Hypoglossal Nerve Stimulator Implantation in an Ambulatory Surgery Center Versus Hospital.

OBJECTIVES/HYPOTHESIS: Hypoglossal nerve stimulator (HGNS) implantation is highly effective in treating obstructive sleep apnea (OSA) in select patient populations that are intolerant of continuous positive airway pressure. Implantation surgery is traditionally performed in hospital outpatient departments (HOPD) due to concern about anesthetic effects and airway manipulation in an OSA population. In this study, we examined complications and efficiency of HGNS implantation in an ambulatory surgery center (ASC) versus HOPD. STUDY DESIGN: Retrospective cohort study. METHODS: Patients with HGNS implantation performed between May 2015-January 2021 at our HOPD or ACS were included. Patient-related characteristics, surgical times, and postoperative complications were obtained via chart review. Reimbursement data on a national level for Medicare patients were calculated based on publicly available data from the Center for Medicare Services. Patient characteristics, surgical times, and complications were summarized as medians with interquartile ranges (IQRs) and proportions in each surgical setting group as appropriate. These were compared between surgical setting groups via Wilcoxon rank-sum testing and χ2 testing. RESULTS: A total of 122 patients were included. Patients in the HOPD group had significantly higher median apnea-hypopnea index (AHI) (42.0 [IQR 27.9-51.0]) compared to the ASC group (31.0 [IQR 21.0-44.2], P = .005). The intervals between in-room and case start, case finish and out-of-room, and time in the postoperative area were significantly shorter in the ASC group compared to the HOPD group. Reimbursement on a national level was estimated at 18% lower for patients with surgery performed at the ASC. There was no significant difference in postoperative complications. CONCLUSIONS: HGNS implantation in an ASC is safe and more efficient than in a HOPD, and may also be more cost-effective. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:706-710, 2022.

Developing a template matching algorithm for benchmarking hospital performance in a diverse, integrated healthcare system.

Template matching is a proposed approach for hospital benchmarking, which measures performance based on matching a subset of comparable patient hospitalizations from each hospital. We assessed the ability to create the required matched samples and thus the feasibility of template matching to benchmark hospital performance in a diverse healthcare system.Nationwide Veterans Affairs (VA) hospitals, 2017.Observational cohort study.We used administrative and clinical data from 668,592 hospitalizations at 134 VA hospitals in 2017. A standardized template of 300 hospitalizations was selected, and then 300 hospitalizations were matched to the template from each hospital.There was substantial case-mix variation across VA hospitals, which persisted after excluding small hospitals, hospitals with primarily psychiatric admissions, and hospitalizations for rare diagnoses. Median age ranged from 57 to 75 years across hospitals; percent surgical admissions ranged from 0.0% to 21.0%; percent of admissions through the emergency department, 0.1% to 98.7%; and percent Hispanic patients, 0.2% to 93.3%. Characteristics for which there was substantial variation across hospitals could not be balanced with any matching algorithm tested. Although most other variables could be balanced, we were unable to identify a matching algorithm that balanced more than ∼20 variables simultaneously.We were unable to identify a template matching approach that could balance hospitals on all measured characteristics potentially important to benchmarking. Given the magnitude of case-mix variation across VA hospitals, a single template is likely not feasible for general hospital benchmarking.

Can network science reveal structure in a complex healthcare system? A network analysis using data from emergency surgical services.

INTRODUCTION: Hospitals are complex systems and optimising their function is critical to the provision of high quality, cost effective healthcare. Metrics of performance have to date focused on the performance of individual elements rather than the whole system. Manipulation of individual elements of a complex system without an integrative understanding of its function is undesirable and may lead to counterintuitive outcomes and a holistic metric of hospital function might help design more efficient services. OBJECTIVES: We aimed to use network analysis to characterise the structure of the system of perioperative care for emergency surgical admissions in our tertiary care hospital. DESIGN: We constructed a weighted directional network representation of the emergency surgical services using patient location data from electronic health records. SETTING: A single-centre tertiary care hospital in the UK. PARTICIPANTS: We selected data from the retrospective electronic health record data of all unplanned admissions with a surgical intervention during their stay during a 3.5-year period, which resulted in a set of 16 500 individual admissions. METHODS: We then constructed and analysed the structure of this network using established methods from network science such as degree distribution, betweenness centrality and small-world characteristics. RESULTS: The analysis showed the service to be a complex system with scale-free, small-world network properties. We also identified such potential hubs and bottlenecks in the system. CONCLUSIONS: Our holistic, system-wide description of a hospital service may provide tools to inform service improvement initiatives and gives us insights into the architecture of a complex system of care. The implications for the structure and resilience of the service is that while being robust in general, the system may be vulnerable to outages at specific key nodes.

