A Novel Surgical Patient Engagement Model: A Qualitative Study of Postoperative Patients.

BACKGROUND: Strong patient engagement is often associated with better postoperative outcomes and reduced risk of dangerous and expensive complications for the patient. Our goal with this project is to define a new model specifically for surgical patient engagement to guide future work to improve patient outcomes. METHODS: Open-ended qualitative interviews were conducted with 38 postoperative patients, analyzed using the conventional content analysis method, and coded with NVivo 11. Patients from either a safety net or private hospital in the Houston area between the ages of 18 and 70 y were recruited after surgery for either thyroid, parathyroid, colon, or rectal cancer, inflammatory bowel disease, and diverticulitis. Pregnant and incarcerated patients in addition to those with postoperative complications or interview time frames greater than 4 wk postoperatively were excluded. RESULTS: Of patients completing the Patient Activation Measure, 98% obtained a score of 3 or 4, indicating optimal levels of activation despite differences in socio-economic status. Upon analysis of coded transcripts, four main themes of "self-efficacy," "resilience," "transitional agency," and "enabling agency," in addition to a fifth emergency rescue activator, "family and social support," were discovered as "drivers" of patient engagement. CONCLUSIONS: A novel model of patient engagement specific to surgical patients is necessary because of the unique recovery track they endure. Our new model can be used to develop interventions for these patients to improve their engagement and thereby their outcomes.

Use of Game Theory to model patient engagement after surgery: a qualitative analysis.

BACKGROUND: Patient engagement is challenging to define and operationalize. Qualitative analysis allows us to explore patient perspectives on this topic and establish themes. A game theoretic signaling model also provides a framework through which to further explore engagement. METHODS: Over a 6-mo period, thirty-eight interviews were conducted within 6 wk of discharge in patients undergoing thyroid, parathyroid, or colorectal surgery. Interviews were transcribed, anonymized, and analyzed using the NVivo 11 platform. A signaling model was then developed depicting the doctor-patient interaction surrounding the patient's choice to reach out to their physician with postoperative concerns based upon the patient's perspective of the doctor's availability. This was defined as "engagement". We applied the model to the qualitative data to determine possible causations for a patient's engagement or lack thereof. A private hospital's and a safety net hospital's populations were contrasted. RESULTS: The private patient population was more likely to engage than their safety-net counterparts. Using our model in conjunction with patient data, we determined possible etiologies for this engagement to be due to the private patient's perceived probability of dealing with an available doctor and apparent signals from the doctor indicating so. For the safety-net population, decreased access to care caused them to be less willing to engage with a doctor perceived as possibly unavailable. CONCLUSIONS: A physician who understands these Game Theory concepts may be able to alter their interactions with their patients, tailoring responses and demeanor to fit the patient's circumstances and possible barriers to engagement.

Population-level outcomes of early versus delayed appendectomy for acute appendicitis using the American College of Surgeons National Surgical Quality Improvement Program.

BACKGROUND: The optimal timing of appendectomy for acute appendicitis has been analyzed with mixed results. We hypothesized that delayed appendectomy would be associated with increased 30-d morbidity and mortality. MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients undergoing nonelective appendectomy from 2012 to 2015 with a postoperative diagnosis of appendicitis. Patients were grouped based on hospital day (HD) of operation. Primary outcomes included 30-d mortality and major complications. Logistic regression was performed to determine predictors of major morbidity and mortality. RESULTS: From 2012 to 2015, 112,122 patients underwent appendectomy for acute appendicitis. Appendectomies performed on HD 3 had significantly worse outcomes as demonstrated by increased 30-d mortality (0.6%) and all major postoperative complications (8%) in comparison with operations taking place on HD 1 (0.1%; 3.4%) or HD 2 (0.1%, P < 0.001; 3.6%, P < 0.001). In subgroup analysis, open operations had significantly higher mortality and major postoperative complications, including organ/space surgical site infections (4.6% open versus 2.1% laparoscopic; P < 0.001). Patients with decreased baseline physical status by the American Society of Anesthesiologists Physical Status class had the worst outcomes (1.5% mortality; 14% major complications) when operation was delayed to HD 3. Logistic regression revealed higher American Society of Anesthesiologists Physical Status class and open operations as predictors of major complications; however, HD was not (P = 0.2). CONCLUSIONS: Data from the American College of Surgeons National Surgical Quality Improvement Program demonstrate similar outcomes of appendectomy for acute appendicitis when the operation is performed on HD 1 or 2; however, outcomes are significantly worse for appendectomies delayed until HD 3. Increased complications in this group are likely not attributable to HD of operation, but rather decreased baseline health status and procedure type.

