More surgery in December among US patients with commercial insurance is offset by unrelated but lesser surgery among patients with Medicare insurance.

STUDY OBJECTIVE: Evaluate whether there is more surgery (in the US State of Florida) at the end of the year, specifically among patients with commercial insurance. DESIGN: Observational cohort study. SETTING: The 712 facilities in Florida that performed inpatient or outpatient elective surgery from January 2010 through December 2019. RESULTS: Among patients with commercial insurance, December had more cases than November (1.108 [1.092-1.125]) or January (1.257 [1.229-1.286]). In contrast, among patients with Medicare insurance (traditional or managed care), December had fewer cases than November (ratio 0.917 [99% confidence interval 0.904-0.930]) or January (0.823 [0.807-0.839]) of the same year. Summing among all cases, December did not have more cases than November (ratio 1.003 [0.992-1.014]) or January (0.998 [0.984-1.013]). Comparing December versus November (January) ratios for cases among patients with commercial insurance to the corresponding ratios for cases among patients with Medicare, years with more commercial insurance cases had more Medicare cases (Spearman rank correlation +0.36 [+0.25], both p < 0.0001). CONCLUSIONS: In the US State of Florida, although some surgeons' procedural workloads may have seasonal variation if they care mostly for patients with one category of insurance, surgical facilities with patients undergoing many procedures will have less variability. Importantly, more commercial insurance cases were not causing Medicare cases to be postponed or vice-versa, providing mechanistic explanation for why forecasts of surgical demand can reasonably be treated as the sum of the independent workloads among many surgeons.

The Distributions of Weekday Discharge Times at Acute Care Hospitals in the State of Florida were Static from 2010 to 2018.

When hospital capacity is near census, either due to limits on the number of physical or staffed beds, delays in patients' discharge can result in domino effects of congestion for the emergency department, the intensive care units, the postanesthesia care unit, and the operating room. Hospital administrators often promote increasing the percentage of patients discharged before noon as mitigation. However, benchmark data from multiple hospitals are lacking. We studied the time of weekday inpatient discharges from all 202 acute care hospitals in the state of Florida between 2010 and 2018 using publicly available data. Statewide, the average length of stay (4.63 days) did not change, but hospital discharges increased 6.1%. There was no change over years in the percentage of patients discharged before 12 noon (13.0% ± 0.28% standard error [SE]) or before 3 PM (42.2% ± 0.25% SE). For every year, the median hour of patient discharge was 3 PM. Only 9 of the 202 hospitals (4.5%) reliably achieved a morning weekday discharge rate ≥ 20.0%. Only 19 hospitals (9.4%) in the state reliably achieved a ≥ 50.0% weekday discharge rate before 3 PM. Hospital administrators seeking to achieve earlier patient discharges can use our provided data as realistic benchmarks to guide efforts. Alternatively, administrators could plan based on a model that beds will not be reliably available for new patients until late in the afternoon and apply other well-developed operational strategies to address bottlenecks affecting the internal transfer of patients within the hospital.

Fibrinolysis Shutdown Is Associated With Thrombotic and Hemorrhagic Complications and Poorer Outcomes After Liver Transplantation.

Detrimental consequences of hypofibrinolysis, also known as fibrinolysis shutdown (FS), have recently arisen, and its significance in liver transplantation (LT) remains unknown. To fill this gap, this retrospective study included 166 adults who received transplants between 2016 and 2018 for whom baseline thromboelastography was available. On the basis of percent of clot lysis 30 minutes after maximal amplitude, patients were stratified into 3 fibrinolysis phenotypes: FS, physiologic fibrinolysis, and hyperfibrinolysis. FS occurred in 71.7% of recipients, followed by physiologic fibrinolysis in 19.9% and hyperfibrinolysis in 8.4%. Intraoperative and postoperative venous thrombosis events occurred exclusively in recipients with the FS phenotype. Intraoperative thrombosis occurred with an overall incidence of 4.8% and was associated with 25.0% in-hospital mortality. Incidence of postoperative venous thrombosis within the first month was deep venous thrombosis/pulmonary embolism (PE; 4.8%) and portal vein thrombosis/hepatic vein thrombosis (1.8%). Massive transfusion of ≥20 units packed red blood cells was required in 11.8% of recipients with FS compared with none in the other 2 phenotype groups (P = 0.01). Multivariate analysis identified 2 pretransplant risk factors for FS: platelet count and nonalcoholic steatohepatitis/cryptogenic cirrhosis. Recursive partitioning identified a critical platelet cutoff value of 50 × 109 /L to be associated with FS phenotype. The hyperfibrinolysis phenotype was associated with the lowest 1-year survival (85.7%), followed by FS (95.0%) and physiologic fibrinolysis (97.0%). Infection/multisystem organ failure was the predominant cause of death; in the FS group, 1 patient died of exsanguination, and 1 patient died of massive intraoperative PE. In conclusion, there is a strong association between FS and thrombohemorrhagic complications and poorer outcomes after LT.