Ultrasound in the surgical ICU: uses, abuses, and pitfalls.

PURPOSE OF REVIEW: Point-of-care ultrasound (POCUS) has become an integral component of daily care in the surgical ICU. There have been many novel advancements in the past two decades, too numerous to count. Many are of critical importance to the intensive care physician, whereas others are still accumulating evidence. Without appropriate training, diligence, and incorporation of the ultrasound findings into the whole clinical picture, this technique can be gravely misused. This review examines POCUS use in the surgical ICU, as well as highlights potential hazards and common pitfalls. RECENT FINDINGS: POCUS is essential for guidance of vascular access procedures, as well as in the characterization and treatment of respiratory failure, shock, and unstable blunt abdominal trauma. Ultrasound has growing evidence for rapidly evaluating many other diseases throughout the entire body, as well as guidance for procedures. Using advanced ultrasound techniques should only be done with corresponding levels of training and experience. SUMMARY: Ultrasound in the critical care setting has become an essential component of the assessment of most ICU patients. As more evidence accumulates, along with ever-increasing availability of ultrasound technology, its use will continue to expand. It, thus, behoves clinicians to not only ensure they are adept at obtaining and interpreting POCUS images but also efficiently incorporate these skills into holistic bedside care without delaying lifesaving therapies.

Geriatric medicine services for older surgical patients in acute hospitals: Results from a binational survey.

OBJECTIVE: To describe perioperative geriatric medicine services in Australia and New Zealand, and to explore geriatricians' views on the need for and challenges in providing perioperative care. METHOD: An electronic questionnaire was sent to heads of geriatric medicine departments. RESULTS: Sixty-seven (83%) of 81 identified geriatric medicine departments responded. Twelve (18%) departments provide a proactive surgical-geriatric medicine service. Their most common features were regular geriatric medicine ward rounds (100%), medication review (92%) and attendance at multidisciplinary meetings (83%). All respondents thought there was a need for geriatric medicine to provide greater input into the care of older surgical patients. Lack of funding (88%) and not enough geriatricians (58%) were the major perceived barriers. CONCLUSIONS: Although geriatricians believe they should provide proactive collaborative care for older surgical patients, only a few hospitals currently provide these services. Funding streams for these services and further research to determine the best models of care are needed.

A presença do familiar/acompanhante da criança submetida à cirurgia ortopédica: implicações para a enfermagem / The presence of the family/child accompanied by orthopedic surgery: implications for nursing

Introdução: Quando a criança é submetida à cirurgia, a presença do familiar transmite segurança e tranquilidade nos momentos que perpassam o período perioperatório. Objetivos: Descrever as experiências do familiar/acompanhante da criança submetida à cirurgia ortopédica no período perioperatório; analisar a presença do familiar/acompanhante da criança submetida à cirurgia no período perioperatório; e discutir a presença do familiar/acompanhante no período perioperatório e suas implicações para a prática assistencial de enfermagem. Método: estudo qualitativo baseado nos conceitos de família saudável e de presença como elemento constitutivo do cuidado familial. O cenário foi uma unidade de pediatria de um hospital especializado em ortopedia no município do Rio de Janeiro. Os participantes foram nove familiares/acompanhantes das crianças internadas e que foram submetidas à cirurgia. Os procedimentos metodológicos foram um formulário de caracterização dos acompanhantes e das crianças e a entrevista não-diretiva em grupo. Os dados foram analisados por meio da análise temática. O projeto foi aprovado no Comitê de Ética em Pesquisa da Escola de Enfermagem Anna Nery e Instituto de Atenção à Saúde São Francisco de Assis e no Comitê de Ética em Pesquisa da instituição coparticipante. Resultados: No pré-operatório, as reações dos familiares/acompanhantes, das crianças e da equipe foram bastante diversificadas, tendo em vista as informações da criança e seu acompanhante e também dos conhecimentos técnico-científicos da equipe. Na sala de cirurgia, os depoimentos apontaram a segurança da criança diante da presença do familiar/acompanhante. No pós-operatório, as depoentes destacaram o êxito da cirurgia e a expectativa de vida das crianças. A religiosidade e a distância da família permeiam as experiências do familiar/acompanhante durante o período perioperatório. Conclusões: A presença do familiar/acompanhante no perioperatório resulta na ampliação da interação família- criança-equipe, estabelecendo situações propícias ao cuidado centrado na criança e sua família em situações cirúrgicas, reafirmando a relevância da presença da família e a garantia do direito da criança de ter um acompanhante.

