Association of Implementation of Operating Room-Based Parathyroid Hormone Testing with Operative Time and Cost.

BACKGROUND: Intraoperative parathyroid hormone (IOPTH) testing facilitates focused parathyroidectomy to establish biochemical cure but may be time-consuming. A dedicated immunoassay machine was relocated to the operating room for IOPTH. These data seek to determine association of operating room-based IOPTH with operative time, laboratory turnaround time (TAT), and cost. METHODS: Patients who underwent parathyroidectomy from June 2017 to February 2020 were reviewed. Clinical and demographic data, operative time, and TAT were collected. Patients were compared by operation dates pre- or post-machine acquisition. A cost model was created to evaluate cost of care before and after operating room-based testing. RESULTS: A total of 285 patients were included. Post-machine, median operative time decreased from 69 minutes (interquartile range [IQR] 60 to 84) to 57 minutes (IQR 50 to 84.5), p 0.03. Additionally, median TAT for IOPTH values (preoperative, 0, 5, 10, and 15 minutes) decreased post-machine: time preoperative, 29 minutes (IQR 23 to 40) vs 18 minutes (IQR 17 to 23.5), p < 0.001; time 0, 33 minutes (IQR 27 to 39) vs 18.5 minutes (17.5 to 21), p < 0.001; time 5 minutes, 31 minutes (IQR 26 to 36) vs 20 minutes (IQR 18.5 to 21), p < 0.001; time 10 minutes, 32 minutes (IQR 27 to 39) vs 20 minutes (IQR 18.5 to 22.5), p < 0.001; and time 15 minutes, 30 minutes (IQR 26 to 36) vs 19 minutes (IQR 17 to 21), p < 0.001. Total costs pre- and post-machine were $4,442 and $4,111, respectively. With $331 cost reduction per operation and 127 operations per year, the IOPTH machine pays for itself in 3 years, or 378 surgeries, and saves $168,589 in the machine's remaining 4-year life span. CONCLUSIONS: Operating room-based parathyroid hormone testing results in improved operating productivity by decreasing result TAT and operative time and reduces cost.

Serum Klotho levels in primary hyperparathyroidism patients before and after parathyroidectomy.

PURPOSE: To investigate Klotho level and its association with biochemical indices of primary hyperparathyroidism (PHPT). METHODS: Fifty PHPT patients and fifty-two age- and body mass index-(BMI) matched healthy control subjects were recruited. In addition, twenty-five PHPT patients underwent parathyroidectomy (PTX) and had 4-month follow-up visits. Intact parathyroid hormone (iPTH), 25-hydroxyvitamin D [25(OH)D], calcium, albumin, corrected calcium, and Klotho levels were determined. RESULTS: There was no significant difference in age and BMI between PHPT subjects and controls (p > 0.05). PHPT patients had Klotho levels (15.4 ± 1.2 ng/mL) about 23% higher compared with those of the controls (11.9 ± 0.8 ng/mL), but this difference was not significant (p = 0.063). However, postmenopausal PHPT patients had 45% higher Klotho levels (17.6 ± 1.5 ng/ml) compared with postmenopausal controls (12.1 ± 0.9 ng/mL, p = 0.008). For postmenopausal subjects, Klotho levels had positive correlation with levels of iPTH (r = 0.25, p = 0.026) and corrected calcium (r = 0.34, p = 0.003), but negative correlation with 25(OH)D (r = -0.23, p = 0.042). After PTX, levels of iPTH and corrected calcium decreased and 25(OH)D levels increased to normal range (p < 0.001). However, there was no significant change in Klotho levels after a 4-month follow-up. CONCLUSIONS: Serum Klotho levels are higher in postmenopausal PHPT patients than in healthy postmenopausal control subjects. The etiology of elevated Klotho level and its clinical significance requires further investigation.

Parathyroid gland weight is associated with high density lipoprotein levels in patients with primary hyperparathyroidism.