Determination of Geolocations for Anesthesia Specialty Coverage and Standby Call Allowing Return to the Hospital Within a Specified Amount of Time.

BACKGROUND: For emergent procedures, in-house teams are required for immediate patient care. However, for many procedures, there is time to bring in a call team from home without increasing patient morbidity. Anesthesia providers taking subspecialty or backup call from home are required to return to the hospital within a designated number of minutes. Driving times to the hospital during the hours of call need to be considered when deciding where to live or to visit during such calls. Distance alone is an insufficient criterion because of variable traffic congestion and differences in highway access. We desired to develop a simple, inexpensive method to determine postal codes surrounding hospitals allowing a timely return during the hours of standby call. METHODS: Pessimistic travel times and driving distances were calculated using the Google distance matrix application programming interface for all N = 136 postal codes within 60 great circle ("straight line") miles of the University of Miami Hospital (Miami, FL) during all 108 weekly standby call hours. A postal code was acceptable if the estimated longest driving time to return to the hospital was ≤60 minutes (the anesthesia department's service commitment to start an urgent case during standby call). Linear regression (with intercept = 0) minimizing the mean absolute percentage difference between the distances (great circle and driving) and the pessimistic driving times to return to the hospital was performed among all 136 postal codes. Implementation software written in Python is provided. RESULTS: Postal codes allowing return to the studied hospital within the specified interval were identified. The linear regression showed that driving distances correlated poorly with the longest driving time to return to the hospital among the 108 weekly call hours (mean absolute percentage error = 25.1% ± 1.7% standard error [SE]; N = 136 postal codes). Great circle distances also correlated poorly (mean absolute percentage error = 28.3% ± 1.9% SE; N = 136). Generalizability of the method was determined by successful application to a different hospital in a rural state (University of Iowa Hospital). CONCLUSIONS: The described method allows identification of postal codes surrounding a hospital in which personnel taking standby call could be located and be able to return to the hospital during call hours on every day of the week within any specified amount of time. For areas at the perimeter of the acceptability, online distance mapping applications can be used to check driving times during the hours of standby call.

Obstetric hemorrhage.

PURPOSE OF REVIEW: To provide a review of the current literature on the management of obstetric hemorrhage. RECENT FINDINGS: Obstetric hemorrhage remains a prominent cause of maternal morbidity and mortality. When postpartum hemorrhage is refractory to manual and pharmacologic treatments, escalating interventions may be needed. Second-line interventions include the use of intrauterine balloon (or gauze) tamponade and uterine compression sutures. If these therapies fail to stop the bleeding, patients may need to undergo radiological embolization, pelvic devascularization, or hysterectomy. In recent years, pelvic arterial embolization has become a common treatment for intractable postpartum hemorrhage in an effort to avoid hysterectomy. The use of prophylactic arterial catheterization in the management of cases with expected major postpartum hemorrhage (e.g., placenta increta or percreta) has also been reported. However, the efficacy and safety of this technique requires further study. SUMMARY: Postpartum hemorrhage is best managed by using a stepwise progressive approach. Manual and pharmacologic interventions are first-line treatments. Second-line treatments are used when bleeding continues; and hysterectomy is reserved for only the most extreme cases. Outcomes may be improved by thorough preparation, anticipating the risk of obstetric hemorrhage, and coordinating consultants for interventional procedures.

Elective surgery growth at Florida hospitals accrues mostly from surgeons averaging 2 or fewer cases per week: A retrospective cohort study.

