Psychosocial Determinants of Readmission After Surgery.

BACKGROUND: Quality of life and psychosocial determinants of health, such as health literacy and social support, are associated with increased health care utilization and adverse outcomes in medical populations. However, the effect on surgical health care utilization is less understood. OBJECTIVE: We sought to examine the effect of patient-reported quality of life and psychosocial determinants of health on unplanned hospital readmissions in a surgical population. RESEARCH DESIGN: This is a prospective cohort study using patient interviews at the time of hospital discharge from a Veterans Affairs hospital. SUBJECTS: We include Veterans undergoing elective inpatient general, vascular, or thoracic surgery (August 1, 2015-June 30, 2017). MEASURES: We assessed unplanned readmission to any medical facility within 30 days of hospital discharge. RESULTS: A total of 736 patients completed the 30-day postoperative follow-up, and 16.3% experienced readmission. Lower patient-reported physical and mental health, inadequate health literacy, and discharge home with help after surgery or to a skilled nursing or rehabilitation facility were associated with an increased incidence of readmission. Classification regression identified the patient-reported Veterans Short Form 12 (SF12) Mental Component Score <31 as the most important psychosocial determinant of readmission after surgery. CONCLUSIONS: Mental health concerns, inadequate health literacy, and lower social support after hospital discharge are significant predictors of increased unplanned readmissions after major general, vascular, or thoracic surgery. These elements should be incorporated into routinely collected electronic health record data. Also, discharge plans should accommodate varying levels of health literacy and consider how the patient's mental health and social support needs will affect recovery.

Symptomatic Diaphragmatic Hernia after Thoracofemoral Bypass.

Despite its relative underutilization in the primary management of aortoiliac occlusive disease, thoracofemoral bypass is an attractive extra-anatomic surgical option in select patients. Thoracofemoral bypass classically entails passing a graft from the left chest into the retroperitoneal space through a small opening created in the diaphragm. While theoretically possible that this maneuver may predispose to a peri-graft diaphragmatic hernia, currently there are no cases of this complication reported in the literature, nor has its surgical repair been described. This case illustrates the rare complication of symptomatic diaphragmatic hernia following a thoracobifemoral bypass.

Axillary-bifemoral and axillary-unifemoral artery grafts have similar perioperative outcomes and patency.

OBJECTIVE: It has been suggested that more bypass outflow targets for bypass grafts improve patency and outcomes. Our objective was to examine this in a multicenter contemporary series of axillary to femoral artery grafts. METHODS: The Vascular Quality Initiative database was queried for all axillary-unifemoral (AxUF) and axillary-bifemoral (AxBF) bypass grafts performed between 2010 and 2017 for claudication, rest pain, and tissue loss. Patients with acute limb ischemia were excluded. Patients' demographics and comorbidities as well as operative details and outcomes were recorded. Univariable, multivariable, and Kaplan-Meier analyses were used to assess long-term outcomes. RESULTS: There were 412 (32.9%) AxUF grafts and 839 (67.1%) AxBF grafts identified. Overall, the mean age of the patients was 68.3 years, 51.1% were male, and 84.7% were white. Compared with AxBF grafts, AxUF grafts were more often performed for urgent cases; in patients who were younger, male, nonambulatory, and diabetic; and in those with preoperative anticoagulation, critical limb ischemia, prior bypass, aneurysm repair, peripheral vascular intervention, and major amputation (P < .05 for all). There were no significant differences between AxUF and AxBF grafts in perioperative wound complications (4.2% vs 2.9%; P = .23), cardiac complications (7.3% vs 10.4%; P = .08), pulmonary complications (4.1% vs 6%, P = .18), early stenosis/occlusion (0.2% vs 0.8%; P = .22), perioperative mortality (2.9% vs 3.2%; P = .77), and length of stay (6.4 ± 5.6 days vs 6.7 ± 8 days; P = .29). The mean estimated blood loss (268.1 mL vs 348.6 mL; P < .001) and mean operative time (201 minutes vs 224.1 minutes; P < .001) were significantly lower for AxUF grafts. Kaplan-Meier analysis showed that AxUF and AxBF grafts had similar freedom from graft occlusion (62.6% vs 71.8%; P = .074), major adverse limb event-free survival (57.1% vs 66.6%; P = .052), and survival (86% vs 86%; P = .897) at 1 year. Major amputation-free survival was lower for AxUF grafts (63.7% vs 73%; P = .028). Multivariable analysis also showed that the type of graft configuration did not independently predict occlusion/death (hazard ratio [HR], 1.06; 95% confidence interval [CI], 0.77-1.46; P = .72), amputation/death (HR, 1.12; 95% CI, 0.83-1.51; P = .45), major adverse limb event/death (HR, 0.97; 95% CI, 0.73-1.3; P = .85), or mortality (HR, 0.91; 95% CI, 0.65-1.26; P = .55). Three-year survival after placement of AxUF and AxBF grafts was similar (75.1% vs 78.2%; P = .414). CONCLUSIONS: AxUF and AxBF grafts have similar perioperative and 1-year outcomes. Graft patency was not significantly different between an AxBF graft and an AxUF graft at 1 year. Overall, patients treated with these reconstructions have many comorbidities and low long-term survival.