OBJECTIVE: To investigate the relationship between parathyroid gland weight and high-density lipoprotein (HDL) levels in patients with primary hyperparathyroidism (PHPT). METHODS: In this retrospective case control study, we reviewed 329 PHPT patients aged from 20 to 85 years who had a parathyroidectomy at Robert Wood Johnson University Hospital. The patients were divided into 5 quintiles according to their parathyroid gland weight: 68 patients had a parathyroid gland weight <0.3 g, 66 patients had a gland weight 0.3-0.45 g, 67 patients had a gland weight 0.45-0.7 g, 63 patients had a gland weight 0.7-1.25 g, and 65 patients had a gland weight ≥1.25 g. RESULTS: Body Mass Index (BMI) trended to be higher across the quintiles of parathyroid gland weight (P = 0.003). Serum calcium and PTH levels were significantly increased across parathyroid gland quintiles (p < 0.0001). HDL levels tended to be lower across the increasing quintiles of parathyroid gland weight (P = 0.01). There was a negative relationship between log parathyroid gland weight and HDL in patients with PHPT in a simple linear regression (r = -0.160, P = 0.003). The negative association remained significant after adjustment for age and BMI (r = -0.114, P = 0.039). Furthermore, parathyroid gland weight was significantly associated with levels of triglyceride (r = 0.126, P = 0.02), but this relationship lost its significance after adjustment for age and BMI (r = 0.082, P Ëƒ 0.05). CONCLUSIONS: PHPT patients with heavier parathyroid glands tended to have higher BMI and lower HDL levels.

Risk Factors for Severe Acute Respiratory Syndrome Coronavirus 2 Infection in Hospital Workers: Results From a Screening Study in New Jersey, United States in Spring 2020.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is a critical concern among healthcare workers (HCWs). Other studies have assessed SARS-CoV-2 virus and antibodies in HCWs, with disparate findings regarding risk based on role and demographics. METHODS: We screened 3904 employees and clinicians for SARS-CoV-2 virus positivity and serum immunoglobulin (Ig)G at a major New Jersey hospital from April 28 to June 30, 2020. We assessed positive tests in relation to demographic and occupational characteristics and prior coronavirus disease 2019 symptoms using multivariable logistic regression models. RESULTS: Thirteen participants (0.3%) tested positive for virus and 374 (9.6%) tested positive for IgG (total positive: 381 [9.8%]). Compared with participants with no patient care duties, the odds of positive testing (virus or antibodies) were higher for those with direct patient contact: below-median patient contact, adjusted odds ratio (aOR) = 1.71 and 95% confidence interval [CI] = 1.18-2.48; above-median patient contact, aOR = 1.98 and 95% CI = 1.35-2.91. The proportion of participants testing positive was highest for phlebotomists (23.9%), maintenance/housekeeping (17.3%), dining/food services (16.9%), and interpersonal/support roles (13.7%) despite lower levels of direct patient care duties. Positivity rates were lower among doctors (7.2%) and nurses (9.1%), roles with fewer underrepresented minorities. After adjusting for job role and patient care responsibilities and other factors, Black and Latinx workers had 2-fold increased odds of a positive test compared with white workers. Loss of smell, taste, and fever were associated with positive testing. CONCLUSIONS: The HCW categories at highest risk for SARS-CoV-2 infection include support staff and underrepresented minorities with and without patient care responsibilities. Future work is needed to examine potential sources of community and nosocomial exposure among these understudied HCWs.

Operative bed recurrence of thyroid cancer: utility of a preoperative needle localization technique.

BACKGROUND: Surgical management of recurrent disease after total thyroidectomy and/or neck dissection for thyroid carcinoma remains a challenging clinical problem. Reoperation is associated with a significant increase in morbidity. Preoperative needle localization technique for non-palpable breast tumors has recently been extrapolated to head and neck surgery. We report on the use of preoperative ultrasound-guided needle localization for non-palpable recurrent operative bed disease as an intraoperative aid in resection. METHODS: Patients with thyroid carcinoma were identified from a retrospective database at a tertiary care center from 2011-2014. Inclusion criteria were history of thyroidectomy and/or neck dissection, non-palpable recurrent disease in the resection bed on surveillance, and ultrasound-guided needle localization of recurrent disease before resection. Perioperative data and outcomes were analyzed. RESULTS: Seventeen patients were identified using the inclusion criteria listed above. Median patient age was 46 years (53% male, 47% female). A total of 23 masses in the previous operative bed were needle-localized successfully with no major long-term sequelae from this technique. The recurrent laryngeal nerve was involved with tumor in six patients. Two patients, in whom the tumor surrounded the nerve circumferentially, experienced recurrent laryngeal nerve injuries. No patients experienced postoperative hypocalcemia. With a routine surveillance and a median follow-up of 558 days, sixteen of the patients remain with no evidence of disease. CONCLUSIONS: Preoperative ultrasound-guided needle localization of non-palpable recurrent operative bed disease after thyroidectomy and/or neck dissection is a potentially safe method to aid in resection and cure.