STUDY OBJECTIVE: Hospital administrators often seek to increase operating room (OR) elective caseload. Previous studies from Iowa demonstrated that surgical growth is mostly from low-caseload surgeons (ie, ≤2 cases per week). We repeated that study using data from Florida, a much more populous state, to confirm the generalizability of the findings. DESIGN: Retrospective cohort study. SETTING: All hospitals in the state of Florida. PATIENTS: All patients undergoing elective surgery during 2018 and 2019. MEASUREMENTS: We determined growth between 2018 and 2019 in regular-workday elective surgical caseload and intraoperative work relative value units (wRVU) at hospitals. Using the two-sided, one group Student t-test, we compared the fractions of those increases attributable to low-caseload surgeons vs. 50% to assess if they accounted for most surgical growth. We used the exact binomial test to compare the fraction of hospitals where most growth (>50%) occurred from low-caseload surgeons to half (50%). MAIN RESULTS: We studied the 1,629,879 elective cases from 202 hospitals. Surgeons averaging ≤2.0 cases per week accounted for 73.3% (P < 0.0001 compared to 50%) of caseload growth and 68.7% (P < 0.0001 compared to 50%) of wRVU growth. The corresponding overall pooled growth estimates among hospitals were 70.8% for caseload and 65.0% for wRVU. There were 76.2% of the N = 202 hospitals with more than half their growth in cases from surgeons performing, on average, ≤2.0 cases per week (P < 0.0001 compared to 50% of hospitals). The vast majority of surgical growth at hospitals accrued from the contributions of low-caseload surgeons. CONCLUSIONS: Surgical growth in elective surgery at Florida hospitals accrued mostly from the increased activity of low-caseload surgeons averaging ≤2.0 cases per week during the preceding year, confirming the generalizability of the previous Iowa study. If growth in caseload is desired, surgical governance committees should ensure that low-caseload surgeons have access to the OR schedule.

Similarities Between Pediatric and General Hospitals Based on Fundamental Attributes of Surgery Including Cases Per Surgeon Per Workday.

Introduction Operating room (OR) management decision-making at both pediatric and adult hospitals is determined, in large part, by the same fundamental attributes of surgery and other considerations related to case duration prediction. These include the non-preemptive nature of surgeries, wide prediction limits for case duration, and constraints to moving or resequencing cases on the day of surgery. Another attribute fundamentally affecting OR management is the median number of cases a surgeon performs on their OR days. Most adult surgeons have short lists of cases (i.e., one or two cases per day). Similarly, at adult hospitals, growth in caseloads is mostly due to the subset of those surgeons who also operate just once or twice per week. It is unknown if these characteristics of surgery apply to pediatric surgeons and pediatric hospitals as well. Methods Our retrospective cohort study included all elective surgical cases performed at the six pediatric hospitals in Florida during 2018 and 2019 (n = 71,340 cases). We calculated the percentages of combinations of surgeon, date, and hospital (lists) comprising one or two cases, or just one case, and determined if the values were statistically >50% (i.e., indicative of "most"). We determined if most of the growth in caseload and intraoperative work relative value units (wRVUs) at the pediatric hospitals between 2018 and 2019 accrued from low-caseload surgeons. Results are reported as mean ± standard error of the mean. Results Averaging among the six pediatric hospitals, the non-holiday weekday lists of most surgeons at each facility had just one or two elective cases, inpatient and/or ambulatory (68.1%; p = 0.016 vs. 50%, n = 27,557 lists). Growth in surgical caseloads from 2018 to 2019 was mostly attributable to surgeons who in 2018 averaged ≤2.0 cases per week (76.3% ± 5.4%, p = 0.0085 vs. 50%). Similarly, growth in wRVUs was mostly attributable to these low-caseload surgeons (73.8% ± 5.4%, p = 0.017 vs. 50%). Conclusions Like adult hospitals, most pediatric surgeons' lists of cases consist of only one or two cases per day, with many lists containing a single case. Similarly, growth at pediatric hospitals accrued from low-caseload surgeons who performed one or two cases per week in the preceding year. These findings indicate that hospitals desiring to increase their surgical caseload should ensure that low-caseload surgeons are provided access to the OR schedule. Additionally, since percent-adjusted utilization and raw utilization cannot be accurately measured for low-caseload surgeons, neither metric should be used to allocate OR time to individual surgeons. Since most adult and pediatric surgeons have low caseloads, this is a fundamental attribute of surgery.

Most surgeons' daily elective lists in Florida comprise only 1 or 2 elective cases, making percent utilization unreliable for planning individual surgeons' block time.

