Optimal Timing of Cholecystectomy for Acute Cholecystitis: A Retrospective Cohort Study.

Background Laparoscopic cholecystectomy performed less than 72 hours from hospital admission for acute cholecystitis has shown to decrease hospital cost without an increase in length of stay (LOS). Very few studies have examined clinical and cost outcomes of performing cholecystectomy less than 24 hours from hospital admission. The aim of this study was to examine the cost and LOS of laparoscopic cholecystectomy performed on an early (less than 24 hours from admission) and late (more than 24 hours from hospital admission) basis. Methods We performed a retrospective observational study of 569 patients at Baystate Medical Center, Springfield, USA, who underwent urgent laparoscopic cholecystectomy for acute cholecystitis between January 1, 2018 and February 28, 2020. We evaluated preoperative/postoperative LOS, operative duration, hospital cost, and patient complications. Results 468 patients underwent urgent laparoscopic cholecystectomy for acute cholecystitis during our study period. Early cholecystectomy (less than 24 hours from admission) had an overall decreased LOS (43.6 hours versus 102.9 hours, p-value < 0.01) and decreased hospital cost ($23,736.70 versus $30,176.40, p-value < 0.01) compared to late cholecystectomy (more than 24 hours from admission). There was also a significantly higher rate of bile leak in patients who underwent surgery more than 24 hours from hospital admission compared to those who had surgery less than 24 hours from admission (5.9% versus 0.4%, p-value < 0.01). Additionally, those procedures performed greater than 24 hours from hospital admission were significantly more likely to be converted to an open procedure (6.9% versus 2.2%, p-value = 0.02).  Conclusion Urgent laparoscopic cholecystectomy performed within 24 hours of hospital admission for acute cholecystitis decreased hospital cost, LOS, and operative complications in our institution's patient population. Our data suggests that performing laparoscopic cholecystectomy within 24 hours of hospital admission would be beneficial from a patient and hospital standpoint.

A Western Massachusetts hospital system's response to the COVID-19 pandemic.

OBJECTIVE: The objective of this paper was to outline a novel model created for the management of the critical care surge due to coronavirus disease 2019 (COVID-19) in a Western Massachusetts hospital. SETTING: This model was created and implemented at a Western Massachusetts Level 1 Trauma and tertiary referral center. CONCLUSIONS: This article outlines a model devised by an interdisciplinary team for rapid expansion of critical care services by increasing allocated space, staffing, and supplies via modifications of existing systems of care to accommodate a predicted large critical care patient surge due to the COVID-19 pandemic. We predict that this model can be utilized and adapted for future critical care surges in times of similar pandemic situations.

Prehospital Blood Product and Crystalloid Resuscitation in the Severely Injured Patient: A Secondary Analysis of the Prehospital Air Medical Plasma Trial.

OBJECTIVE: The aim of this study was to determine whether prehospital blood products reduce 30-day mortality in patients at risk for hemorrhagic shock compared with crystalloid only resuscitation. SUMMARY OF BACKGROUND DATA: Hemorrhage is the primary cause of preventable death after injury. Large volume crystalloid resuscitation can be deleterious. The benefits of prehospital packed red blood cells (PRBCs), plasma, or transfusion of both products among trauma patients is unknown compared with crystalloid. METHODS: Secondary analysis of the multicenter PAMPer trial was performed on hypotensive injured patients from the scene. The trial randomized 27 helicopter bases to prehospital plasma or standard resuscitation. Standard resuscitation at the sites was equally divided between crystalloid and crystalloid + PRBC. This led to 4 prehospital resuscitation groups: crystalloid only; PRBC; plasma; and PRBC+plasma. Cox regression determined the association between resuscitation groups and risk-adjusted 30-day mortality. The dose effect of resuscitation fluids was also explored. RESULTS: Four hundred seven patients were included. PRBC+plasma had the greatest benefit [hazard ratio (HR) 0.38; 95% confidence interval (95% CI) 0.26-0.55, P < 0.001], followed by plasma (HR 0.57; 95% CI 0.36-0.91, P = 0.017) and PRBC (HR 0.68; 95% CI 0.49-0.95, P = 0.025) versus crystalloid only. Mortality was lower per-unit of PRBC (HR 0.69; 95% CI 0.52-0.92, p = 0.009) and plasma (HR 0.68; 95% CI 0.54-0.88, P = 0.003). Crystalloid volume was associated with increased mortality among patients receiving blood products (HR 1.65; 95% CI 1.17-2.32, P = 0.004). CONCLUSION: Patients receiving prehospital PRBC+plasma had the greatest mortality benefit. Crystalloid only had the worst survival. Patients with hemorrhagic shock should receive prehospital blood products when available, preferably PRBC+plasma. Prehospital whole blood may be ideal in this population.