An Evaluation of Postoperative Complications and Cost After Short-Stay Thyroid Operations.

BACKGROUND: Concern for postoperative complications causing airway compromise has limited widespread acceptance of ambulatory thyroid surgery. We evaluated differences in outcomes and hospital costs in those monitored for a short stay of 6 h (SS), inpatient observation of 6-23 h (IO), or inpatient admission of >23 h (IA). METHODS: We retrospectively reviewed all patients undergoing thyroidectomy from 2006 to 2012. The incidence of postoperative hemorrhage, nerve dysfunction, and hypocalcemia were evaluated, as well as cost data comparing the SS and IO groups. RESULTS: Of 1447 thyroidectomies, 880 (60.8 %) were performed as SS, 401 (27.7 %) as IO, and 166 (11.5 %) as IA. Fewer patients in the SS group (59 %) underwent total thyroidectomy than IO (73 %) and IA (71 %; p < 0.01), and SS patients had smaller thyroid weights (27.9 g) compared with IO and IA (47.2 and 98.9 g, respectively; p < 0.01). Ten (0.69 %) patients developed hematomas requiring reoperation, five of the ten patients received antiplatelet or anticoagulant therapy perioperatively. Only one patient in the IA group bled within the 6- to 23-h period, and no patients with bleeding who were discharged at 6 h would have benefitted from 23-h observation. Twenty-four (1.66 %) recurrent laryngeal nerve injuries were identified, 16 with temporary neuropraxias. In addition, 24 (1.66 %) patients had symptomatic hypocalcemia, which was transient in 17 individuals. Financial data showed higher payments and lower costs associated with SS compared with IO. CONCLUSIONS: Selective SS thyroidectomy can be safe and cost effective, with few overall complications in patients undergoing more complex operations involving larger thyroids who were admitted to hospital.

A risk model to determine surgical treatment in patients with thyroid nodules with indeterminate cytology.

BACKGROUND: Thyroid nodules are present in 19-67 % of the population and have a 5-10 % risk of malignancy. Fine needle aspiration biopsies are indeterminate in 20-30 % of patients, often necessitating thyroid surgery for diagnosis. We hypothesized that developing a risk model incorporating factors associated with malignancy could help predict the risk of malignancy in patients with indeterminate thyroid nodules. METHODS: We identified 151 patients with a cytologic diagnosis of follicular neoplasm (Bethesda IV) who progressed to surgery. We retrospectively analyzed demographic, clinical, sonographic, and cytological variables in relation to thyroid carcinoma. RESULTS: Of 151 patients, 51 (33.8 %) had a final diagnosis of thyroid carcinoma. Papillary carcinoma was diagnosed in 34 patients (66.7 %), follicular carcinoma in 15 (29.4 %), and Hürthle cell carcinoma in 2 (3.9 %). On univariate analysis, younger age, male gender, tobacco use, larger nodule size, and calcifications on ultrasound, nuclear atypia on cytology, and suspicious frozen section were associated with the presence of malignancy. When determining odds ratios, four factors were most predictive of malignancy: nodule calcification [odds ratio (OR) 6.37, 95 % confidence interval (CI) 1.62-25.1, p < 0.01] and nodule size (OR 1.75, 95 % CI 1.19-2.57, p < 0.01) on ultrasound, nuclear atypia on cytology (OR 4.91, 95 % CI 1.90-12.66, p < 0.01), and tobacco use (OR 4.59, 95 % CI 1.30-16.27, p < 0.02). A multivariable model based on these four factors resulted in a c-statistic of 0.82. CONCLUSIONS: A multivariable model based on calcification, nodule size, nuclear atypia, and tobacco use may predict the risk of thyroid cancer requiring a total thyroidectomy in patients with thyroid nodules of indeterminate cytology.

The utility of lymph node mapping sonogram and thyroglobulin surveillance in post thyroidectomy papillary thyroid cancer patients.