STUDY OBJECTIVE: Operating room (OR) utilization has been shown in multiple studies to be an inappropriate metric for planning OR time for individual surgeons. Among surgeons with low daily caseloads, percentage utilization cannot be measured accurately because confidence limits are extremely wide. In Iowa, a largely rural state, most surgeons performed only 1 or 2 elective cases on their OR days. To assess generalizability, we analyzed Florida, a state with many high-population density areas. DESIGN: Observational cohort study. SETTING: The 602 facilities in Florida that performed inpatient or outpatient elective surgery from January 2010 through December 2019. SUBJECTS: The providers licensed to perform surgery in Florida (physician, oral surgeons, dentists, and podiatrists) were identified by their national provider number. Hospitals were deidentified before analysis. MEASUREMENTS: The primary endpoint was the mean among facilities in percentages of surgeon-day combinations ("lists") containing 1 or 2 cases. Proportions were calculated using Freeman-Tukey transformation and the harmonic mean of the number of lists at each facility. Comparison to "most" (>50%) used Student's two-sided one-group t-test. MAIN RESULTS: Averaging among hospitals, most surgeons' lists included 1 or 2 cases (64.4%; 99% confidence interval [CI] 61.3%-67.4%) P < 0.00001). Many lists had 1 case (44.2%, 99% CI 41.2%-47.2%). Nearly all (96.7%) surgeons operated at just one hospital on their OR days. CONCLUSIONS: Most surgeons' lists of elective surgical cases comprised 1 or 2 cases in the largely urban state of Florida, as previously found in the largely rural state of Iowa. Results were insensitive to organizational size or county population. Thus, our finding is generalizable in the United States. Consequently, neither adjusted nor raw utilization should be used solely when allocating OR time to individual surgeons. Anesthesia and nursing coverage of cases can be based on maximizing the efficiency of use of OR time.

Airway management and initial resuscitation of the trauma patient.

PURPOSE OF REVIEW: This review will analyze and comment on selected recent literature pertaining to airway management and initial fluid resuscitation in the trauma patient. It will also review airway devices currently being used in the trauma setting. RECENT FINDINGS: Although a recent study has questioned the efficacy of manual inline immobilization, this technique continues to be endorsed by trauma guidelines and is safely used in most trauma centers. Clinicians have also incorporated the use of videolaryngoscopy and other adjuncts for difficult airway management in trauma patients. However, no single airway management tool has proven to be superior in this setting. Crystalloid solutions remain frontline therapy for the initial resuscitation of the hemorrhagic trauma patient, as studies with hypertonic saline and vasopressors have not shown superior results. Conversely, increased amounts of fresh frozen plasma and fibrinogen have been reported to increase survival in trauma patients. SUMMARY: As trauma continues to be a major cause of morbidity and mortality worldwide, the use of newer airway adjuncts needs to be specifically investigated in trauma patients, as this population frequently has airway management difficulties. Further research is also required to elucidate the type and amount of fluid that will provide an adequate organ perfusion without increasing nonsurgical bleeding.

Opioid prescriptions for acute pain after outpatient surgery at a large public university-affiliated hospital: Impact of state legislation in Florida.

BACKGROUND: In response to the growing opioid crisis, Florida recently implemented a law restricting the duration of opioid prescriptions for acute pain. Little is known about the impact of such legislation on opioid prescription practices at the time of discharge after surgery. The objective of this study was to determine whether Florida's new legislation changed opioid prescription practices for analgesia after surgery. METHODS: Adults 18 years of age and older undergoing cholecystectomy, appendectomy, hernia repair, hysterectomy, mastectomy, or lymph node dissection were included in this retrospective cohort study at a large public university-affiliated hospital. We analyzed opioid prescriptions on discharge after these common outpatient surgical procedures between June 1, 2017, and December 31, 2018. Florida House Bill 21 was passed on March 2, 2018, and subsequent implementation of this law took place on July 1, 2018. The law restricts the duration of opioid prescriptions for acute pain to 3 days, which can be extended up to a maximum of 7 days with additional documentation. The outcomes studied included the following: the proportion of patients receiving opioid prescriptions on discharge, total opioid dose prescribed, daily opioid dose prescribed, and the proportion of patients receiving more than a 3-day supply of opioids. We colledted data on emergency department cumulative visits within 7 and 30 days after discharge. Drug doses were converted to morphine milligram equivalents and calculated for each selected procedure. RESULTS: A total of 1,467 surgical encounters were included. The cohort was predominantly female (963 [65.6%]) with a mean (SD) age of 49.6 (14.4) years. At 6 months after implementation of HB 21, the proportion of patients receiving opioid prescriptions decreased by 21% (95% CI 16.8% to 25.3%, P < .001), mean total opioid dose prescribed decreased by 64.2 morphine milligram equivalents (95% CI 54.7 to 73.7, P < .001) from a baseline mean (SD) of 172.5 (78.9) morphine milligram equivalents. The mean daily opioid dose prescribed increased by 3.5 morphine milligram equivalents (95% CI 1.8 to 5.1, P < .001) from a baseline mean (SD) of 30.5 (9.4) morphine milligram equivalents. The proportion of patients receiving opioid prescriptions for longer than a 3-day supply decreased by 68% (95% CI 63.4% to 72.7%, P < .001). We observed no change in the number of postoperative emergency department visits before and after implementation of the law. CONCLUSION: Opioid prescriptions for patients undergoing common outpatient surgical procedures at a large public university-affiliated hospital in Florida were substantially reduced within 6 months after implementation of state legislation limiting the duration of opioid prescriptions. This reduction was not associated with an increase in the number of postoperative emergency department visits. The legislation should significantly decrease the amount of unused opioid pills potentially available for diversion and abuse. Secondary effects from the enactment of this law remain to be evaluated.

