Comparison of predictive equations and indirect calorimetry in critical care: Does the accuracy differ by body mass index classification?

BACKGROUND: Nutrition support professionals are tasked with estimating energy requirements for critically ill patients. Estimating energy leads to suboptimal feeding practices and adverse outcomes. Indirect calorimetry (IC) is the gold standard for determining energy expenditure. However, access is limited, so clinicians must rely on predictive equations. METHODS: A retrospective chart review of critically ill patients who underwent IC in 2019 was conducted. The Mifflin-St Jeor equation (MSJ), Penn State University equation (PSU), and weight-based nomograms were calculated using admission weights. Demographic, anthropometric, and IC data were extracted from the medical record. Data were stratified by body mass index (BMI) classifications, and relationships between estimated energy requirements and IC were compared. RESULTS: Participants (N = 326) were included. Median age was 59.2 years, and BMI was 30.1. The MSJ and PSU were positively correlated with IC in all BMI classes (all P < 0.001). Median measured energy expenditure was 2004 kcal/day, which was 1.1-fold greater than PSU, 1.2-fold greater than MSJ, and 1.3-fold greater than weight-based nomograms (all P < 0.001). CONCLUSION: Despite the significant relationships between measured and estimated energy requirements, the significant fold-differences suggest that using predictive equations leads to significant underfeeding, which may result in poor clinical outcomes. Clinicians should rely on IC when available, and increased training in the interpretation of IC is warranted. In the absence of IC, the use of admission weight in weight-based nomograms could serve as a surrogate, as these calculations provided the closest estimate to IC in participants with normal weight and overweight, but not obesity.

"Delayed-Immediate" Hernia Repairs in Infected Wounds: Clinical and Economic Outcomes.

BACKGROUND: Wound class in hernia repairs impacts surgical technique and outcomes. Hernia recurrence and complications are high when dirty wounds are treated in one stage. We hypothesize patients who undergo intentionally staged repairs are less likely to have adverse outcomes and associated costs. METHODS: Patients were identified by retrospective chart review. Patient characteristics and outcome variables were collected. An economic analysis of cost variables was performed using medical records and published meta-analyses. RESULTS: There were 8 patients in the staged repairs group and 10 patients in the control group. Length of stay was 14.9 days (±8.8), and 8.7 days (±6.4), respectively. Rate of hernia recurrence within 1 year was 14.3% and 37.5%. Rate of mesh infection at 30 days was 0% and 10%. Compared to controls, delayed-immediate repairs had a nearly 2-fold index surgical cost. DISCUSSION: Although there is an increased cost associated with delayed-immediate repairs, this cost may be offset by the decreased infection, seroma, dehiscence, enterocutaneous fistula formation, and hernia recurrence rate that necessitates future interventions. Further data collection is required to determine if clinical and economic benefit is seen long-term.

Optimizing Perioperative Fluid Management in Complex Abdominal Wall Reconstruction to Prevent Postoperative Acute Kidney Injury.

BACKGROUND: Acute kidney injury (AKI) is a serious postoperative complication of abdominal wall reconstruction that can significantly impact outcomes of these patients. This study examines AKI following abdominal wall hernia repair to determine incidence and risk factors and outline potential mitigation strategies. METHODS: Using a single institution IRB-approved prospective database, patients undergoing complex abdominal wall reconstruction from 2013 to 2021 were identified. Patients with AKI were compared to controls and preoperative and intraoperative characteristics were evaluated. Multivariate analysis was utilized to identify factors associated with development of AKI. RESULTS: 297 patients were reviewed, 21.2 % (n = 63 patients) had AKI. Patients with AKI had a greater decrease in postoperative GFR to preoperative GFR (40.5% vs 18.3%, p <0.0001). Factors associated with AKI included ASA score >2 (odds ratio (OR) = 2.10, [1.50; 5.12], p = 0.02), HTN (OR = 2.05, [1.05; 4.0], p = 0.04), higher baseline Cr (OR = 5.98, [2.56; 13.98], p <0.0001), and diabetes (OR = 0.135, [0.0275; 0.666], p = 0.01). Operative time was longer in patients who developed AKI [average 400 min (range: 278-510 min) vs 310 min (range: 260-374 min), p = 0.04] and was an independent predictor of developing AKI (OR = 319.59, [137.25; 744.65], p <0.0001). DISCUSSION: Preoperative identification of patients with medical comorbidities undergoing elective complex abdominal wall reconstruction continues to be imperative to improve outcomes. This study demonstrates that perioperative management for high risk patients requires flexibility, including potential adjustments to enhanced recovery after surgery protocols in order to adequately address the risks for AKI.