Growth factor directed chondrogenic differentiation of porcine bone marrow-derived progenitor cells.

BACKGROUND: Despite advances in surgical technique, reconstruction of a mandibular condyle still causes significant donor-site morbidity. The purpose of this study was to compare the effect of 3 different growth factors and define optimal cell culture conditions for bone marrow-derived progenitor cells to differentiate into chondrocytes for mandibular condyle reconstruction. METHODS: Porcine bone marrow-derived progenitor cells (pBMPCs) were cultured as a pellet for 2, 3, and 4 weeks under the following conditions: group 1, TGF-ß3 + standard medium; group 2, TGF-ß3 + BMP-2 + standard medium; group 3, TGF-ß3 + IGF-1 + standard medium; and group 4, TGF-ß3 + BMP-2 + IGF-1 + standard medium. Chondrogenic differentiation was evaluated using 3 lineage differentiation markers. RESULTS: The mean type II collagen positive area increased over weeks 2, 3, and 4 in group 4 compared to all the other groups (ANOVA; P = 0.005). At week 4, there was significantly greater type II collagen production in group 4 compared to all the other groups (ANOVA; P = 0.003). The medium in group 4 produces the greatest amount of cartilage when compared to groups 1, 2, and 3, and that 4 weeks produces the greatest amount of type II collagen. CONCLUSIONS: The results of this study indicate that the most efficacious medium for chondrogenic differentiation of pBMPCs was group 4 medium and the most type II collagen was produced at 4 weeks.

Human acellular dermal matrix grafts for rhinoplasty.

Rhinoplasty often relies on graft material for structural support in the form of cartilage, bone grafts, or fascia. In addition, pliable grafts are often helpful for contouring and can function as a barrier. Unfortunately, grafts carry the disadvantage of requiring an additional donor site, with associated complications. Human acellular dermal matrix (ADM) biological implants offer an exciting alternative for structural support and nonstructural implantation in rhinoplasty procedures. To examine the efficacy of ADM placement in rhinoplasty and septoplasty, the authors report the results from a series of 51 patients. In this series, there were no cases of infection, skin discoloration, seroma formation, septal perforation, significant resorption, extrusion, or other complications related to ADM placement. Therefore, the authors believe that ADM offers a safe and effective alternative to traditional grafting methods for functional and aesthetic rhinoplasty.

The effects of systemic, intrastriatal, and intrapallidal injections of caffeine and systemic injections of A2A and A1 antagonists on forepaw stepping in the unilateral 6-OHDA-lesioned rat.

RATIONALE AND OBJECTIVES: Given that adenosine A2A antagonists appear to be therapeutic in several animal models of Parkinson's disease (PD), we examined the extent to which caffeine and selective A2A and A1 antagonists could enhance contralateral forepaw stepping in the unilateral 6-OHDA-lesioned rat. MATERIALS AND METHODS: Following unilateral injections of 12 microg 6-OHDA into the medial forebrain bundle (MFB), frequency of stepping with both front paws was counted separately as the paws were dragged anteriorally and laterally by a treadmill. RESULTS: The MFB lesions decreased contralateral stepping by 74-83%, and 8 mg/kg 3,4-dihydroxy-L-phenylalanine (L-DOPA) increased contralateral stepping by 25-26%. Caffeine given systemically (15 mg/kg) or into the dorsal striatum or external globus pallidus (GPE; 20-40 microg) increased contralateral forepaw stepping by 14%, 27%, and 26%, respectively, and enhanced the effect of 8 mg/kg L-DOPA on stepping. The selective A(2A) antagonist SCH-58261 (2 mg/kg) also increased stepping by 13% and enhanced the therapeutic effect of L-DOPA, whereas the selective A(1) [corrected] antagonist 8-cyclopentyltheophylline (3-7 mg/kg) and A(1) agonist N(6)-cyclopentyladenosine (0.03-0.2 mg/kg) had no effect. None of these drugs appeared to produce dyskinesic effects. CONCLUSIONS: In this well-validated animal model of the akinesic effects of PD, caffeine and a selective A2A, but not an A1, antagonist were able to provide both monotherapeutic and adjunctive therapeutic effects. These data are consistent with the hypothesis that A2A antagonists may be therapeutic in human PD patients and indicate that the dorsal striatum and GPE are critical sites of therapeutic action.