BACKGROUND: The American Thyroid Association recommends lymph node mapping (LNM) ultrasonography 6-12 months after thyroidectomy for patients with papillary thyroid cancer (PTC). The yield of LNM over thyroglobulin (TG) screening is not well defined. We sought to investigate this relationship. METHODS: Post thyroidectomy LNM was performed on 163 patients with PTC. LNM was considered positive based on these criteria: Loss of fatty hilum (LOFH), microcalcifications, hypervascularity, architectural distortion, or short axis (>8 mm). Serum TG levels were compared to LNM and fine needle aspiration (FNA). RESULTS: Sixty-nine patients had suspicious LNM (42%) and 17 had PTC on FNA (25%). There were 135 suspicious lymph nodes described with malignant nodes found in 6 of 65 patients (9%) with LOFH, 13 of 18 patients (76%) with microcalcifications, 11 of 12 patients (92%) with hypervascularity, 16 of 28 patients (52%) with architectural distortion, and 4 of 7 patients (52%) with enlarged size on FNA. The positive predictive value of LNM was 0.34, increasing to 0.66 when LOFH was excluded. Among 152 patients with documented TG data, LNM identified cervical nodal metastasis in 4 patients with TG < 0.5 pg/mL (anti-TG antibody negative, thyroid-stimulating hormone suppressed). Of the 15 patients with positive anti-TG antibody, 3 with recurrence were found on LNM. CONCLUSION: LNM can detect recurrent PTC when TG level is undetectable, and LOFH is a low-yield sonographic characteristic.

Does nodule size predict compressive symptoms in patients with thyroid nodules?

BACKGROUND: Thyromegaly and thyroid nodules are known to cause compressive symptoms, but the exact relationship between nodule size and development of compressive symptoms is unclear. We sought to determine whether compressive symptoms are directly related to nodule size. METHODS: A retrospective analysis of 99 patients who underwent thyroidectomy by a single surgeon was performed. Patients were placed into one of two cohorts: those who experienced preoperative compressive symptoms (N=51) and those who did not (N=48). Compressive symptoms were defined as experiencing neck fullness, dysphagia, choking, or dyspnea. Nodule size, thyroid lobe size, and the presence of visible thyromegaly were compared between the two groups. RESULTS: Average nodule size in patients with compressive symptoms was 3.8 versus 2.2 cm in asymptomatic patients (P<0.0001). Average lobe diameter was 6.2 cm in patients with compressive symptoms versus 4.9 cm in asymptomatic patients (P<0.001). Visible thyromegaly was present in 65.2% of patients with compressive symptoms and 15.4% of asymptomatic patients (P<0.0001). The most common symptom was dysphagia, occurring in 80% of patients, followed by neck fullness (69%), choking (49%), and dyspnea (32%). Of patients who underwent surgery for compressive symptoms, 92.7% had improvement in their symptoms postoperatively. Of patients with a thyroid nodule greater than 1.5 cm, 97% showed improvement in symptoms postoperatively. CONCLUSIONS: Thyroid nodule size and lobe size appear to directly correlate with compressive symptoms. Of patients with compressive symptoms and a thyroid nodule >1.5 cm, 97% experienced improvement in symptoms postoperatively.

Gastrointestinal endoscopy training in general surgery residency: what has changed since 2009?

BACKGROUND: The Residency Review Committee for Surgery increased the endoscopy requirement for general surgery residents graduating in 2009 and thereafter. These changes led to the release of a position paper from 4 major gastroenterology societies claiming that the brief exposure of general surgery residents to endoscopy is not sufficient to gain competency. The societies also stated that these increased requirements will place an undue burden on gastroenterologists to supervise surgical residents in endoscopy training. METHODS: We designed a retrospective study to see if general surgery residents at our university-based training program were able to meet the 2009 requirements, and if reliance on nonsurgical faculty has increased. The case logs of all general surgery residents graduating from our institution during seven consecutive years were reviewed. SETTING: All endoscopic procedures were carried out at our main university hospital and at our two affiliated university hospitals. Residents spend two thirds of the year at the main campus and the remaining time at the affiliates. RESULTS: We found that our surgical residents have met the new Accreditation Council for Graduate Medical Education requirements. In our program, surgeons continue to provide most of the resident supervision for endoscopic procedures. Although there was an initial increased utilization of nonsurgical faculty for upper endoscopy, reliance on nonsurgical faculty for endoscopy training has declined every year since the guidelines were revised. CONCLUSIONS: It is possible for general surgery residents to meet the new Accreditation Council for Graduate Medical Education requirements in endoscopy without placing an undue burden on gastroenterologists.

Diagnosing thyroid lymphoma: steroid administration may result in rapid improvement of dyspnea : a report of two cases.