Comparing Opioid Usage in Non-Intensive Care Unit Trauma Patients After Implementing Multimodal Analgesia Order Sets.

INTRODUCTION: Opioid addiction frequently occurs after exposure to prescribed pain medications. Trauma patients are likely to receive opioids due to injuries and surgeries resulting in high levels of pain. Multimodal analgesia has been shown to decrease opioid consumption postoperatively. A multimodal analgesia order set was implemented with the goal of increasing prescription of multimodal analgesia contributing to decreased overall opioid use. We hypothesized that the multimodal order set would be associated with significantly less opioid utilization without affecting pain scores. METHODS: This single-center retrospective cohort analysis included non-intensive care unit trauma patients. Patients were propensity-matched by the year of treatment. Oral morphine equivalents and pain scores were compared before and after implementation of the order set. The primary objective was to evaluate differences in oral morphine equivalents 24 h prior to discharge before and after implementation of the multimodal analgesia order sets. RESULTS: One hundred and fourteen patients in the preimplementation group and 121 patients in the postimplementation group met inclusion criteria. Oral morphine equivalents did not differ significantly between the cohorts, 21.3 [0-53.5] OME in 2018 versus 18.8 [0-56.3] in 2020 (P = 0.85). Pain scores 24 h prior to discharge, 6 [4-8] versus 5.7 [3.5-7] (P = 0.4), did not differ significantly between groups despite more operations in the 2020 cohort. CONCLUSIONS: Implementation of a multimodal order set was not associated with significant reduction in the amount of opioids used in non-intensive care unit trauma patients. However, pain scores were unchanged despite an increased number of procedures performed suggesting that multimodal analgesia sets may be a useful tool to aid in decreasing opioid utilization after traumatic injuries.

Building a Center for Abdominal Core Health: The Importance of a Holistic Multidisciplinary Approach.

BACKGROUND: This article seeks to be a collection of evidence and experience-based information for health care providers around the country and world looking to build or improve an abdominal core health center. Abdominal core health has proven to be a chronic condition despite advancements in surgical technique, technology, and equipment. The need for a holistic approach has been discussed and thought to be necessary to improve the care of this complex patient population. METHODS: Literature relevant to the key aspects of building an abdominal core health center was thoroughly reviewed by multiple members of our abdominal core health center. This information was combined with our authors' experiences to gather relevant information for those looking to build or improve a holistic abdominal core health center. RESULTS: An abundance of publications have been combined with multiple members of our abdominal core health centers members experience's culminating in a wide breadth of information relevant to those looking to build or improve a holistic abdominal core health center. CONCLUSIONS: Evidence- and experience-based information has been collected to assist those looking to build or grow an abdominal core health center.

Traumatic Brain Injury Causes Chronic Cortical Inflammation and Neuronal Dysfunction Mediated by Microglia.

