Inverted Appendix in a Patient With Weakness and Occult Bleeding.

Background: Appendiceal mucinous neoplasms (AMNs) are rare adenomatous primary tumors of the appendix. Although of low malignant potential, these neoplasms can cause serious potentially fatal complications such as bowel obstruction and pseudomyxoma peritonei, making prompt identification and removal of utmost importance. AMNs often present with nonspecific gastrointestinal symptoms or are asymptomatic and found incidentally. Case Presentation: A patient aged 72 years presented with generalized weakness and appeared on imaging to have acute appendicitis complicated by rupture. On colonoscopy, the patient was found to have an inverted appendix that after appendectomy was revealed to harbor a perforated low-grade AMN. Conclusions: Although AMNs are rare, physicians should still consider it when imaging suggests appendicitis. Having AMNs as part of the differential diagnosis is especially necessary in cases, such as this one, in which the patient has appendiceal inversion, is aged > 50 years, and has concurrent colorectal neoplasms.

Left-Sided Amyand Hernia: Case Report and Review of the Literature.

Left-sided Amyand hernia is a rare condition that requires a high degree of clinical suspicion to correctly diagnose.

Constipation and Postprandial Pain in a Patient With Shortness of Breath.

Incidental image findings may be important for resolving seemingly unrelated symptoms at presentation.

Evaluating the Impact of Provider Type and Patient Diagnosis on Patient No-Shows to Vascular Clinic.

BACKGROUND: No-shows are a source of burden that lead to wasted resources. While prior research has established that many patient-level affect impact no-show rates, the impact of referring provider-level factors, in particular the type of referring provider-and specific diagnosis are still largely unknown. MATERIALS AND METHODS: Retrospective chart review examining new patient consults scheduled for outpatient vascular surgery clinic from August 1, 2014 through February 28, 2015 was conducted. The specialty types of the referring physicians and the reason for referral (patient diagnosis) were recorded. RESULTS: Of 227 new patient consults scheduled, 30% were no-shows to their appointment. No-show rates were significantly higher when the patient was referred by a primary care physician versus a specialist and differed significantly based on patient diagnosis. CONCLUSIONS: Given that referring provider type and patient diagnosis significantly affect noshow rates, interventions that integrate the community of providers are needed to reduce noshows.

Cardiovascular Disease, Drug Therapy, and Mortality in Covid-19.

BACKGROUND: Coronavirus disease 2019 (Covid-19) may disproportionately affect people with cardiovascular disease. Concern has been aroused regarding a potential harmful effect of angiotensin-converting-enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) in this clinical context. METHODS: Using an observational database from 169 hospitals in Asia, Europe, and North America, we evaluated the relationship of cardiovascular disease and drug therapy with in-hospital death among hospitalized patients with Covid-19 who were admitted between December 20, 2019, and March 15, 2020, and were recorded in the Surgical Outcomes Collaborative registry as having either died in the hospital or survived to discharge as of March 28, 2020. RESULTS: Of the 8910 patients with Covid-19 for whom discharge status was available at the time of the analysis, a total of 515 died in the hospital (5.8%) and 8395 survived to discharge. The factors we found to be independently associated with an increased risk of in-hospital death were an age greater than 65 years (mortality of 10.0%, vs. 4.9% among those ≤65 years of age; odds ratio, 1.93; 95% confidence interval [CI], 1.60 to 2.41), coronary artery disease (10.2%, vs. 5.2% among those without disease; odds ratio, 2.70; 95% CI, 2.08 to 3.51), heart failure (15.3%, vs. 5.6% among those without heart failure; odds ratio, 2.48; 95% CI, 1.62 to 3.79), cardiac arrhythmia (11.5%, vs. 5.6% among those without arrhythmia; odds ratio, 1.95; 95% CI, 1.33 to 2.86), chronic obstructive pulmonary disease (14.2%, vs. 5.6% among those without disease; odds ratio, 2.96; 95% CI, 2.00 to 4.40), and current smoking (9.4%, vs. 5.6% among former smokers or nonsmokers; odds ratio, 1.79; 95% CI, 1.29 to 2.47). No increased risk of in-hospital death was found to be associated with the use of ACE inhibitors (2.1% vs. 6.1%; odds ratio, 0.33; 95% CI, 0.20 to 0.54) or the use of ARBs (6.8% vs. 5.7%; odds ratio, 1.23; 95% CI, 0.87 to 1.74). CONCLUSIONS: Our study confirmed previous observations suggesting that underlying cardiovascular disease is associated with an increased risk of in-hospital death among patients hospitalized with Covid-19. Our results did not confirm previous concerns regarding a potential harmful association of ACE inhibitors or ARBs with in-hospital death in this clinical context. (Funded by the William Harvey Distinguished Chair in Advanced Cardiovascular Medicine at Brigham and Women's Hospital.).