IMAGING LOCALIZATION AND SURGICAL APPROACH IN THE MANAGEMENT OF ECTOPIC PARATHYROID ADENOMAS.

OBJECTIVE: ( 1) Review the anatomy and epidemiology of ectopic parathyroid adenomas (EPAs), ( 2) summarize the role of relevant imaging modalities in the localization of EPAs, and ( 3) characterize surgical approaches for various ectopic locations. METHODS: Literature review of published English-language articles from 1995 through August 2017. RESULTS: Summary of the literature indicates that the prevalence of EPA is approximately 20% in unexplored patients with primary hyperparathyroidism, but it is as high as 66% in re-operative patients. EPAs may be located anywhere from the carotid bifurcation to the aorto-pulmonary window. Ultrasound has limited accuracy in identifying EPAs except near the thyroid and thyrothymic ligament and requires expert experience from the user. Among dual-phase 99mTc sestamibi scintigraphy techniques, hybrid imaging with both single-photon emission computed tomography (SPECT) and computed tomography (CT) (SPECT/CT) is superior to planar scintigraphy or SPECT alone at localizing EPAs. Four-dimensional computed tomography (4DCT) precisely delineates important anatomic relationships and is highly sensitive in localizing EPAs. Although 4DCT requires radiation, intravenous iodinated contrast, and reader experience, it is well-equipped to detect lesions at various ectopic sites and guide the surgical approach. EPAs frequently require alternative surgical approaches. Re-operative parathyroidectomy may be attempted in patients having previously undergone bilateral neck exploration by an experienced surgeon once the lesion is colocalized by 2 repeat imaging modalities. Removal of nonlocalized disease requires a careful and systematic exploration of superior and inferior gland locations. CONCLUSION: EPAs pose challenges during both localization and surgical removal. High-volume experience and multidisciplinary care are necessary for optimal outcomes. ABBREVIATIONS: CT = computed tomography; 4DCT = 4-dimensional CT; EPA = ectopic parathyroid adenoma; EPG = ectopic parathyroid gland; PHPT = primary hyperparathyroidism; RLN = recurrent laryngeal nerve; SPECT = single-photon emission computed tomography; TE = tracheo-esophageal.

Endovascular management of traumatic peripheral arterial injuries.

BACKGROUND: Traumatic injuries to peripheral arterial vessels are increasingly managed with endovascular techniques. Early small series have suggested that endovascular therapy is feasible and decreases operative blood loss, but these data are limited. The purpose of this study was to evaluate the feasibility and outcomes of endovascular management of nonaortic arterial trauma. MATERIALS AND METHODS: We reviewed records of traumatic nonaortic arterial injuries presenting at an urban level 1 trauma center from December 2009-July 2013. Patients undergoing treatment in interventional radiology and patients whose injuries occurred >72 h before presentation were excluded. Demographics, indicators of injury severity, operative blood loss, transfusion requirements, and clinical outcome were compared between patients undergoing endovascular and open management using appropriate inferential statistics. RESULTS: During the study period, 17 patients underwent endovascular interventions and 20 had open surgery. There were 19 upper extremity and/or thoracic outlet arterial injuries, 15 lower extremity injuries and 11 pelvic injuries. Endovascular cases were completed using a vascular imaging C-arm in a standard operating room. Estimated blood loss during the primary procedure was significantly lower with endovascular management (150 versus 825 cc, P < 0.001). No differences were observed between cohorts in age, injury severity score, intensive care unit length of stay, arterial pH, transfusion requirements, inpatient complication rate, or mortality. CONCLUSIONS: Our experience with endovascular management demonstrates its feasibility with commonly available tools. Operative blood loss may be significantly decreased using endovascular techniques. Further study is needed to refine patient selection criteria and to define long-term outcomes.

Surgical follow-up costs disproportionately impact low-income patients.