INTRODUCTION: Thyroid nodules, whether benign or malignant, are slow growing masses. There are certain clinical situations where sudden rapid growth may occur and cause acute respiratory compromise secondary to tracheal compression. CASE PRESENTATION: Here we describe two patients with suddenly enlarging thyroid nodules, who developed acute respiratory compromise in the absence of tracheal compression. Their symptoms rapidly improved with administration of corticosteroids, and in subsequent workup, both were diagnosed as thyroid lymphoma. CONCLUSIONS: The potent effect of corticosteroids in the rapid improvement of respiratory compromise associated with thyroid lymphoma represents an important clinical finding. This opens the possibility for the favorable response to corticosteroid therapy to be regarded as a possible preliminary diagnostic tool for thyroid lymphoma in acute respiratory distress patients in the absence of tracheal compression. Subsequent retrospective studies are necessary to verify this hypothesis.

Is one benign fine needle aspiration enough?

BACKGROUND: Fine needle aspiration (FNA) is used to diagnose thyroid nodules, but the follow-up of benign FNA is unclear. We sought to determine whether routine repeat FNAs after initial benign FNA reduces false negatives. METHODS: We identified 265 patients who had at least one benign FNA that either progressed to surgery or had at least one repeat FNA. We reviewed their ultrasonography, FNA cytology, and surgical pathology. RESULTS: Of 127 patients with initial benign FNA that had surgery, 13 had a malignancy, yielding a 10.2% false-negative rate. Of 22 patients who had surgery after at least two benign FNAs, one had a malignancy, yielding a 4.5% false-negative rate. Initially benign cytology (Bethesda II) was upgraded to a cytology requiring surgical intervention (Bethesda IV-VI) in 7 of 129 (5.4%) patients after two FNAs. Suspicious features on ultrasound, including size >4 cm, calcifications, or increased vascularity were found in 90% of patients with a false-negative FNA. CONCLUSIONS: The overall false-negative rate of thyroid FNAs is 10.2%, which is reduced to 4.5% with a second benign FNA. Ninety percent of patients with a false-negative FNA had suspicious sonographic features. Reaspiration should be considered in patients with sonographically suspicious nodules.

Athlete's hernia--a true, early direct inguinal hernia: diagnosis, pathophysiology, and surgical treatment.

Athlete's hernia (AH) is an activity limiting condition that presents as chronic inguinal pain in elite athletes. The diagnosis involves a thorough history and physical examination and can be aided by ultrasound interrogation of the groin. Operative treatment with a direct tissue repair of the inguinal floor successfully alleviates symptoms and allows for full return to activity. A retrospective analysis of patients with the diagnosis of AH from January 1998 to May 2010 who underwent operative repair was reviewed. Patients were evaluated based on age, gender, sport, time to presentation, subjective and objective physical findings, imaging findings, operative findings, length of follow-up, and return to activity. Ninety-six patients (6 females) with a median age of 22.6 years were evaluated. In the majority of these patients, operative exploration revealed a wide external ring with separation of the fibers of the external oblique aponeurosis and an unprotected and bulging transverses abdominis aponeurosis, very akin to an early direct inguinal hernia. The mean initial follow-up time was 6 weeks at which point all but two of the patients were able to resume their full level of activity without restrictions. The diagnosis of AH, although somewhat elusive, can be easily established with a high degree of suspicion after doing a thorough history and physical exam augmented with ultrasonography. AH is equivalent to an early direct inguinal hernia found in young athletes and can be surgically corrected allowing return to full activity.

Calcitonin-negative neuroendocrine tumor of the thyroid: a distinct clinical entity.

BACKGROUND: Medullary thyroid carcinoma (MTC) is a neuroendocrine tumor (NET) that arises from the parafollicular cells (C-cells) of the thyroid gland which produces calcitonin (CT) and is, therefore, a serum and immunohistochemical biomarker of MTC. Here, we describe a patient with another form of NET arising with the thyroid gland. PATIENT FINDINGS: This is a forty-year-old woman who underwent total thyroidectomy for a thyroid nodule that had features of an NET on fine needle aspiration. Her serum CT and carcinoembryonic antigen were normal. Surgical pathology showed a well-differentiated NET with immunohistochemical stains positive for markers of follicular cells (thyroglobulin and synaptophysin), positive for neuroendocrine markers (neuron specific enolase and chromogranin A), but negative for CT, the defining marker of MTC. CONCLUSIONS: We describe a rare case of a nonmedullary NET of the thyroid gland arising from thyroid follicular cells, not parafollicular cells. We suggest that calcitonin-negative neuroendocrine tumor of the thyroid gland (CNNETT) may be an entity that has not been recognized in the literature. This distinction between MTC and CNNETT may be important, as the treatment and prognosis may differ.