Cardiovascular Risk Factors in Younger Black Women: Results from the 10,000 Women Community Screening Project.

Background: Cardiovascular Disease (CVD) risk factors are prevalent in black women, but when these risk factors arise is not clear. We aimed to determine when obesity, hypertension, and hyperlipidemia appear in black women within a community screening program. Methods: 945 black women who enrolled in the 10,000 Women community screening project in the metro Atlanta area were included (2015-2018). Socioeconomic, lifestyle, and traditional CVD risk factor information was patient-reported and measured. Characteristics of three cohorts stratified by age, 20-39 years old (yo), 40-59 yo, and ≥60 yo, were compared using pairwise analysis. Results: All cohorts had class 1 obesity. Mean systolic blood pressure was higher in older cohorts [20-39 yo: 122 ± 15; 40-59 yo: 133 ± 19; ≥60 yo: 142 ± 20 mmHg; p < 0.001]. All age groups had mean total cholesterol levels below 200 mg/dL and were lowest in women 20-39 yo, (p < 0.001). All age groups had mean LDL levels below 100 mg/dL and were highest in women 20-39 yo, (p < 0.01). All age groups had mean HDL levels greater than 50 mg/dL and were highest in women ≥60 yo, (p-value = 0.03). A higher proportion of ≥60 yo limited salt intake, (p ≤ 0.001), and ate fast food less than three times a week, (p < 0.001), compared to younger women. Conclusion: We report that CVD risk factors, like elevated blood pressure and obesity, are prevalent at young ages in black women, which could be due to lifestyle practices. Earlier initiation of CVD preventive care in black women could be beneficial; however, this needs to be studied further.

Correction to: Mifepristone: An Uncommon Cause of Drug-Induced Liver Injury.

[This corrects the article DOI: 10.14740/gr1188.].

Mifepristone: An Uncommon Cause of Drug-Induced Liver Injury.

Mifepristone is frequently used in large doses for management of Cushing's syndrome. This is a case of a 35-year-old woman with Cushing's syndrome, who presented with abdominal pain and jaundice. A month prior to admission, she had been started on a daily dose of 1,200 mg mifepristone. After evaluating for various other causes of liver injury, biopsy revealed cholestatic pattern of liver disease, likely associated with drug-induced hepatotoxicity. Mifepristone was discontinued and her symptoms resolved. We believe this is one of the first few reported cases of drug-induced liver injury (DILI) associated with mifepristone use.

Teamwork training improves the clinical care of trauma patients.

OBJECTIVES: We investigated these questions: Does formal team training improve team behaviors in the trauma resuscitation bay? If yes, then does improved teamwork lead to more efficiency in the trauma bay and/or improved clinical outcomes? DESIGN: This intervention study used a pretraining/posttraining design. The intervention was TeamSTEPPS augmented by simulation. The evaluation instrument, which was the Trauma Team Performance Observation Tool (TPOT), was used by trained evaluators to assess teams' performance during trauma resuscitations. From November 2008 to February 2009, a convenience sample (n = 33) of trauma resuscitations was evaluated. From February to April 2009, team training was conducted. From May to July 2009, another sample (n = 40) of resuscitations were evaluated. Clinical data were gathered from our trauma registry. The clinical parameters included time from arrival to computed tomography (CT) scanner, arrival to intubation, arrival to operating room, arrival to Focused Assessment Sonography in Trauma (FAST) examination, time in emergency department (ED), hospital length of stay (LOS), intensive care unit LOS, complications, and mortality. Comparing pretraining and posttraining resuscitations, we calculated means, standard deviations, and p values for teamwork ratings and clinical parameters, and we determined significance using the independent samples t-test. SETTING: Level I Trauma Center. PARTICIPANTS: The trauma team included surgery residents, faculty, and nurses. RESULTS: Our trauma team showed significant improvement in all teamwork domain ratings and overall ratings from pretraining to posttraining-leadership (2.87-3.46, p = 0.003), situation monitoring (3.30-3.91, p = 0.009), mutual support (3.40-3.96, p = 0.004), communication (2.90-3.46, p = 0.001), and overall (3.12-3.70, p < 0.001). The times from arrival to the CT scanner (26.4-22.1 minutes, p = 0.005), endotracheal intubation (10.1-6.6 minutes, p = 0.49) and the operating room (130.1-94.5 minutes, p = 0.021) were decreased significantly after the training. CONCLUSIONS: Structured trauma resuscitation team training augmented by simulation improves team performance, resulting in improved efficiency of patient care in the trauma bay. We propose that formal teamwork training augmented by simulation be included in surgery residency training as well as Advanced Trauma Life Support (ATLS).