BACKGROUND: Surgical procedures have significant costs at the national level, but the financial burden on patients is equally important. Patients' out-of-pocket costs for surgery and surgical care include not only direct medical costs but also the indirect cost of lost wages and direct nonmedical costs including transportation and childcare. We hypothesized that the nonmedical costs of routine postoperative clinic visits disproportionately impact low-income patients. MATERIALS AND METHODS: This was a cross-sectional study performed in the postoperative acute care surgery clinic at a large, urban county hospital. A survey containing items about social, demographic, and financial data was collected from ambulatory patients. Nonmedical costs were calculated as the sum of transportation, childcare, and lost wages. Costs and cost to income ratios were compared between income strata. RESULTS: Ninety-seven patients responded to the survey of which 59 reported all items needed for cost calculations. The median calculated cost of a clinic visit was $27 (interquartile range $18-59). Components of this cost were $16 ($14-$20) for travel, $22 ($17-$50) for childcare among patients requiring childcare, and $0 ($0-$30) in lost wages. Low-income patients had significantly higher (P = 0.0001) calculated cost to income ratios, spending nearly 10% of their monthly income on these costs. CONCLUSIONS: The financial burden of routine postoperative clinic visits is significant. Consistent with our hypothesis, the lowest income patients are disproportionately impacted, spending nearly 10% of their monthly income on costs associated with the clinic visit. Future cost-containment efforts should examine alternative, lower cost methods of follow-up, which reduce financial burden.

Use of Twitter to document the 2013 Academic Surgical Congress.

BACKGROUND: Social media is a cornerstone of modern society and its use in health care has rapidly expanded in recent years. "Live Tweeting" of professional meetings is a growing way for participants to communicate with peers. The goal of this study was to analyze the initial experience with implementation of a Twitter Team at the 2013 Academic Surgical Congress (ASC). MATERIALS AND METHODS: Four ASC attendees were designated as the "Twitter Team" for the 2013 meeting. Organizational leadership prominently promoted the unique meeting hashtag (#2013ASC). Twdocs and TweetReach were used to aggregate data 1 wk after the meeting. RESULTS: A total of 58 independent users posted tweets with the #2013ASC hashtag during the week of the meeting. Total tweets numbered 434, with 288 original tweets. Of the 37 users who were identifiable individuals, 19 were in attendance at the ASC; 18 of the identifiable individuals were members of either the Association for Academic Surgery and/or the Society of University Surgeons. The ASC Twitter Team was responsible for 76% of all #2013ASC tweets. The three most common content areas for tweets were promotional (147), content related from presidential sessions (96), and social (75). CONCLUSIONS: Twitter provides a meaningful social media format for sharing information during academic surgical meetings. The use of Twitter sharply expands the available audience for meeting proceedings and broadens the discussion venue for scholarly activity. "Tweeting the meeting" represents an important future direction for information dissemination in academic surgery.

Utility of routine postoperative visit after appendectomy and cholecystectomy with evaluation of mobile technology access in an urban safety net population.

BACKGROUND: The value of routine postoperative visits after general surgery remains unclear. The objective of this study was to evaluate the utility of routine postoperative visits after appendectomy and cholecystectomy and to determine access to mobile technology as an alternative platform for follow-up. METHODS: Retrospective review of 219 appendectomies and 200 cholecystectomies performed at a safety net hospital. One patient underwent both surgeries. Patient demographics, duration of clinic visit, and need for additional imaging, tests or readmissions were recorded. Access to mobile technology was surveyed by a validated questionnaire. RESULTS: Of 418 patients, 84% percent completed a postoperative visit. At follow-up, 58 patients (14%) required 70 interventions, including staple removal (16, 23%), suture removal (4, 6%), drain removal (8, 11%), additional follow-up (20, 28%), medication action (16, 21%), additional imaging (3, 4%), and readmission (1, 1%). Occupational paperwork (62) and nonsurgical clinic referrals (28) were also performed. Average check-in to check-out time was 100 ± 54 min per patient. One intervention was performed for every 7.8 h of time in the clinic. Additionally, 88% of the surveyed population reported access to cell phone technology, and 69% of patients <40 y had smartphone access. CONCLUSIONS: Routine in-person follow-up after surgery consumes significant time and resources for patients and healthcare systems but has little impact on patient care. Most of the work done in the clinic is administrative and could be completed using mobile technology, which is pervasive in our population.

Thyroid lobectomy for indeterminate FNA: not without consequences.