Introduction: When the child undergoes surgery, the presence of the relative conveys safety and tranquility during the perioperative period. Objectives: describe the experiences of the family member / companion of the child submitted to orthopedic surgery in the perioperative period; presence of the family member / companion of the child submitted to surgery in the perioperative period, to discuss the presence of the family member / companion in the perioperative period and its implications for nursing care practice. Method: qualitative study based on the concepts of healthy family and presence as a constituent element of family care. The setting was a pediatric unit of a hospital specialized in orthopedics in the city of Rio de Janeiro. Participants were nine relatives / companions of hospitalized children who underwent surgery. The methodological procedures were a form of characterization of the companions and the children, non-directive interview in the group. The data were analyzed by means of the thematic analysis. The project was approved by the Research Ethics Committee of the Anna Nery School of Nursing and the São Francisco de Assis Health Care Institute and the Research Ethics Committee of the co-participating institution. Results: In the preoperative period, the reactions of the family / companions, the child and the team were quite diversified considering the information of the child and his / her companion, as well as the technical-scientific knowledge of the team. In the operating room, the testimonies pointed to the child's safety in the presence of the relative / companion. In the postoperative period, the deponents highlighted the success of the surgery and the children's life expectancy. The religiosity and the experiences of the family membercompanion during the perioperative period. The presence of the family membercompanion in the perioperative results in the expansion of the family-child-team interaction, establishing situations propitious to care centered on the child and his family in surgical situations, reaffirming the relevance of family presence and the guarantee the right of the child to have an accompanying person.

Antibiotic susceptibility of wound swab isolates in a tertiary hospital in Southwest Nigeria.

Background: Wounds are commonly encountered in the clinical practice. Microbacterial colonization and infection negatively affect wound outcomes. With increasing emergence of antibiotic-resistant strains, it is essential to determine local patterns of wound microbiological profile and antibiotic susceptibility to guide rational empirical antibiotic use. Materials and Methods: Consecutive patients who presented to the plastic surgery unit were recruited to the study over a 6-month period. Wound swab cultures were performed at presentation using standard protocols and media. The wound swab was performed by the Levine technique and data were analyzed using a statistical software package. Results: Eighty-five microbial isolates were obtained from the eighty patients (55 males and 25 females) recruited. Gram-positive isolates were 35 (41.2%) and Gram-negative were 50 (58.8%). There was equal distribution of acute and chronic wounds. Pseudomonas aeruginosa was the most common isolate at 30.6%, followed by Staphylococcus aureus (27.1%), Escherichia coli (9.4%), Streptococcus species (8.2%), and Morganella morganii (7.1%). The isolates demonstrated resistance to amoxicillin-clavulanate, ampicillin, cloxacillin, cefuroxime, ceftazidime; low-to-moderate sensitivity to erythromycin, gentamicin, streptomycin, tetracycline, ciprofloxacin, and ofloxacin; and a moderate sensitivity to ceftriaxone and a high sensitivity to imipenem. There was significant difference in antibiotic resistance patterns between Gram-positive isolates from acute and chronic wound infections but not for acute and chronic wound Gram-negative isolates. Conclusion: Most of the microbial isolates, particularly the Gram-negative isolates demonstrated low sensitivity to commonly used antibiotics and moderate-to-high sensitivity to less commonly used newer antibiotics.