Incidence, recurrence and risk factors of hernias following stoma reversal.

BACKGROUND: To determine the incidence and risk factors for stoma site (SSH) and incisional (IH) hernias following stoma reversal as well as their recurrence following repair. METHODS: A cohort of VA Surgical Quality Improvement Program patients undergoing stoma reversal from 2002 to 2014 were evaluated at a single institution. Variables were selected a priori and evaluated by univariate analyses. RESULTS: Of 114 stoma reversals, 63 utilized a midline approach. The incidence of SSH and IH was 9.6% and 31.7% over a median follow-up of 5.7 (0.5-14) and 4.0 (0.1-14) years, respectively. Five SSH and 10 IH were repaired with no recurrences. Myofascial release and superficial surgical site infections (SSI) were associated with SSH while body mass index, preoperative radiotherapy, American Society of Anesthesiologists classification ≥3, operative duration ≥2.5 h and deep SSIs were associated with IH. CONCLUSIONS: Incisional hernia incidence after stoma reversal is high for both the stoma site and midline. Risk factors differ for each hernia type. A low recurrence rate exists in short term follow-up following repair of a hernia occurrence.

The impact of surgical hand antisepsis technique on surgical site infection.

BACKGROUND: Limited evidence exists regarding the effect on superficial and deep incisional surgical site infections (SDSSIs) of alcohol-based hand rubs (ABR) versus traditional aqueous surgical scrubs (TSS). User preferences and practice are unknown. METHODS: A retrospective cohort study examining SDSSIs using VA Surgical Quality Improvement Program cases before ABR implementation (2007-2009, TSS group) and after (2013-2014, ABR group). A descriptive survey. RESULTS: SDSSI rates were 1.8% and 1.5% for TSS (n=4051) and ABR (n=2293), respectively (p=0.31). The adjusted odds of SDSSI using ABR was not significant (OR 0.82; 95% CI, 0.51-1.32). Greatest SDSSI risk was from preoperative radiotherapy (OR, 2.78; 95% CI, 1.14-6.78), general surgery (OR, 2.39; 95% CI, 1.30-4.39) and preoperative smoking (OR, 1.58; 95% CI, 1.02-2.44). Of 95 surveys included, 52% favored ABR. Although 95% self-reported correct product application, improper duration was revealed in both groups (TSS 18% and ABR 10%). CONCLUSIONS: Implementation of an ABR for use in surgical hand antisepsis did not alter SDSSI rates. Improving product knowledge and compliance may improve SSI rates.

Effect of Hand Antisepsis Agent Selection and Population Characteristics on Surgical Site Infection Pathogens.