Small Bowel Obstruction in a Surgically Naïve Abdomen.

Finding the cause of small bowel obstructions can lead to the discovery of important and treatable underlying disease.

Comparison of Wait Times for New Patients Between the Private Sector and United States Department of Veterans Affairs Medical Centers.

Importance: Concerns have been raised about the adequacy of health care access among patients cared for within the United States Department of Veterans Affairs (VA) health care system. Objectives: To determine wait times for new patients receiving care at VA medical centers and compare wait times in the VA medical centers with wait times in the private sector (PS). Design, Setting, and Participants: A retrospective, repeated cross-sectional study was conducted of new appointment wait times for primary care, dermatology, cardiology, or orthopedics at VA medical centers in 15 major metropolitan areas in 2014 and 2017. Comparison data from the PS came from a published survey that used a secret shopper survey approach. Secondary analyses evaluated the change in overall and unique patients seen in the entire VA system and patient satisfaction survey measures of care access between 2014 and 2017. Main Outcomes and Measures: The outcome of interest was patient wait time. Wait times in the VA were determined directly from patient scheduling. Wait times in the PS were as reported in Merritt Hawkins surveys using the secret shopper method. Results: Compared with the PS, overall mean VA wait times for new appointments in 2014 were similar (mean [SD] wait time, 18.7 [7.9] days PS vs 22.5 [7.3] days VA; P = .20). Department of Veterans Affairs wait times in 2014 were similar to those in the PS across specialties and regions. In 2017, overall wait times for new appointments in the VA were shorter than in the PS (mean [SD], 17.7 [5.9] vs 29.8 [16.6] days; P < .001). This was true in primary care (mean [SD], 20.0 [10.4] vs 40.7 [35.0] days; P = .005), dermatology (mean [SD], 15.6 [12.2] vs 32.6 [16.5] days; P < .001), and cardiology (mean [SD], 15.3 [12.6] vs 22.8 [10.1] days; P = .04). Wait times for orthopedics remained longer in the VA than the PS (mean [SD], 20.9 [13.3] vs 12.4 [5.5] days; P = .01), although wait time improved significantly between 2014 and 2017 in the VA for orthopedics while wait times in the PS did not change (change in mean wait times, increased 1.5 days vs decreased 5.4 days; P = .02). Secondary analysis demonstrated an increase in the number of unique patients seen and appointment encounters in the VA between 2014 and 2017 (4 996 564 to 5 118 446, and 16 476 461 to 17 331 538, respectively), and patient satisfaction measures of access also improved (satisfaction scores increased by 1.4%, 3.0%, and 4.0% for specialty care, routine primary care, and urgent primary care, P < .05). Conclusions and Relevance: Although wait times in the VA and PS appeared to be similar in 2014, there have been interval improvements in VA wait times since then, while wait times in the PS appear to be static. These findings suggest that access to care within the VA has improved over time.

Progesterone for Prevention of Preterm Birth: Shortcomings and Unintended Consequences of the Orphan Drug Act.

Preterm birth is a problem of major public health significance that continues to plague our country despite the existence of a therapy, 17α-hydroxyprogesterone caproate, with known efficacy in reducing the risk of spontaneous preterm birth among high-risk women. Over the past several years, the Louisiana Department of Health has undertaken a robust, multifaceted initiative to improve access to 17α-hydroxyprogesterone caproate, which resulted in a 3.5-fold increase in the percentage of eligible high-risk pregnant women in the Medicaid program who received the therapy between 2013 and 2016. Yet despite Louisiana's progress, the vast majority of the eligible population still fails to receive 17α-hydroxyprogesterone caproate. In this Current Commentary, we argue that the high price of progesterone since U.S. Food and Drug Administration approval has unnecessarily complicated access, and our nation has potentially suffered nearly 60,000 avoidable premature births as a consequence. We present the history of the orphan drug approval and manufacturer-imposed price increase for injectable progesterone, the interplay between the drug's high price and the persistence of racial and ethnic disparities in preterm birth, which are particularly germane in Louisiana, and Louisiana's broad-reaching efforts to improve progesterone coverage. The story of 17α-hydroxyprogesterone caproate highlights the durable barriers that high prices place in the way of access and helps illuminate the shortcomings and unintended consequences of the Orphan Drug Act. This case, however, is not an outlier; it is the far-too-common product of monopoly pricing in the U.S. pharmaceutical market, inadvertently bolstered by existing law, at the expense of affordability and patient access.