Airway Management of Near-Complete Tracheal Transection by Through-the-Wound Intubation: A Case Report.

We present an approach to airway management in a patient with machete injuries culminating in near-complete cricotracheal transection, in addition to a gunshot wound to the neck. Initial airway was established by direct intubation through the cricotracheal wound. Once the airway was secured, a bronchoscopy-guided orotracheal intubation was performed with simultaneous retraction of the cricotracheal airway to optimize the surgical field. This case offers insight into a rarely performed approach to airway management. Furthermore, our case report demonstrates that, in select airway injuries, performing through-the-wound intubation engenders a multitude of benefits.

Roentgenographic investigation of frequency and degree of canal curvatures in human permanent teeth.

Canal curvatures of 700 permanent human teeth were determined by measuring the angle and the radius of the curvatures and the length of the curved part of the canal. For each type of tooth (except third molars) 50 were selected at random and were investigated. Size 08 silver points were inserted into the canals, and the teeth were radiographed from a facial and proximal view by using a standardized technique. All radiographs were analyzed by a computerized digital image processing system. Of the 1163 root canals examined, 980 (84%) were curved and 65% showed an angle < or = 27 degrees with radii < 40 mm. Thirteen percent displayed angles between 27 degrees and 35 degrees with radii not greater than 15 mm, and 9% of all canals that were investigated had curves > 35 degrees with the greatest radius of 13 mm. The greatest angle of all the teeth was 75 degrees with a radius of 2 mm. To define the canal curvature mathematically and unambiguously, the angle, the radius, and the length of the curve should be given.

Xantoastrocitoma pleomórfico / Pleomorphic Xanthoastrocytoma

El xantoastrocitoma pleomórfico, por su extrema rareza, conlleva alta complejidad en el diagnóstico histopatológico. Se presenta el caso clínico en un sujeto de sexo masculino, de 40 años, con antecedentes de crisis convulsivas de presentación tardía, secundarias a meningioma atípico grado II localizado en región occipital izquierda, resecado por dos ocasiones en el transcurso de 6 años. Recibió radioterapia a dosis completa luego de la segunda resección. El diagnóstico histopatológico inicial fue meningioma atípico gra-do II. El paciente acude al HCAM por cefalea holocraneal intensa y hemiparesia braquiocrural derecha; en los estudios de resonancia magnética nuclear con gadolinio se observó el crecimiento de una lesión occipi-tal izquierda con edema perilesional que ameritó resección total de la lesión a través de la craniectomía previa. Como hallazgo macroscópico, se describe una masa violácea que infiltra duramadre carente de un plano de clivaje; el estudio histopatológico detalla una neoplasia glial hipercelular con infiltración difusa con reacción inmunohistoquímica intensa para PGAF (proteína glial acida fibrilar), S100 y CD56 en células tumorales, CD34 positivo. KI67 positivo en 3% y P53 débilmente positivo, compatible con xantoastroci-toma pleomórfico WHO II.(AU)

The pleomorphic xantoastrocytoma, due to its extreme rarity, carries high complexity in the histo-pathological diagnosis. The clinical case is presented in a male subject, 40 years old, with a history of sei-zures with late presentation, secondary to atypical meningioma grade II located in the left occipital region, resected twice in the course of 6 years. He received full-dose radiation therapy after the second resection. The initial histopathological diagnosis was atypical meningioma grade II. The patient comes to HCAM due to intense holocranial headache and right brachiocrural hemiparesis; In the gadolinium nuclear magnetic resonance studies the growth of a left occipital lesion with perilesional edema that warranted total resec-tion of the lesion through previous craniectomy was observed. As a macroscopic finding, a violaceous mass is described which infiltrates dura mater lacking a plane of cleavage; The histopathological study details a hypercellular glial neoplasia with diffuse infiltration with intense immunohistochemical reaction for PGAF (glial acidic glial protein), S100 and CD56 in tumor cells, CD34 positive. It was KI67 positive in 3% and P53 weakly positive, compatible with pleomorphic xantoastrocytoma WHO II. (AU)