BACKGROUND: Selection of a pre-operative hand antisepsis agent has not been studied in relation to surgical site infection (SSI) culture data. In our hospital, we introduced an alcohol-based hand rub (ABR) in 2012 as an alternative to traditional aqueous surgical scrubs (TSS). It was the goal of this study to review any effect of this implementation on SSI pathogen characteristics. In addition, we sought to compare our SSI culture data with available National Healthcare Safety Network (NHSN) data. We hypothesized that SSI pathogens and resistant isolates are affected by surgical hand antisepsis technique. METHODS: Data collected prospectively between 2007 and 2014 were retrospectively analyzed for two time periods at the Veterans Affairs Boston Healthcare System (VABHS): Before ABR implementation (TSS group) and after (ABR group). Pathogen distribution and pathogenic isolate resistance profiles were compared for TSS and ABR, and similar comparisons, along with procedure-associated SSI comparisons, were made between VABHS and NHSN. All VABHS data were interpreted and categorized according to NHSN definitions. RESULTS: Compared with TSS (n = 4,051), ABR (n = 2,293) had a greater rate of Staphylococcus aureus (42.6% vs. 38.0%), Escherichia coli (12.8% vs. 9.9%), Pseudomonas aeruginosa (8.5% vs. 2.8%), and Enterobacter spp. (10.6% vs. 2.8%), and a lower rate of Klebsiella pneumoniae/K. oxytoca (4.3% vs. 8.5%) cultured from superficial and deep SSIs (p < 0.05). Of the S. aureus isolates, 35.0% and 44.4% were resistant to oxacillin/methicillin (MRSA) in ABR and TSS, respectively (p = 0.06). Looking at all SSIs, coagulase-negative staphylococci and K. pneumoniae/K. oxytoca at VABHS (4.0% and 10.4%, respectively) accounted for the biggest difference from NHSN (11.7% and 4.0%, respectively). Aside from MRSA, where there was no difference between VABHS and NHSN (42.9% vs. 43.7%, respectively; p = 0.87), statistically significant (p < 0.05) differences were observed among multi-drug-resistant K. pneumoniae/K. oxytoca (0% vs. 6.8%, respectively) and Escherichia coli (10.0% vs. 1.6%, respectively), as well as among extended-spectrum cephalosporin-resistant K. pneumoniae/K. oxytoca (4.8% vs. 13.2%, respectively) and Enterobacter (58.3% vs. 27.7%, respectively). VABHS had a greater proportion of SSIs in abdominal and vascular cases than did NHSN (48.6% vs. 22.5% and 13.2% vs. 1.5%, respectively). Overall, these differences were significant (p < 0.05). CONCLUSIONS: The TSS and ABR groups differed in the distribution of pathogens recovered. Those differences, along with SSI pathogen distribution, pathogenic isolate resistance profiles, and procedure-associated SSIs between VABHS and NHSN, warrant further investigation.

Detection and potential consequences of intraoperative adverse events: A pilot study in the veterans health administration.

Surgical quality improvement efforts have focused on tracking and reducing postoperative mortality and morbidity. However, the prevalence of intraoperative adverse events (IAEs) and their association with postoperative surgical outcomes has been poorly studied. In this study, we detected IAEs using both retrospective chart review and prospective provider reporting. We then examined the association of IAEs with postoperative outcomes. The overall IAE detection rate per case was 0.7 and 0.07 (P < 0.0001) based on chart review and provider reporting, respectively. Types of IAEs varied between detection methods. Provider-reported IAEs were more serious, i.e., had a stronger association with 30-day postoperative complications than chart-identified IAEs (risk-adjusted odds ratios were 1.52 vs 1.02, respectively, both p < 0.0001). Our findings suggest that IAEs can be detected using either retrospective chart review or prospective provider reporting. However, provider reporting appears more likely to detect serious (albeit infrequent) IAEs compared to chart review.

Vestibular evoked myogenic potentials (VEMP) can detect asymptomatic saccular hydrops.

OBJECTIVE: The objective of this study was to explore the useful of vestibular evoked myogenic potential (VEMP) testing for detecting endolymphatic hydrops, especially in the second ear of patients with unilateral Ménière disease (MD). METHODS: This study was performed at a tertiary care academic medical center. Part I consisted of postmortem temporal bone specimens from the temporal bone collection of the Massachusetts Eye & Ear Infirmary; part II consisted of consecutive consenting adult patients (n = 82) with unilateral MD by American Academy of Otolaryngology-Head and Neck Surgery criteria case histories. Outcome measures consisted of VEMP thresholds in patients and histologic saccular endolymphatic hydrops in postmortem temporal bones. RESULTS: Saccular hydrops was observed in the asymptomatic ear in six of 17 (35%) of temporal bones from donors with unilateral MD. Clinic patients with unilateral MD showed elevated mean VEMP thresholds and altered VEMP tuning in their symptomatic ears and, to a lesser degree, in their asymptomatic ears. Specific VEMP frequency and tuning criteria were used to define a "Ménière-like" response. This "Ménière-like" response was seen in 27% of asymptomatic ears of our patients with unilateral MD. CONCLUSIONS: Bilateral involvement is seen in approximately one third of MD cases. Saccular hydrops appears to precede symptoms in bilateral MD. Changes in VEMP threshold and tuning appear to be sensitive to these structural changes in the saccule. If so, then VEMP may be useful as a detector of asymptomatic saccular hydrops and as a predictor of evolving bilateral MD.

Surgical Hand Antisepsis and Surgical Site Infections.