BACKGROUND: Thyroid nodules are exceedingly common, and the cytologic interpretation of fine needle aspiration (FNA) findings has been the reference standard for diagnosing nodules as benign, atypia or a follicular lesion of undetermined significance, suspicious for follicular or Hürthle cell neoplasm, suspicious for malignancy, or malignant. Many patients undergo thyroid lobectomy for indeterminate FNA findings (atypia or a follicular lesion of undetermined significance or suspicious for follicular or Hürthle cell neoplasm), although the risk of malignancy is low. The general data have quoted a 20% risk of hypothyroidism after lobectomy. The purpose of the present study was to determine the risk of hypothyroidism after lobectomy in our diverse population. METHODS: The pathology records from a large county hospital were reviewed to identify patients with indeterminate FNA findings. The incidence of hypothyroidism was determined by the need for thyroid hormone replacement therapy. Categorical variables were compared using the chi-square and continuous variables using the Mann-Whitney U test. RESULTS: A total of 655 FNAs were performed during the study period, and 60 resulted in indeterminate cases. Of these 60 patients, 17 subsequently underwent diagnostic lobectomy. The mean age was 52.8 ± 16.5 years, 88% were women, and 67% were Hispanic and 22% were African American. Only 6% had a final diagnosis of cancer, and eight patients (47%) became hypothyroid postoperatively. CONCLUSIONS: The incidence of hypothyroidism after diagnostic thyroid lobectomy in our patient population was much higher than previously reported. It is necessary to preoperatively counsel patients about this increased risk, in addition to the usual risks of nerve palsy and bleeding, with thyroid lobectomy. As testing of thyroid nodules evolves, the expense of preoperative testing should be weighed against the increased incidence for lifelong thyroid hormone replacement.

Assessment and standardization of resident handoff practices: PACT project.

BACKGROUND: Accreditation Council for Graduate Medical Education duty hour guidelines have resulted in increased patient care transfers. Although structured hand-over processes are required in the guidelines, how to implement these processes is not defined. The purpose of this study is to investigate current handoff methods at our center in order to develop an effective structured handoff process. MATERIALS AND METHODS: This is a prospective study conducted at two hospitals with large in-house patient censuses. Resident focus groups were used to define current practices and future directions. Based on this input, we developed a direct observation handoff analysis tool to study time spent in handoffs, content, quality, and number of interruptions. RESULTS: Trained medical students observed 86 handoffs. Survey response rates among junior and senior residents were 63% and 54%, respectively. Average daily patient census was 36 ± 10 patients with an average handoff time of 12 ± 9 min. There were 1.5 ± 1.8 interruptions per handoff. The majority of handoffs were unstructured. Based on information they were given in the handoff, junior residents had a 58% rate of incompletion of the assigned tasks and 54% incidence of being unable to answer a key patient status question. CONCLUSIONS: Current handoffs are primarily unstructured, with significant deficits. Determination of key elements of an effective handoff coupled with evaluation of existing deficiencies in our program is essential in developing an institution-specific method for effective handoffs. We propose utilization of the mnemonic PACT (Priority, Admissions, Changes, Task) to standardize handoff communication.

A multicenter, randomized controlled trial of immediate total-body CT scanning in trauma patients (REACT-2).

BACKGROUND: Computed tomography (CT) scanning has become essential in the early diagnostic phase of trauma care because of its high diagnostic accuracy. The introduction of multi-slice CT scanners and infrastructural improvements made total-body CT scanning technically feasible and its usage is currently becoming common practice in several trauma centers. However, literature provides limited evidence whether immediate total-body CT leads to better clinical outcome then conventional radiographic imaging supplemented with selective CT scanning in trauma patients. The aim of the REACT-2 trial is to determine the value of immediate total-body CT scanning in trauma patients. METHODS/DESIGN: The REACT-2 trial is an international, multicenter randomized clinical trial. All participating trauma centers have a multi-slice CT scanner located in the trauma room or at the Emergency Department (ED). All adult, non-pregnant, severely injured trauma patients according to predefined criteria will be included. Patients in whom direct scanning will hamper necessary cardiopulmonary resuscitation or who require an immediate operation because of imminent death (both as judged by the trauma team leader) are excluded. Randomization will be computer assisted. The intervention group will receive a contrast-enhanced total-body CT scan (head to pelvis) during the primary survey. The control group will be evaluated according to local conventional trauma imaging protocols (based on ATLS guidelines) supplemented with selective CT scanning. Primary outcome will be in-hospital mortality. Secondary outcomes are differences in mortality and morbidity during the first year post trauma, several trauma work-up time intervals, radiation exposure, general health and quality of life at 6 and 12 months post trauma and cost-effectiveness. DISCUSSION: The REACT-2 trial is a multicenter randomized clinical trial that will provide evidence on the value of immediate total-body CT scanning during the primary survey of severely injured trauma patients. If immediate total-body CT scanning is found to be the best imaging strategy in severely injured trauma patients it could replace conventional imaging supplemented with CT in this specific group. TRIAL REGISTRATION: ClinicalTrials.gov: (NCT01523626).