RésuméContexte: Les plaies sont généralement rencontrés dans la pratique clinique. La colonisation et l'infection Microbacterial négatif sur blessure Les résultats. Avec l'augmentation de l'émergence de souches résistantes aux antibiotiques, il est essentiel de déterminer les tendances locales de plaie profil microbiologique Sensibilité aux antibiotiques et de guider l'utilisation d'antibiotiques empiriques rationnelle. Matériel et méthodes: Patients consécutifs qui ont présenté à la Unité de chirurgie en plastique ont été recrutés pour l'étude sur une période de 6 mois. Écouvillon blessure cultures ont été effectuées à la présentation en utilisant des protocoles standard et des médias. L'écouvillonnage de la plaie a été effectuée par la technique de Levine et les données ont été analysées à l'aide d'un logiciel statistique. Résultats: Quatre-vingt-cinq isolats microbiens ont été obtenues à partir de 80 patients (55 hommes et 25 femmes) recrutés. Les isolats Gram-positives ont été 35 (41,2%) et Gram-négatives sont 50 (58,8%). Il y a égalité de répartition des blessures aiguës et chroniques. Pseudomonas aeruginosa est le plus fréquent d'isoler à 30,6%, suivi de Staphylococcus aureus (27,1%), Escherichia coli (9,4%), streptocoques (8,2%), et de Morganella morganii (7,1%). Les isolats présentaient une résistance à l'amoxicilline-clavulanate, ampicilline, cloxacillin, céfuroxime, ceftazidime, faible à modérée de la sensibilité à l'érythromycine, la gentamicine, la streptomycine, la tétracycline, la ciprofloxacine, l'ofloxacine et; et une sensibilité modérée à la ceftriaxone et une forte sensibilité à l'imipénème. Il y avait une différence dans les profils d'antibiorésistance entre les isolats de Gram-positives des infections de plaies aiguës et chroniques mais pas pour les plaies aiguës et chroniques des isolats de bactéries Gram-négatives. Conclusion: La plupart des isolats microbiens, en particulier les bactéries Gram-négatives isolats présentaient une faible sensibilité aux antibiotiques couramment utilisés et l'effet d'une grande sensibilité aux antibiotiques plus récents moins fréquemment utilisés.

Screening and management of postoperative hypoparathyroidism-induced hypocalcemia in thyroidectomized patients in the endocrine ward compared with the surgical ward.

Transient hypoparathyroid-associated hypocalcemia is a common side effect after thyroidectomy. Not only may it be life-threatening, but it also can distinctly affect length of hospital stay and treatment costs. Screening and treatment practices are suspected to differ between clinicians in endocrine and surgical wards. We therefore compared discipline-related differences in screening and treatment of hypocalcemia as well as the length of hospital stay of patients after thyroidectomy. Data from 170 patients treated with total thyroidectomy in the Department of Otolaryngology (n = 29), General Surgery (n = 49) and Endocrinology (n = 92) were analyzed, and measurements of postoperative calcium and parathyroid hormone, calcium at time of discharge, percentage of discharge with a calcium level <1.9 mmol/L (defined as severe hypocalcemia), treatment of hypocalcemia, and duration of hospitalization were compared between disciplines. Postoperative calcium levels were measured in 97.8% of patients in endocrine wards compared with 83.3% in surgical departments (p = 0.001), and discharge with a calcium level <1.9 mmol/L was statistically more frequent in surgical vs. endocrine wards. Additional to calcium supplementation, active vitamin D was administered in 95% of patients treated in endocrine wards vs. 35% in surgical wards. Length of hospitalization was 8.12 (±6.62) days (endocrinology) to 10.55 (±9.39) days (surgical wards) (p = 0.05). Monitoring of calcium levels is an important indicator of the quality of postoperative care after thyroidectomy. To prevent postoperative hypocalcemia-induced complications and to reduce the length of hospital stay, an interdisciplinary approach for the management of hypocalcemia after thyroidectomy might be a promising model for future treatment concepts.

[Establishment of a trauma surgical department at the Diospi Suyana missionary hospital in Curahuasi, Peru]. / Aufbau einer unfallchirurgischen Abteilung am Missionsspital Diospi Suyana in Curahuasi, Peru.