Traumatic brain injury (TBI) can lead to significant neuropsychiatric problems and neurodegenerative pathologies, which develop and persist years after injury. Neuroinflammatory processes evolve over this same period. Therefore, we aimed to determine the contribution of microglia to neuropathology at acute [1 d postinjury (dpi)], subacute (7 dpi), and chronic (30 dpi) time points. Microglia were depleted with PLX5622, a CSF1R antagonist, before midline fluid percussion injury (FPI) in male mice and cortical neuropathology/inflammation was assessed using a neuropathology mRNA panel. Gene expression associated with inflammation and neuropathology were robustly increased acutely after injury (1 dpi) and the majority of this expression was microglia independent. At 7 and 30 dpi, however, microglial depletion reversed TBI-related expression of genes associated with inflammation, interferon signaling, and neuropathology. Myriad suppressed genes at subacute and chronic endpoints were attributed to neurons. To understand the relationship between microglia, neurons, and other glia, single-cell RNA sequencing was completed 7 dpi, a critical time point in the evolution from acute to chronic pathogenesis. Cortical microglia exhibited distinct TBI-associated clustering with increased type-1 interferon and neurodegenerative/damage-related genes. In cortical neurons, genes associated with dopamine signaling, long-term potentiation, calcium signaling, and synaptogenesis were suppressed. Microglial depletion reversed the majority of these neuronal alterations. Furthermore, there was reduced cortical dendritic complexity 7 dpi, reduced neuronal connectively 30 dpi, and cognitive impairment 30 dpi. All of these TBI-associated functional and behavioral impairments were prevented by microglial depletion. Collectively, these studies indicate that microglia promote persistent neuropathology and long-term functional impairments in neuronal homeostasis after TBI.SIGNIFICANCE STATEMENT Millions of traumatic brain injuries (TBIs) occur in the United States alone each year. Survivors face elevated rates of cognitive and psychiatric complications long after the inciting injury. Recent studies of human brain injury link chronic neuroinflammation to adverse neurologic outcomes, suggesting that evolving inflammatory processes may be an opportunity for intervention. Here, we eliminate microglia to compare the effects of diffuse TBI on neurons in the presence and absence of microglia and microglia-mediated inflammation. In the absence of microglia, neurons do not undergo TBI-induced changes in gene transcription or structure. Microglial elimination prevented TBI-induced cognitive changes 30 d postinjury (dpi). Therefore, microglia have a critical role in disrupting neuronal homeostasis after TBI, particularly at subacute and chronic timepoints.

Stop Flying the Patients! Evaluation of the Overutilization of Helicopter Transport of Trauma Patients.

INTRODUCTION: Helicopter transport is a resource intensive and expensive method for transportation of patients by helicopter. The primary objective of this study was to evaluate the appropriateness of helicopter transport determined by procedural care within 1-h of transfer at an urban level I trauma center. METHODS: All trauma patients transported by helicopter from January 2015-December 2017 to an urban level I trauma center from referring hospitals or the scene were retrospectively analyzed. A subgroup analysis was performed evaluating patients that required a procedure or operation within 1-h of transport compared with the remainder of the patient cohort who were transported via helicopter. RESULTS: A total of 1590 patients were transported by helicopter. Thirty-nine percent of patients (n = 612) were admitted directly to the floor from the trauma bay and 16% (n = 249) of patients required only observation or were discharged home after helicopter transfer. Approximately one-third of the entire study cohort (36%, n = 572) required any procedure, with a median time to procedure of 31.5 h (interquartile range 54.4). Only 13% (n = 74) required a procedure within 1-h of helicopter transport. The average distance (in miles) if the patient had been driven by ground transport rather than helicopter was 67.0 miles (SD ± 27.9) and would take an estimated 71.5 min (±28.4) for patients who required a procedure within 1-h compared with 61.6 miles (SD ± 30.9) with an estimated 66.1 min (SD ± 30.8) for the remainder of the cohort (P value 0.899 and 0.680, respectively). CONCLUSIONS: This analysis demonstrates that helicopter transport was not necessary for the vast majority of trauma patients transported via helicopter.

Comparison between midline and lateral fluid percussion injury in mice reveals prolonged but divergent cortical neuroinflammation.

Animal models are critical for determining the mechanisms mediating traumatic brain injury-induced (TBI) neuropathology. Fluid percussion injury (FPI) is a widely used model of brain injury typically applied either midline or parasagittally (lateral). Midline FPI induces a diffuse TBI, while lateral FPI induces both focal cortical injury (ipsilateral hemisphere) and diffuse injury (contralateral hemisphere). Nonetheless, discrete differences in neuroinflammation and neuropathology between these two versions of FPI remain unclear. The purpose of this study was to compare acute (4-72 h) and subacute (7 days) neuroinflammatory responses between midline and lateral FPI. Midline FPI resulted in longer righting reflex times than lateral FPI. At acute time points, the inflammatory responses to the two different injuries were similar. For instance, there was evidence of monocytes and cytokine mRNA expression in the brain with both injuries acutely. Midline FPI had the highest proportion of brain monocytes and highest IL-1ß/TNFα mRNA expression 24 h later. NanoString nCounter analysis 7 days post-injury revealed robust and prolonged expression of inflammatory-related genes in the cortex after midline FPI compared to lateral FPI; however, Iba-1 cortical immunoreactivity was increased with lateral FPI. Thus, midline and lateral FPI caused similar cortical neuroinflammatory responses acutely and mRNA expression of inflammatory genes was detectable in the brain 7 days later. The primary divergence was that inflammatory gene expression was greater and more diverse subacutely after midline FPI. These results provide novel insight to variations between midline and lateral FPI, which may recapitulate unique temporal pathogenesis.