Durability of focused minimally invasive parathyroidectomy in young patients with sporadic primary hyperparathyroidism.

BACKGROUND: Historically, multigland hyperplasia was believed to be the predominant cause of primary hyperparathyroidism (PHPT) in young patients, and hence a relative contraindication for minimally invasive parathyroidectomy. Recent studies, however, demonstrate that the most common aetiology across all age groups is a solitary functioning adenoma. The aim of this study was to compare long-term outcomes in young patients (≤ 45 years), especially those under 30 years of age, with their older counterparts (> 45 years) following focused minimally invasive parathyroidectomy (FMIP). MATERIALS AND METHODS: Patients ≤ 45 years who underwent FMIP between January 1999 and December 2007 were identified from an endocrine surgery database and compared with a matched control group of patients > 45 years old also undergoing FMIP within that time period. The patients' most recent calcium levels (≥ 6 months postoperatively) were examined to establish recurrence rates. Recurrence was defined as an elevation of serum calcium more than 6 months after surgery following initial postsurgical normocalcemia. RESULTS: A total of 117 patients ≤ 45 years and 160 patients > 45 years who underwent FMIP were examined. Follow-up calcium levels were available for 72% of patients. The median length of follow-up was 46 months. No recurrences were identified in both the younger and older cohort of patients; therefore, no statistically significant difference in rates of recurrence could be determined between age groups. CONCLUSION: Recurrence of PHPT following FMIP is rare with no evidence of a higher incidence in younger patients. FMIP can be safely offered to young patients as a long-term durable treatment option.

Adrenal incidentalomas: risk of adrenocortical carcinoma and clinical outcomes.

INTRODUCTION: The number of incidentally discovered adrenal lesions is increasing due to the widespread use of abdominal imaging. Although most incidentalomas are benign, larger suspicious lesions will require adrenalectomy. The aim of this study is to determine the risk of malignancy in patients undergoing surgery for adrenal incidentaloma; and to compare clinical outcomes in those with adrenocortical carcinoma (ACC) based on the mode of presentation. METHODS: A retrospective study of consecutive patients who underwent adrenalectomy between 1995 and 2008 was performed. Data were retrieved from a prospectively maintained adrenal tumor database. Those with adrenal incidentaloma were selected and histopathology reviewed. All patients with ACC (presenting with symptoms or incidentally) during the same time period were identified and clinical outcomes compared. RESULTS: Adrenalectomy was performed in 274 patients of whom 73 (27%) were characterized pre-operatively as incidentaloma. Benign, non-functioning adrenocortical adenoma was the most common histopathological finding (46 patients, 63%). There was a trend (P = 0.08) towards increased survival amongst the seven patients with ACC presenting incidentally compared to the nine patients with symptomatic ACC. CONCLUSIONS: Adrenal incidentalomas have a small but important risk of malignancy. ACC presenting as incidentaloma appear to have a more favorable prognosis than symptomatic or functioning ACC.

Osseous Manifestations of Primary Hyperparathyroidism: Imaging Findings.

Primary hyperparathyroidism is a systemic endocrine disease that has significant effects on bone remodeling through the action of parathyroid hormone on the musculoskeletal system. These findings are important as they can aid in distinguishing primary hyperparathyroidism from other forms of metabolic bone diseases and inform physicians regarding disease severity and complications. This pictorial essay compiles bone-imaging features with the aim of improving the diagnosis of skeletal involvement of primary hyperthyroidism.