The confusingly structured and in many areas corrupt health system in Peru even today provides only a fragmentary and insufficient medical treatment especially for the indigenous population (mainly Quechua Indians). Since October 2007 the Diospi Suyana missionary hospital in Curahuasi (State of Apurímac) has provided an affordable medical treatment at a high level mainly for these indigenous people of Peru; however, so far the hospital could only insufficiently meet the traumatological needs of the region. The establishment of a surgical trauma department aims to meet those needs but is also encumbered by special problems and challenges. Some patients, for example only present at the hospital after the fractures have already incorrectly healed, sometimes many weeks or even months after the trauma either due to a long journey through the country to different hospitals where treatment was not possible or they could not pay for the treatment and sometimes because of inadequate prior treatment, for example by traditional healers. Cultural and infrastructural particularities of the country must be included in the process of choosing the right method of treatment.

Apendicitis aguda. Estudio comparativo entre puerto único, laparoscopia convencional versus laparotomía / Acute appendicitis. Comparative study of single port, conventional laparoscopic versus laparotomy

Objetivo:Comparar las tres técnicas de abordaje para la apendicectomía: puerto único (APU), laparoscopia convencional (ALC) y laparotomía (AL) en pacientes con diagnóstico de apendicitis aguda. Métodos: se realizó AL por incisión de McBurney, ALC por tres puertos y APU. Para las cirugías por APU y ALC se utilizó pinza de LigaSure AtlasTM 37cms Hand de 10mm (Covidien®) para ligar el mesoapéndice, sutura crómico catgut® 0 o endoloop®para ligar la base de la apéndice, en abierta o laparoscopica, respectivamente. Para la APU se utilizó el SILS Port™ (Covidien®). Se realizó un estudio comparativo, prospectivo, monocéntrico, entre abril 2014 y octubre 2014, en pacientes con diagnóstico de apendicitis aguda en el Hospital General del Este "Dr. Domingo Luciani"y que cumplieron los criterios de inclusión. Resultados: Se realizaron 58 apendicectomías, 20 AL, 20 ALC y 18 APU. El tiempo quirúrgico y la estancia hospitalaria fueron menores en las ALC con promedio de 47 minutos y 33,6 horas, respectivamente. La incidencia de complicaciones intraoperatorias y postoperatorias fueron mayores el las AL estableciéndose una relación estadística-mente significativa entre la técnica quirúrgica y la infección del sitio operatorio (p < 0,05). La técnica quirúrgica influye en la manifestación de dolor en las primeras 08 horas de postoperatorio (p < 0,05). Conclusión: La decisión del abordaje quirúrgico será determinado por la experiencia del cirujano y la disponibilidad del instrumental quirúrgico, sin embargo, la evidencia actual sugiere que la ALC debe ser considerada como primera elección(AU)

Objective: To compare the three techniques approach appendectomy: single port (SPA), conventional laparoscopy (CLA) and laparotomy (LA) in patients with acute appendicitis. Methods: LA was performed by McBurney incision, CLA was performed with three ports and SPA. LigaSure clamp 10mm Hand AtlasTM 37cms (Covidien®) was used to cut the mesoappendix, chromic suture catgut® 0 or endoloop® to ensure the base of the appendix, in open or laparoscopic, respectively. The SILS™ Port (Covidien®) was used for the SPA. A comparative, prospective, single-center study was conducted between April 2014 and October 2014, in patients with a diagnosis of acute appendicitis in East General Hospital "Dr.Domingo Luciani" and who met the inclusion criteria. Results: 58 appendectomies, 20 LA, 20 CLA and 18 SPA were performed. The operative time and hospital stay were lower in the CLA average of 47 minutes and 33.6 hours, respectively. The incidence of intraoperative and postoperative complications were higher on the LA establishing a statistically significant relationship between surgical technique and surgical site infection (p <0.05). The surgical technique influences the manifestation of pain in the first 08 hours postoperatively (p <0.05). Conclusion: The decision of surgical approach will be determined by the surgeon's experience and availability of surgical instruments, however, current evidence suggests that CLA should be considered as first choice(AU)

A resource planning analysis of district hospital surgical services in the Democratic Republic of the Congo.