Combating the Opioid Epidemic in Acute General Surgery: Reframing Inpatient Acute Pain Management.

BACKGROUND: The devastating effects of the opioid epidemic are well documented. We implemented a surgeon/pharmacist opioid reduction initiative at an academic medical center that incorporated multimodal pain therapy in an attempt to reduce total inpatient opioids prescribed. We hypothesized that less opioids would be used postoperatively without affecting pain scores or length of stay. METHODS: This single-center observational cohort analysis included patients admitted to the acute general surgical service and had one of 10 emergent general surgical (nontrauma) procedures. Patients who underwent surgery before the opioid reduction initiative were compared with patients who underwent surgery postinitiative. The primary objective was to evaluate differences in daily oral morphine equivalents and average pain scores in patients before and after implementation of the surgeon/pharmacist initiative. RESULTS: Eighty-three patients in the preopioid reduction initiative group and 92 patients in the postopioid reduction initiative group met inclusion criteria. Oral morphine equivalents were significantly different at 24 h before discharge when comparing across both year (P = 0.032) and number of procedures (P = 0.013). Our results showed decreased opioid utilization in the postopioid reduction initiative group on all observed postoperative days with unaffected pain scores. CONCLUSIONS: An opioid reduction initiative showed promise in lowering the number of opioids used during inpatient admission without affecting pain scores in emergent general surgical procedures. This initiative can be easily reproduced at other institutions to help combat the opioid epidemic.

Modeling Human Cancer-induced Cachexia.

Cachexia is a wasting syndrome characterized by pronounced skeletal muscle loss. In cancer, cachexia is associated with increased morbidity and mortality and decreased treatment tolerance. Although advances have been made in understanding the mechanisms of cachexia, translating these advances to the clinic has been challenging. One reason for this shortcoming may be the current animal models, which fail to fully recapitulate the etiology of human cancer-induced tissue wasting. Because pancreatic ductal adenocarcinoma (PDA) presents with a high incidence of cachexia, we engineered a mouse model of PDA that we named KPP. KPP mice, similar to PDA patients, progressively lose skeletal and adipose mass as a consequence of their tumors. In addition, KPP muscles exhibit a similar gene ontology as cachectic patients. We envision that the KPP model will be a useful resource for advancing our mechanistic understanding and ability to treat cancer cachexia.

Discharge disposition to skilled nursing facility after emergent general surgery predicts a poor prognosis.

BACKGROUND: Emergency general surgery can have a profound impact on the functional status of even previously independent patients. The role and influence of discharging a patient to a skilled nursing facility, however, remains largely unknown. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program for community-dwelling adults who underwent 1 of 7 emergency general surgery procedures and were discharged home or to a skilled nursing facility from 2012 to 2016. Propensity score matching and multivariable regression analyses were performed to determine the relationship between discharge disposition and outcomes. RESULTS: Overall, 140,922 patients met the inclusion criteria. The majority were discharged home (95.9%). After applying 1:1 propensity score matching, in comparison to patients discharged home, individuals discharged to a skilled nursing facility had a greater odds of respiratory (odds ratio 2.32; 95% confidence interval, 1.59-3.38) and septic complications (odds ratio 1.63, 95% confidence interval 1.12-2.36) after discharge. Furthermore, following surgery, individuals discharged to a skilled nursing facility had a greater odds of 30-day readmission (odds ratio 1.14; 95% confidence interval, 1.01-1.29), and death within 30 days of the procedure (odds ratio 2.07; 95% confidence interval, 1.65-2.61). CONCLUSION: After accounting for patient severity and perioperative course, discharge to a skilled nursing facility is an independent risk factor for death, readmission, and postdischarge complications.