PulseCam: a camera-based, motion-robust and highly sensitive blood perfusion imaging modality.

Blood carries oxygen and nutrients to the trillions of cells in our body to sustain vital life processes. Lack of blood perfusion can cause irreversible cell damage. Therefore, blood perfusion measurement has widespread clinical applications. In this paper, we develop PulseCam - a new camera-based, motion-robust, and highly sensitive blood perfusion imaging modality with 1 mm spatial resolution and 1 frame-per-second temporal resolution. Existing camera-only blood perfusion imaging modality suffers from two core challenges: (i) motion artifact, and (ii) small signal recovery in the presence of large surface reflection and measurement noise. PulseCam addresses these challenges by robustly combining the video recording from the camera with a pulse waveform measured using a conventional pulse oximeter to obtain reliable blood perfusion maps in the presence of motion artifacts and outliers in the video recordings. For video stabilization, we adopt a novel brightness-invariant optical flow algorithm that helps us reduce error in blood perfusion estimate below 10% in different motion scenarios compared to 20-30% error when using current approaches. PulseCam can detect subtle changes in blood perfusion below the skin with at least two times better sensitivity, three times better response time, and is significantly cheaper compared to infrared thermography. PulseCam can also detect venous or partial blood flow occlusion that is difficult to identify using existing modalities such as the perfusion index measured using a pulse oximeter. With the help of a pilot clinical study, we also demonstrate that PulseCam is robust and reliable in an operationally challenging surgery room setting. We anticipate that PulseCam will be used both at the bedside as well as a point-of-care blood perfusion imaging device to visualize and analyze blood perfusion in an easy-to-use and cost-effective manner.

Supplementing Glycine and N-acetylcysteine (GlyNAC) in Aging HIV Patients Improves Oxidative Stress, Mitochondrial Dysfunction, Inflammation, Endothelial Dysfunction, Insulin Resistance, Genotoxicity, Strength, and Cognition: Results of an Open-Label Clinical Trial.

Background: Patients with HIV (PWH) develop geriatric comorbidities, including functional and cognitive decline at a younger age. However, contributing mechanisms are unclear and interventions are lacking. We hypothesized that deficiency of the antioxidant protein glutathione (GSH) contributes to multiple defects representing premature aging in PWH, and that these defects could be improved by supplementing the GSH precursors glycine and N-acetylcysteine (GlyNAC). Methods: We conducted an open label clinical trial where eight PWH and eight matched uninfected-controls were studied at baseline. PWH were studied again 12-weeks after receiving GlyNAC, and 8-weeks after stopping GlyNAC. Controls did not receive supplementation. Outcome measures included red-blood cell and muscle GSH concentrations, mitochondrial function, mitophagy and autophagy, oxidative stress, inflammation, endothelial function, genomic damage, insulin resistance, glucose production, muscle-protein breakdown rates, body composition, physical function and cognition. Results: PWH had significant defects in measured outcomes, which improved with GlyNAC supplementation. However, benefits receded after stopping GlyNAC. Conclusions: This open label trial finds that PWH have premature aging based on multiple biological and functional defects, and identifies novel mechanistic explanations for cognitive and physical decline. Nutritional supplementation with GlyNAC improves comorbidities suggestive of premature aging in PWH including functional and cognitive decline, and warrants additional investigation.

Clinical significance of distinguishing between follicular lesion and follicular neoplasm in thyroid fine-needle aspiration biopsy.

BACKGROUND: Subclassifying indeterminate thyroid fine-needle aspiration (FNA) biopsy findings as follicular lesion or follicular neoplasm has been suggested as useful in triaging patients to observation or surgery, respectively. However, terminology and therefore the probability of malignancy vary between pathologists and institutions. The purpose of this study was to evaluate a single institution's experience with indeterminate thyroid FNA results to determine if subclassification (neoplasm versus lesion) aids in identifying patients at higher risk for malignancy. METHODS: From 1990 to 2006, all patients with indeterminate thyroid FNA results (follicular lesion or neoplasm) at The University of Texas M.D. Anderson Cancer Center were evaluated for FNA correlation with the surgical specimen diagnosis. Patients with FNAs suspicious for papillary thyroid carcinoma or with definitive malignant disease (i.e., metastases) were excluded. RESULTS: Indeterminate FNA results were present in 540 patients, including 410 as follicular lesion and 130 as follicular neoplasm. Two hundred ninety-seven (55.0%) patients underwent surgical resection: 199 (48.5%) follicular lesions and 98 (75.4%) follicular neoplasms. Incidence of malignancy was higher in thyroid nodules classified as neoplasm compared with lesion (21.4% versus 7.0%, respectively; P=0.0005) and increased in follicular neoplasms with nodule size (37.5% malignant if nodule was [4 cm, P=0.03). CONCLUSIONS: Subclassification of indeterminate thyroid FNA biopsy results into neoplasm and lesion successfully defines high- and low-risk nodules, respectively. These findings support surgical resection for follicular neoplasms, selective use of surgical intervention for follicular lesions at our institution, and continued efforts to define unified terminology between institutions.

