001). Risk factors associated with an increased risk of complication include ranks E1-E4, behavioral health diagnosis, "open" vs. "combined" technique with liposuction, length of operation greater than 58 minutes, and excised breast mass greater than 17.9 g. CONCLUSIONS: Gynecomastia surgery is associated with a detriment to personnel readiness. Surgery should be reserved for patients with severe symptoms that prevent the performance of daily duties. Furthermore, factors associated with an increased risk for complications include ranks E1-E5, behavioral health diagnosis, length of operation >58 minutes, and excised breast mass >17.9 g. The operating surgeon should be mindful of these factors.

Optimizing combat readiness for military surgeons without trauma fellowship training: Engaging the "voluntary faculty" model.

BACKGROUND: Appropriate operative volume remains a critical component in mitigating surgical atrophy and maintaining clinical competency. The initiation of military-civilian surgical partnerships (MCPs) has been proposed for addressing knowledge, skills, and abilities (KSA) metrics to address concerns over operational readiness and the low acuity experienced by military surgeons. This study investigates the first partnership for Navy surgical staff at a nonacademic Military Treatment Facility (MTF) with a regional academic Army Military Treatment Facility (AMTF) and a civilian, nonacademic level II trauma center devised to improve operational readiness for attending surgeons. We hypothesize that a skill sustainment MCP will allow military surgeons to meet combat readiness standards as measured by the KSA metric. METHODS: A memorandum of understanding was initiated between the Navy Military Treatment Facility (NMTF), the AMTF, and the level II civilian trauma center (CTC). The single military surgeon in this study was classified as "voluntary faculty" at the CTC. Total case volume and acuity were recorded over an 11-month period. Knowledge, skills, and abilities metrics were calculated using the standard national provider identifier number and the novel case-log based method. RESULTS: A total of 156 cases were completed by a single surgeon over the study period, averaging 52 cases per institution. Significantly more KSAs were obtained at the CTC compared with NMTF (5,954 vs. 2,707; p < 0.001). Significantly more emergent cases were observed at the CTC compared with the MTFs (χ 2 = 7.1, n = 96, p < 0.05). At a single site, AMTF, a significant difference in the calculated KSA score, was observed between the national provider identifier and case-log methods (5,278 vs. 3,297; p = 0.04). CONCLUSION: The skill sustainment MCP between NMTF and CTC increased surgical readiness and exposed surgeons to increased operative acuity. The voluntary faculty model reduces direct litigation exposure and encourages clinical competency for military surgeons while remaining a deployable asset to the global military effort. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Visually Evoked Response Differences to Contrast and Motion in Children with Autism Spectrum Disorder.

High-density electroencephalography (EEG) was used to examine the utility of the P1 event-related potential (ERP) as a marker of visual motion sensitivity to luminance defined low-spatial frequency drifting gratings in 16 children with autism and 16 neurotypical children. Children with autism displayed enhanced sensitivity to large, high-contrast low-spatial frequency stimuli as indexed by significantly shorter P1 response latencies to large vs. small gratings. The current study also found that children with autism had larger amplitude responses to large gratings irrespective of contrast. A linear regression established that P1 adaptive mean amplitude for large, high-contrast sinusoidal gratings significantly predicted hyperresponsiveness item mean scores on the Sensory Experiences Questionnaire for children with autism, but not for neurotypical children. We conclude that children with autism have differences in the mechanisms that underlie low-level visual processing potentially related to altered visual spatial suppression or contrast gain control.

Burden of chronic obstructive pulmonary disease in Medicare beneficiaries residing in long-term care facilities.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. COPD increases health care resource utilization and spending and adversely affects quality of life. Data from the clinical and economic outcomes in Medicare beneficiaries with COPD who reside in long-term care (LTC) facilities are limited. OBJECTIVE: The purpose of this study was to investigate the clinical and economic outcomes associated with COPD in Medicare beneficiaries residing in LTC facilities. METHODS: This retrospective cohort study analyzed data from MarketScan Medicaid, a large US administrative claims database containing data on Medicaid programs in 8 states. The study cohort comprised LTC facility residents aged > or =60 years who had a diagnosis of COPD. Eligible patients also had a prescription filled between January 1, 2003, and June 30, 2005, for one of the following COPD treatments: fluticasone propionate + salmeterol xinafoate, tiotropium bromide, ipratropium bromide, or ipratropium bromide + albuterol sulfate. The date of the first prescription fill was considered the index date. Measures of health care resource utilization included COPD-related and all-cause hospitalizations and emergency department (ED) visits. Cost analysis outcomes included COPD-related and all-cause inpatient, outpatient, pharmacy, LTC, and total costs during the 12-month postindex period. RESULTS: Data from 3037 patients were included (63.0% women; 82.2% white; mean [SD] age, 78.1 [10.0] years). A total of 43.3% of patients had > or =1 hospitalization; 90.0%, > or =1 ED visit. With the exception of age <70 years, age was associated with all-cause hospitalization (age 70-<75 years, hazard ratio [HR] = 1.31 [95% CI, 1.03-1.68]; age 75-<80 years, HR = 1.40 [95% CI, 1.11-1.78]; age > or =80 years, HR = 1.48 [95% CI, 1.19-1.85]). Age was not associated with COPD-related hospitalization, all-cause ED visits, or COPD-related ED visits. The risk for all-cause hospitalization in white patients was significantly lower compared with that in nonwhite patients (HR = 0.79 [95% CI, 0.69-0.91]). Patients with comorbid asthma had a higher risk for a COPD-related ED visit (HR = 1.34 [95% CI, 1.08-1.66]) than did patients without asthma. Preindex all-cause hospitalization was associated with COPD-related hospitalization (HR = 1.78 [95% CI, 1.49-2.14]) and all-cause hospitalization (HR = 2.05 [95% CI, 1.932.19]). Twelve-month COPD-related and all-cause direct expenditures per beneficiary were US $7391 and $48,183. In COPD-related and all-cause estimates, mean (SD) LTC costs were the largest cost components ($5629 [$12,562] and $32,966 [$14,871], respectively), followed by pharmacy costs ($956 [$957] and $5565 [$3873]), inpatient costs ($466 [$3393] and $6436 [$22,603]), and outpatient costs ($341 [$1793] and $3216 [$6458]). CONCLUSION: This study found that the utilization of health care resources and economic burden of LTC residents with COPD were primarily due to LTC, pharmacy, and inpatient costs.