Eliminating Critical Incident Tracking Network Patient Safety Events at a Veterans Affairs Institution Through Crew Resource Management Training.

The objective of this study was to determine whether rates of Critical Incident Tracking Network (CITN) patient safety adverse events change after implementation of crew resource management (CRM) training at a Veterans Affairs (VA) hospital. CRM training was conducted for all surgical staff at a VA hospital. Compliance with briefing and debriefing checklists was assessed for all operating room procedures. Tracking of adverse patient safety events utilizing the VA CITN events was performed. There was 100% adherence to performance of briefings and debriefings after initiation of CRM training. There were 3 CITN events in the year prior to implementation of CRM training; following CRM training, there have been zero CITN events. Following CRM training, CITN events were eliminated, and this has been sustained for 2.5 years. This is the first study to demonstrate the impact of CRM training on CITN events, specifically, in a VA medical center.

Decreasing 30-day surgical mortality in a VA Medical Center utilizing the ACS NSQIP Surgical Risk Calculator.

BACKGROUND: The Overton Brooks VA Medical Center Surgical Service had a high mortality. In an effort to reduce surgical mortality, we implemented a series of quality improvement interventions, including utilization of the ACS Surgical Risk Calculator to identify high-risk surgical patients for discussion in a multidisciplinary Pre-Operative Consultation Committee. METHODS: Retrospective study describing the implementation of a risk stratification intervention incorporating the ACS Surgical Risk Calculator Tool and a multidisciplinary Pre-Operative Consultation Committee to target high-risk patients. Measurement of 30 day surgical mortality and risk adjusted Observed to Expected (O/E) mortality ratio. RESULTS: From May 2013 to September 2014, 614 high-risk patients were selected utilizing the ACS Risk Calculator and presented at the Pre-Operative Consultation Committee. Following implementation of this risk stratification intervention, 30-day mortality decreased by 66% from 0.9% to 0.3%, and risk adjusted O/E mortality ratio decreased from 2.5 to 0.8. Among the high risk patients presented, there was no increase in referrals to other facilities. There was a significant increase in cases requiring further preoperative optimization, from 6.3% at the beginning of the study period to 17.5% at the end of the study period. CONCLUSIONS: Implementation of a preoperative risk stratification intervention utilizing the ACS Surgical Risk Calculator along with a multidisciplinary Pre-Operative Consultation Committee can be successfully accomplished, with a significant decrease in 30-day surgical mortality. This is the first published report of utilization of the ACS Risk calculator as part of a systematic quality improvement tool to decrease surgical mortality.

Improving staff perception of a safety climate with crew resource management training.

BACKGROUND: Communication failure is one of the top root causes in patient safety adverse events. Crew resource management (CRM) is a team building communication process intended to improve patient safety by improving team dynamics. First, to describe implementation of CRM in a Veterans Affair (VA) surgical service. Second, to assess whether staff CRM training is related to improvement in staff perception of a safety climate. MATERIAL AND METHODS: Mandatory CRM training was implemented for all surgical service staff at a VA Hospital at 0 and 12 mo. Safety climate questionnaires were completed by operating room staff at a baseline, 6 and 12 mo after the initial CRM training. RESULTS: Participants reported improvement on all 27 points on the safety climate questionnaire at 6 mo compared with the baseline. At 12 mo, there was sustained improvement in 23 of the 27 areas. CONCLUSIONS: This is the first published report about the effect of CRM training on staff perception of a safety climate in a VA surgical service. We demonstrate that CRM training can be successfully implemented widespread in a surgical program. Overall, there was improvement in 100% of areas assessed on the safety climate questionnaire at 6 mo after CRM training. By 1 y, this improvement was sustained in 23 of 27 areas, with the areas of greatest improvement being the performance of briefings, collaboration between nurses and doctors, valuing nursing input, knowledge about patient safety, and institutional promotion of a patient safety climate.