BACKGROUND: The impact of surgical conditions on global health, particularly on vulnerable populations, is gaining recognition. However, only 3.5% of the 234.2 million cases per year of major surgery are performed in countries where the world's poorest third reside, such as the Democratic Republic of the Congo (DRC). METHODS: Data on the availability of anesthesia and surgical services were gathered from 12 DRC district hospitals using the World Health Organization's (WHO's) Emergency and Essential Surgical Care Situation Analysis Tool. We complemented these data with an analysis of the costs of surgical services in a Congolese norms-based district hospital as well as in 2 of the 12 hospitals in which we conducted the situational analysis (Demba and Kabare District Hospitals). For the cost analysis, we used WHO's integrated Healthcare Technology Package tool. RESULTS: Of the 32 surgical interventions surveyed, only 2 of the 12 hospitals provided all essential services. The deficits in procedures varied from no deficits to 17 services that could not be provided, with an average of 7 essential procedures unavailable. Many of the hospitals did not have basic infrastructure such as running water and electricity; 9 of 12 had no or interrupted water and 7 of 12 had no or interrupted electricity. On average, 21% of lifesaving surgical interventions were absent from the facilities, compared with the model normative hospital. According to the normative hospital, all surgical services would cost US$2.17 per inhabitant per year, representing 33.3% of the total patient caseload but only 18.3% of the total district hospital operating budget. At Demba Hospital, the operating budget required for surgical interventions was US$0.08 per inhabitant per year, and at Kabare Hospital, US$0.69 per inhabitant per year. CONCLUSION: A significant portion of the health problems addressed at Congolese district hospitals is surgical in nature, but there is a current inability to meet this surgical need. The deficient services and substandard capacity in the surveyed district hospitals are systemic in nature, representing infrastructure, supply, equipment, and human resource constraints. Yet surgical services are affordable and represent a minor portion of the total operating budget. Greater emphasis should be made to appropriately fund district hospitals to meet the need for lifesaving surgical services.

Significado do cuidado para enfermagem de centro cirúrgico / The meaning of care for operating room nursing

Objetivo: conhecer o significado do cuidado para os técnicos de enfermagem que laboram no Centro Cirúrgico de um hospital geral da fronteira oeste do Rio Grande do Sul/Brasil. Método: pesquisa de abordagem qualitativa, do tipo exploratório e descritivo. Técnica para coleta de dados foi entrevista semiestruturada e ainda, teve-se como suporte, anotações no diário de campo. Foram entrevistados oito técnicos de enfermagem deste Centro Cirúrgico. Resultados: os participantes valorizam os aspectos psicológicos, sociais e afetivos de pacientes e familiares, expressando também visão holística no que se refere ao cuidado de si e com o outro. Conclusão: cuidar, nesta unidade, é uma atividade com múltiplos aspectos, envolvendo pacientes, familiares e equipe. Os significados valorizados pelos profissionais revelam o desprender-se do tecnicismo para valorizar questões psicológicas, sociais e afetivas do cuidado.

The use of multiple qualitative methods to characterize communication events between physicians and nurses.

Despite the importance of communication to patient safety in hospital settings, we know surprisingly little about communication patterns between physicians and nurses, particularly on general medical-surgical units. Poor communication is the leading cause of preventable adverse events in hospitals, as well as a major root cause of sentinel events. The literature provides little guidance on what qualitative methods are best for capturing different types of communication events and patterns. The purpose of this study was to develop a methodology for identifying and characterizing communication events between physicians and nurses to better understand communication patterns on general medical-surgical units. We used a sequential qualitative mixed method design beginning with general observation, progressing to shadowing and focus groups of physicians and nurses who worked on two medical-surgical units at one academically affiliated U.S. Department of Veterans Affairs (VA) hospital. Each data collection method (observation, shadowing, and focus groups) had its own advantages and disadvantages for capturing communication events and patterns. Through observation we were able to see the "what": communication activities. Shadowing was most useful for understanding "how" physicians and nurses communicated. Focus groups helped answer "why" certain patterns emerged and allowed us to further explore communication events within a group setting. By using all three methods we were able to more thoroughly characterize communication events than by using a single method alone, providing a more holistic picture of how communication occurs on an inpatient medical-surgical unit.

Use of palliative care and hospice among surgical and medical specialties in the Veterans Health Administration.