Complications after vascularized jejunal mesenteric lymph node transfer: A 3-year experience.

BACKGROUND: Vascularized lymph node transfer (VLNT) is a well-established method for the surgical management of refractory extremity lymphedema. Generally, donor lymph nodes are harvested from the axilla, groin, or supraclavicular area. However, these sites offer their own disadvantages and introduce risk for inducing lymphedema at the surgical donor site. In our experience, the jejunal mesentery can be an excellent source of lymph nodes without the risk of donor site lymphedema. Long term complications are unknown for this procedure; we report our experience, complication rates, and lessons learned. METHODS: A retrospective review was performed for all patients at our institution undergoing surgical treatment of lymphedema using jejunal mesenteric VLNT from February 2015 to February 2018. Demographic data, length of follow up, and surgical complications were reviewed. RESULTS: Twenty-nine patients have undergone jejunal VLNT at our institution during the three-year study period, with a total of 30 transfers. Five patients had a concurrent omental lymph node transfer. Average length of follow up was 17.6 months (range 1.0-36.8 months). There was one flap loss in this time frame (3.3%). Four patients developed hernias post-operatively (13.8%), and three had nonoperative small bowel obstructions (10.3%). One patient had a postoperative wound infection at the abdominal incision (3.4%). CONCLUSIONS: Jejunal VLNT can be an effective option for surgical treatment of lymphedema, without the risk of postoperative donor site lymphedema. Patients and surgeons should be aware of the risks of hernia and small bowel obstruction with this method compared to other lymph node sources.

Evaluation of Rectal Vancomycin Irrigation for Treatment of Clostridioides difficile Infection in Patients Post-Colectomy for Toxic Colitis.

Background: Clostridioides difficile infection (CDI) accounts for as many as 25% of episodes of antibiotic-associated diarrhea and is the most common cause of healthcare-associated diarrhea. Rectal vancomycin irrigation is a therapy option; however, evidence is limited for its value post-colectomy. The objective of this study was to describe outcomes of patients who underwent total colectomy for fulminant C. difficile colitis and received rectal vancomycin post-operatively. Methods: This was a single-center retrospective chart review of adult patients who underwent total colectomy for fulminant CDI. Efficacy outcomes were all-cause in-hospital death, intensive care unit (ICU) and hospital length of stay, ventilator-free days at day 28 post-procedure, development of proctitis or pseudomembranes, need for re-initiation of CDI therapy, and normalization of infectious signs and symptoms at completion of CDI therapy. The primary safety outcome was the incidence of rectal stump blowout. Results: Of the 50 patients included, 38 (76%) received treatment with rectal vancomycin at the discretion of the surgeon. The Sequential Organ Failure Assessment score on the day of the procedure was higher in the rectal vancomycin group; however, this difference did not reach statistical significance. No difference was observed between the groups in the primary outcome of all-cause death. There was no significant difference between the groups for hospital length of stay, but there was a trend toward longer ICU length of stay for patients who received rectal vancomycin (9.5 days vs. 2.5 days; p = 0.05). No differences in the remaining secondary efficacy outcomes were observed. No episodes of rectal stump blowout were observed in either group. Conclusions: This study aimed to add to the limited data on the use of rectal vancomycin irrigation post-colectomy for toxic C. difficile colitis. Although our results do not support routine use of rectal vancomycin irrigation, they suggest that this therapy is not harmful if providers are considering its use for severe infections refractory to alternative treatment.

µImpact of a nursing-driven sedation protocol with criteria for infusion initiation in the surgical intensive care unit.

PURPOSE: Analgesia and sedation protocols (ASPs) reduce duration of mechanical ventilation (MV) in the medical intensive care unit (ICU), but data in the surgical ICU (SICU) are limited. The objective of this study was to determine the impact of a nursing-driven ASP with criteria for infusion initiation in the SICU. MATERIALS AND METHODS: A single-center, retrospective study compared ventilator-free days at day 28 from start of MV (VFD28) before and after ASP implementation. Secondary endpoints included cumulative opioid and sedative requirements, level of sedation, incidence of delirium, SICU and hospital length of stay. RESULTS: One hundred thirty two patients were included (66 per group). The protocol group had greater VFD28 compared to the control group (21 vs. 14.5 days, p = .04). Lower rates of benzodiazepine (42.4% vs. 84.8%, p < .001) and opioid (24.2 vs. 78.8, p < .001) infusion use occurred in the protocol group, resulting in lower cumulative doses per ventilator-day through day 7. The protocol group had more documented sedation scores within target range. There were no differences in ICU delirium, SICU or hospital length of stay. CONCLUSIONS: A nursing-driven ASP with criteria for infusion initiation in mechanically-ventilated SICU patients may increase ventilator-free time, maintain patients at the target sedation goal, and reduce opioid and benzodiazepine utilization.