Analysis of Human Performance Deficiencies Associated With Surgical Adverse Events.

Importance: Potentially preventable adverse events remain a formidable cause of patient harm and health care expenditure despite advances in systems-based risk-reduction strategies. Objective: To analyze and describe the incidence of human performance deficiencies (HPDs) during the provision of surgical care to identify opportunities to enhance patient safety. Design, Setting, and Participants: This quality improvement study used a new taxonomy to inform the development and implementation of an HPD classifier tool to categorize HPDs into errors associated with cognitive, technical, and team dynamic functions. The HPD classifier tool was then used to concurrently analyze surgical adverse events in 3 adult hospital affiliates-a level I municipal trauma center, a quaternary care university hospital, and a US Veterans Administration hospital-from January 2, 2018, to June 30, 2018. Surgical trainees presented data describing all adverse events associated with surgical services at weekly hospital-based morbidity and mortality conferences. Adverse events and HPDs were classified in discussion with attending faculty and residents. Data were analyzed from July 9, 2018, to December 23, 2018. Main Outcomes and Measures: The incidence and primary and secondary causes of HPDs were classified using an HPD classifier tool. Results: A total of 188 adverse events were recorded, including 182 adverse events (96.8%) among 5365 patients who underwent surgical operations and 6 adverse events (3.2%) among patients undergoing nonoperative treatment. Among these 188 adverse events, 106 (56.4%) were associated with HPDs. Among these 106 HPD adverse events, a total of 192 HPDs (mean [SD], 1.8 [0.9] HPDs per HPD event) were identified. Human performance deficiencies were categorized as execution (98 HPDs [51.0%]), planning or problem solving (55 HPDs [28.6%]), communication (24 HPDs [12.5%]), teamwork (9 HPDs [4.7%]), and rules violation (6 HPDs [3.1%]). Human performance deficiencies most commonly presented as cognitive errors in execution of care or in case planning or problem solving (99 of 192 HPDs [51.6%]). In contrast, technical execution errors without other associated HPDs were observed in 20 of 192 HPDs (10.4%). Conclusions and Relevance: Human performance deficiencies were identified in more than half of adverse events, most commonly associated with cognitive error in the execution of care. These data provide a framework and impetus for new quality improvement initiatives incorporating cognitive training to mitigate human error in surgery.

Ideal timing of early cholecystectomy for acute cholecystitis: An ACS-NSQIP review.

BACKGROUND: Current guidelines fail to specify optimal timing of early cholecystectomy for acute cholecystitis. We hypothesized delaying operation past hospital day (HD) 2 would result in increased 30-day morbidity and mortality. METHODS: The ACS-NSQIP database was queried from 2012 to 2015 for all cholecystectomies for acute cholecystitis from HD 1-7. RESULTS: Delay in cholecystectomy to HD 3-7 was observed in 30% of patients with acute cholecystitis. Patients undergoing operation on HD 3-7 were older with higher rates of comorbidities (median 58yrs; 66%) than HD 1 (48yrs; 51%) or HD 2 (51yrs, p < 0.001; 55%, p < 0.001). Operations on HD 3-7 had increased 30-day mortality (1.0%) and morbidity (12%) in comparison to HD 1 (0.3%, 7%) or HD 2 (0.5%, p < 0.001; 8%, p < 0.001). On multivariable analysis, HD was an independent predictor of mortality (OR 1.15, 95% CI [1.04-1.26]). CONCLUSIONS: Acute cholecystitis should be treated with an urgent operation within 2 days of admission due to increased morbidity and mortality when delayed past HD 2.