BACKGROUND: Surgical site infections (SSI) remain a significant problem to both the patients and the healthcare system. Value care and standardized quality measures continue to promote improvement in surgical asepsis, but certain debates remain unresolved in the field of surgical hand antisepsis. METHODS: Review of relevant accounts and literature. RESULTS: Controversy has existed regarding the U.S. Food and Drug Administration (FDA)'s 1994 Tentative Final Monograph (TFM), which defined how surgical hand antisepsis products are assessed. Issues involving neutralizers and demonstration of a cumulative effect were addressed in the FDA's Proposed Rule in 2015. Few studies have used SSI as a primary outcome and instead have used a surrogate marker (colony-forming units [CFU]). Quantitative microbiology studies suggest a minimum bacterial inoculum of 105-107 CFU/mL is necessary to cause a clinical infection. Outcomes of antisepsis likely are driven by both active ingredient(s) and overall product formulation. Povidone-iodine aqueous scrubs are inferior to chlorhexidine gluconate (CHG) 4% aqueous scrubs and alcohol-based rubs (ABR). The SSI and CFU outcomes studies support the equivalence or superiority of ABR over CHG. CONCLUSIONS: Both ABRs and CHG 4% are preferred to povidone-iodine for surgical hand antisepsis. Well-powered randomized controlled trials measuring SSI as a primary outcome, as well as those designed according to either TFM or European methodology, with appropriate controls and neutralizers, are warranted. These trials should incorporate different ABR formulations and CHG 4%, as well as skin tolerance assessments and a cost analysis.

Results of a Tailored Approach to Zenker's Diverticulum: A Single VA Experience.

The transoral division of the esophageal-diverticula septum with a linear stapler, with CO2 laser, or with harmonic scalpel under rigid endoscopy has revolutionized the surgical management of Zenker's diverticula. Nevertheless, the open approach still plays a role in select cases. Our goals are to illustrate the techniques and the results of our tailored approach to the surgical management of Zenker's diverticula in U.S. veterans.

Transitional care interventions and hospital readmissions in surgical populations: a systematic review.

BACKGROUND: Despite hospital readmission being a targeted quality metric, few studies have focused on the surgical patient population. We performed a systematic review of transitional care interventions and their effect on hospital readmissions after surgery. DATA SOURCES: PubMed was searched for studies evaluating transitional care interventions in surgical populations within the years 1995 to 2015. Of 3,527 abstracts identified, 3 randomized controlled trials and 7 observational cohort studies met inclusion criteria. CONCLUSIONS: Discharge planning programs reduced readmissions by 11.5% (P = .001), 12.5% (P = .04), and 23% (P = .26). Patient education interventions reduced readmissions by 14% (P = .28) and 23.5% (P < .05). Primary care follow-up reduced readmissions by 8.3% for patients after high-risk surgeries (P < .001). Home visits reduced readmissions by 7.69% (P = .023) and 4% (P = .161), respectively. Therefore, improving discharge planning, patient education, and follow-up communication may reduce readmissions.

Released intranasal eosinophilic major basic protein as a diagnostic marker for polypoid chronic rhinosinusitis.

OBJECTIVE: To investigate the hypothesis that eosinophil major basic protein is released in high concentrations in the nasal mucus of patients with polypoid chronic rhinosinusitis. STUDY DESIGN: Single center, open, prospective trial. SETTING: Medical University of Graz, Austria. SUBJECTS AND METHODS: Patients with polypoid chronic rhinosinusitis (n = 23) were compared to three different control groups: patients with chronic rhinosinusitis-like symptoms but without general mucosal thickening, patients who underwent functional endoscopic sinus surgery for reasons other than chronic rhinosinusitis, and patients without sinus disease (total n = 21). Mucus was harvested from each patient using a standardized technique and analyzed for eosinophil major basic protein with an enzyme-linked immunosorbent assay. RESULTS: In the patient group with polypoid chronic rhinosinusitis, 20 of 23 (87%) were positive for eosinophil major basic protein. In contrast, only one control patient was positive, whereas the remainder had no detectable amount of eosinophil major basic protein in the mucus (P < 0.001 vs chronic rhinosinusitis). CONCLUSION: Toxic eosinophil major basic protein levels are elevated in polypoid chronic rhinosinusitis patients compared to control groups that have similar clinical presentations but upon closer examination turn out not to have chronic rhinosinusitis. In the future, the detection of eosinophil major basic protein in nasal mucus may become a sensitive and specific marker for chronic rhinosinusitis and a helpful diagnostic tool.