IMPORTANCE: Many hospitals have undertaken initiatives to improve care during the end of life, recognizing that some individuals have unique needs that are often not met in acute inpatient care settings. Studies of surgical patients have shown this population to receive palliative care at reduced rates in comparison with medical patients. OBJECTIVE: To determine differences in the use of palliative care and hospice between surgical and medical patients in an integrated health care system. DESIGN, SETTING, AND PARTICIPANTS: Veterans Health Administration (VHA) enrollment data and administrative data sets were used to identify 191,280 VHA patients who died between October 1, 2008, and September 30, 2012, and who had an acute inpatient episode in the VHA system in the last year of life. Patients were categorized as surgical if at any time during the year preceding death they underwent a surgical procedure (n = 42,143) or medical (n = 149,137) if the patient did not receive surgical treatment in the last year of life. MAIN OUTCOMES AND MEASURES: Receipt of palliative or hospice care and the number of days from palliative or hospice initiation to death were determined using VHA administrative inpatient, outpatient, and fee-based encounter-level data files. RESULTS: Surgical patients were significantly less likely than medical patients to receive either hospice or palliative care (odds ratio = 0.91; 95% CI, 0.89-0.94; P < .001). When adjusting for demographics and medical comorbidities, this difference was even more pronounced (odds ratio = 0.84; 95% CI, 0.81-0.86). Yet, among patients who received hospice or palliative care, surgical patients lived significantly longer than their medical counterparts (a median of 26 vs 23 days, respectively; P < .001) yet had similar relative use of these services after risk adjustment. CONCLUSIONS AND RELEVANCE: In the VHA population, surgical patients are less likely to receive either hospice or palliative care in the year prior to death compared with medical patients, yet surgical patients have a longer length of time in these services. Determining criteria for higher-risk medical and surgical patients may help with increasing the relative use of these services. Potential barriers and differences may exist among surgical and medical services that could impact the use of palliative care or hospice in the last year of life.

75 years of neurosurgery at the University of Minnesota.

Neurosurgery began as a distinct discipline at the University of Minnesota in 1937 with the appointment of William Peyton as head of the division. Under the leadership of Peyton, Lyle French, and Shelley Chou, the Department rose to national prominence. Substantial contributions included the introduction of dexamethasone to the practice of neurosurgery by Galicich and French, early procedures for the transthoracic correction of spinal deformity, important contributions to the understanding of brain death, the early laboratory work that led to the development of nimodopine, one of the first intraoperative magnetic resonance imaging facilities in the United States (1996), and the training of many academic neurosurgeons and department chairmen. The challenges of managed care and more recent changes in the health care system have been met, and the Department is a thriving clinical, educational, and research center for 21st-century neurosurgery.

Experience of the MACE procedure at a regional pediatric surgical unit: a 15-year retrospective review.

INTRODUCTION: The Malone antegrade continence enema (MACE) procedure is an established treatment option for children with constipation or fecal incontinence. This study retrospectively analyses the management and outcomes of children who underwent MACE procedures at a regional pediatric surgery unit. PATIENTS AND METHODS: Children who underwent a MACE procedure in our unit between 1998 and 2012 were identified. Demographic and clinical data were obtained from contemporaneous records. Using the continence scale described by Malone, overall outcomes were categorized as full, partial, or failure (full: totally clean or minor rectal leakage on night of washout; partial: clean but significant stoma or rectal leakage, occasional major leak and/or still wearing protection but perceived by child or parent to be an improvement; failure: regular soiling or constipation persisted, no perceived improvement, procedure was abandoned). Data entry and statistical analysis were performed using Excel and SPSS (IBM Corp., Armonk, New York, United States). RESULTS: A total of 40 children (29 male) were identified for inclusion. Underlying diagnoses were idiopathic constipation (16), anorectal anomalies (14) and Hirschprung's disease (10). The MACE procedure was performed laparoscopically in 26 cases and using an open technique in 14 cases. Mean age at the time of surgery was 8.9 years (range, 3-19 years) and mean follow-up time was 6.5 years (range, 1-10 years). Outcomes categorized as full were 62.5% for chronic idiopathic constipation (CIC), 71.4% for anorectal malformation (ARM), and 70% for Hirschsprung disease (HD). Overall success rates (full and partial outcomes combined) were 87.5% for CIC, 92.8% for ARM, 100% for HD, and 92.5% for all diagnoses taken together. Eleven MACE procedures (27.5%) were reversed, in seven (17.5%) due to the return of spontaneous and regular bowel movements and in four (10%) due to stomal problems. CONCLUSION: This study identified a high success rate (combining full and partial outcomes) of 92.5% for MACE procedures within our unit. An encouraging finding is that the procedure was reversed in a significant proportion of patients following the return of normal bowel habits.