Traumatic brain injury-induced neuronal damage in the somatosensory cortex causes formation of rod-shaped microglia that promote astrogliosis and persistent neuroinflammation.

Microglia undergo dynamic structural and transcriptional changes during the immune response to traumatic brain injury (TBI). For example, TBI causes microglia to form rod-shaped trains in the cerebral cortex, but their contribution to inflammation and pathophysiology is unclear. The purpose of this study was to determine the origin and alignment of rod microglia and to determine the role of microglia in propagating persistent cortical inflammation. Here, diffuse TBI in mice was modeled by midline fluid percussion injury (FPI). Bone marrow chimerism and BrdU pulse-chase experiments revealed that rod microglia derived from resident microglia with limited proliferation. Novel data also show that TBI-induced rod microglia were proximal to axotomized neurons, spatially overlapped with dense astrogliosis, and aligned with apical pyramidal dendrites. Furthermore, rod microglia formed adjacent to hypertrophied microglia, which clustered among layer V pyramidal neurons. To better understand the contribution of microglia to cortical inflammation and injury, microglia were eliminated prior to TBI by CSF1R antagonism (PLX5622). Microglial elimination did not affect cortical neuron axotomy induced by TBI, but attenuated rod microglial formation and astrogliosis. Analysis of 262 immune genes revealed that TBI caused profound cortical inflammation acutely (8 hr) that progressed in nature and complexity by 7 dpi. For instance, gene expression related to complement, phagocytosis, toll-like receptor signaling, and interferon response were increased 7 dpi. Critically, these acute and chronic inflammatory responses were prevented by microglial elimination. Taken together, TBI-induced neuronal injury causes microglia to structurally associate with neurons, augment astrogliosis, and propagate diverse and persistent inflammatory/immune signaling pathways.

Improving the mortality index by capturing patient acuity through interprofessional real-time documentation improvement in a single hospital system.

BACKGROUND: The observed to expected mortality ratio is a standardized way for reporting inpatient mortality and is used as a measure for hospital quality rankings and Centers for Medicare & Medicaid Services value-based payments. The goal of this study is to describe a single institution's mortality index improvement initiative through improved documentation of patient severity. METHODS: Data were prospectively collected October 2016 through May 2017 on patients discharged from the acute care surgery, open heart surgery, neurosurgery, and University Hospital East. Mortalities were reviewed by a multidisciplinary committee for missed coding opportunities. These captured codes were adjusted based on the Vizient risk-adjustment model for mortality and the observed to expected mortality ratio was calculated. RESULTS: Every service reviewed showed improvement in the expected mortality rate. Additional coding opportunities were present in 55.6% of acute care surgery, 24.3% of neurosurgery, 18.3% of open heart surgery, and 35.3% of University Hospital East cases. A total of 70 codes were improved during the 8-month period. The acute care surgery service showed the most improvement, with a 0.45 improvement in the observed to expected mortality ratio, followed by neurosurgery, with 0.43 improvement. CONCLUSION: Institutional observed to expected mortality ratio can be improved by targeting high-acuity services and capturing coding opportunities, leading to improvement in value-based payments and rankings.

Mesoappendix as potential donor site for vascularized lymph node transfer: anatomic study.

BACKGROUND: The standard of care for treatment of lymphedema is manual lymphatic drainage and compression therapy, which is time intensive and requires a life-long commitment. Autologous lymph node transfer is a microsurgical treatment in which a vascularized lymph node flap is harvested with its blood supply and transferred to the lymphedematous region to assist with lymph fluid clearance. An ideal donor lymph node site minimizes the risk of iatrogenic lymphedema and other donor site morbidity. To address this, we have used jejunal mesentery lymph nodes and omental flaps and hypothesize that the mesoappendix, as a "spare part," may be an ideal autologous lymph node transfer donor site. METHODS: In this Institutional Review Board-approved study, 25 mesoappendix pathology specimens resected for benign disease underwent gross pathologic examination for the presence of lymph nodes and measurement of the appendicular artery and vein caliber and length. RESULTS: A single lymph node was present in two of 25 specimens (8%). Mean arterial and vein calibers at the point of ligation were 0.87 ± 0.44 mm and 0.86 ± 0.48 mm (range 0.30-2.2 mm and 0.25-2.2 mm), respectively. Mean arterial and vein length was 1.70 ± 1.06 cm and 1.84 ± 1.09 cm (range 0.8-4.5 cm for each), respectively. CONCLUSIONS: The mesoappendix rarely contains a lymph node. The artery and vein calibers of 46% of the specimens were greater than 0.8 mm, the minimum caliber preferred for microsurgical anastomosis. If transplantation of a vascularized lymph node for the treatment of lymphedema is desired, the mesoappendix is inconsistent in providing adequate lymph nodes.

Daily review of AHRQ patient safety indicators has important impact on value-based purchasing, reimbursement, and performance scores.

BACKGROUND: The Patient Safety Indicators (PSIs) Composite (PSI 90) of the Agency for Healthcare Research and Quality has been found to have low positive predictive values. Because scores can affect hospital reimbursement and ranking, our institution designed a review process to ensure accurate data and incur minimal penalties under the Hospital Value-Based Purchasing Program. METHODS: A multidisciplinary team was assembled to review PSI 90 within a performance period. The positive predictive value of each PSI was calculated. Weight-adjusted PSI rates were used to recalculate the PSI 90 Performance Period Index Value (PPIV). The adjusted PPIV was used to estimate what the achievement points and financial impact would have been if PSI review had not been implemented. Differences in PPIV, achievement points, and financial impact before and after PSI review were calculated. RESULTS: A total of 1,470 cases were flagged for PSI over a 2-year period. The positive predictive value was 63.3%. Refuting 36.7% of PSIs resulted in a decrease in the PPIV from 0.696 to 0.508, an increase in achievement points from 5 to 10, resulting in a decreased net loss of $111,773. CONCLUSION: Multidisciplinary review processes are practical and effective in identifying false-positive patient safety events. The real-time process affects hospital performance and resultant Medicare reimbursement substantially.

Vascularized Jejunal Mesenteric Lymph Node Transfer: A Novel Surgical Treatment for Extremity Lymphedema.

BACKGROUND: Vascularized lymph node transfer (VLNT) is a surgical treatment for lymphedema. Multiple donor sites have been described and each has significant disadvantages. We propose the jejunal mesentery as a novel donor site for VLNT. STUDY DESIGN: We performed a cadaveric anatomic study analyzing jejunal lymph nodes (LNs) and describe outcomes from the first patients who received jejunal mesenteric VLNT for treatment of lymphedema. RESULTS: In 5 cadavers, the average numbers of total LNs and peripheral LNs were identified in the proximal, middle, and distal segments of jejunum. Totals counted were 19.2/13.8/9.6, (SD 7.0/4.4/1.1), respectively; of those, 10.4/6.8/3.4 (SD 3.6/2.3/2.6), respectively, were in the periphery. There were significantly more total and peripheral lymph nodes in the proximal segment compared with the middle and distal segments (p = 0.027 and p = 0.008, respectively). The jejunal VLNT was used in 15 patients for treatment of upper (n = 8) or lower (n = 7) extremity lymphedema. Average follow-up was 9.1 (±6.4) months (range 1 to 19 months). Of 14 patients with viable flaps (93.3%), 12 had subjective improvement (87.5%). Ten patients had preoperative measurements, and of those, 7 had objective improvement in lymphedema (70%). CONCLUSIONS: The jejunal mesenteric VLNT is an excellent option for lymphedema treatment because there is no risk of donor site lymphedema or nerve damage, and the scar is easily concealed. Harvest from the periphery of the proximal jejunum is optimal. Improvement from lymphedema can be expected in a majority of patients.