[Challenges in building a surgical obesity center]. / Herausforderungen beim Aufbau eines operativen Adipositaszentrums.

BACKGROUND: It is estimated that approximately 1 million adults in Germany suffer from grade III obesity. The aim of this article is to describe the challenges faced when constructing an operative obesity center. METHODS: The inflow of patients as well as personnel and infrastructure of the interdisciplinary Diabetes and Obesity Center in Heidelberg were analyzed. The distribution of continuous data was described by mean values and standard deviation and analyzed using variance analysis. RESULTS: The interdisciplinary Diabetes and Obesity Center in Heidelberg was founded in 2006 and offers conservative therapeutic treatment and all currently available operative procedures. For every operative intervention carried out an average of 1.7 expert reports and 0.3 counter expertises were necessary. The time period from the initial presentation of patients in the department of surgery to an operation was on average 12.8 months (standard deviation SD ± 4.5 months). The 47 patients for whom remuneration for treatment was initially refused had an average body mass index (BMI) of 49.2 kg/m(2) and of these 39 had at least the necessity for treatment of a comorbidity. Of the 45 patients for whom the reason for the refusal of treatment costs was given as a lack of conservative treatment, 30 had undertaken a medically supervised attempt at losing weight over at least 6 months. Additionally, 19 of these patients could document participation in a course at a rehabilitation center, a Xenical® or Reduktil® therapy or had undertaken the Optifast® program. For the 20 patients who supposedly lacked a psychosomatic evaluation, an adequate psychosomatic evaluation was carried out in all cases. CONCLUSIONS: The establishment of an operative obesity center can last for several years. A essential prerequisite for success seems to be the constructive and targeted cooperation with the health insurance companies.

[Antibiotic prophylaxis and therapy of pancreatonecrosis in multifield surgical hospital].

The article is based on an analysis of results of complex treatment of 497 patients with pancreatonecrosis at the period from 2010 to 2014. All patients were admitted to the surgical departments of Republican hospital No 2 and Centre of Emergency Medicine of Republic of Sakha (Yakutia). The investigation allowed adaptation and development of antibiotic prophylaxis and therapy management in pancreatonecrosis in multifield surgical hospital. More than 80% of patients avoided a contamination of necrotic destruction zones. The level of lethality was reduced in group of patients with infectious complications of pancreatonecrosis from 45.8% to 37.7%.

[Preoperative chemotherapy in the surgical treatment of colorectal liver metastases]. / Preoperatív kemoterápia a colorectalis májáttétes betegek sebészi kezelésében.

INTRODUCTION: The only curative treatment of colorectal liver metastases (CRLM) is surgical resection. Preoperative/neoadjuvant chemotherapy can be used for resectable, for borderline resectable or even for irresectable CRLM patients. PATIENTS: Data of CRLM patients treated with surgical resection at the Uzsoki Hospital were analysed. Patients were classified into two groups, (A) who received preoperative chemotherapy before hepatic resection, and (B) who received no chemotherapy before resection. RESULTS: Between 01.01.2007. and 31.12.2010. 128 CRLM patients were treated with hepatic resection. 68 patients (53%) received chemotherapy before hepatic resection, 60 patients (47%) were resected without neoadjuvant chemotherapy. There was no significant difference in the complications between the groups (p = 0.39). Median overall survival was 41 months. The progression free survival (PFS) at 3 and 5 years were 25%, the 3 and 5 year overall survival (OS) were 55% and 31%. Both PFS and OS were significantly worse in the chemotherapy group (p = 0.014, p = 0.015). The subgroup of patients receiving bevacizumab containing preoperative chemotherapy has significanly better PFS than patients receiving only cytotoxic chemotherapy (p = 0.004). CONCLUSION: Surgical resection of CRLM patients results good survival data even in non-selected patients, although the very long survival results reported in the literature couldn't have been reproduced in this patient population. When preoperative chemotherapy was combined with bevacizumab, survival was similar to the upfront resected patients.