Routine second-opinion cytopathology review of thyroid fine needle aspiration biopsies reduces diagnostic thyroidectomy.

BACKGROUND: Follicular thyroid carcinoma cannot be distinguished reliably from benign follicular neoplasia by fine needle aspiration (FNA) biopsy. Given an estimated 20% risk of malignancy, many patients with indeterminate FNA biopsies require thyroidectomy for diagnosis. Some centers have shown significant discordance when a second pathologist evaluates the same FNA biopsy. We sought to determine whether routine second-opinion cytopathology reduces the need for diagnostic thyroidectomy, especially in patients with indeterminate FNA biopsies. METHODS: In all, 331 thyroid FNA biopsy specimens obtained from outside centers from 2004 to 2009 were reviewed at our institution. The FNA biopsy results were categorized into nondiagnostic (Bethesda I), benign (Bethesda II), indeterminate (follicular/Hurthle cell neoplasm, follicular/Hurthle cell lesion; Bethesda III & IV), and malignant (papillary or suspicious for papillary or other malignancy; Bethesda V and VI). Second-opinion cytology was compared with the initial opinion in 331 cases and with final operative pathology in the 250 patients who progressed to thyroidectomy. RESULTS: The average patient age was 51 with a predominant number of female (79%) participants. The overall cytology concordance for all 331 FNA biopsies was 66% (218/331). Concordance was highest at 86% (74/86) with malignant FNA biopsies. Concordance in the 129 patients with indeterminate FNA biopsies was only 37% (48/129). Indeterminate FNA biopsies were reread as nondiagnostic in 21% (27/129) of patients and as benign in 42% (54/129) of patients. Twenty-two patients with an indeterminate FNA biopsy reread as benign progressed to operative therapy for reasons other than cytology (eg, symptomatic nodule and radiation exposure/high risk) and were found to be benign in 95% (21/22) of patients on operative pathology for a 95% negative predictive value. An additional 11 patients with an indeterminate FNA reread as benign had follow-up FNA biopsies, each of which was benign. Indeterminate FNA biopsies on initial cytology had a malignancy rate of 13% (17/129) on operative pathology compared with 29% (14/48) for indeterminate FNA biopsies from second opinion. A second opinion improved FNA biopsy accuracy from 60% to 74%. Overall, second-opinion cytology of indeterminate FNA biopsies avoided diagnostic operation in 25% (32/129). CONCLUSION: Routine second opinion review of indeterminate thyroid FNA biopsies can potentially obviate the need for diagnostic thyroidectomy in 25% of patients without increases in false negatives.

Gastrointestinal complications following cardiac surgery: a comprehensive review.

INTRODUCTION: Gastrointestinal (GI) complications following cardiac surgery are associated with a high morbidity and mortality, prolonged hospital stay and increased cost of hospitalization. METHODS: A literature search was carried out using Medline for articles published in the past 30 years. Prospective and retrospective papers that dealt with coronary artery bypass grafting (CABG), CABG/valve operations were selected and those that dealt with thoracic and transplant complications were excluded. RESULTS: We reviewed 151,652 patients reported over the past 30 years; GI complications occurred on average after 1.21% of cardiac operations and had an associated mortality of 34.1%. The most common risk factors identified include age greater than 70 years, low cardiac output, peripheral vascular disease, reoperative surgery, chronic renal insufficiency, increased number of blood transfusions, prolonged cardiopulmonary bypass time, arrhythmias, and use of an intraaortic balloon pump. A critical examination of the available literature revealed multifactorial etiologies (often related to hypoperfusion) leading to GI complications. Delayed diagnosis was associated with poor outcomes. CONCLUSION: GI complications are rare events, but early diagnosis is essential. Unfortunately few of the risk factors we have defined are specific and are often indicators of ill patients. A low threshold to initiate laboratory evaluation and/or imaging studies should be employed if a patient shows signs of deviating from the normal course following cardiac surgery.

Risk factors for blunt thoracic aortic injury in children.

BACKGROUND/PURPOSE: Because blunt thoracic aortic injury is rare in children, a high index of suspicion is needed to identify this injury. The purpose of this study was to use a large national trauma database to define the risk factors for blunt thoracic aortic injury in children. METHODS: Using the National Trauma Database, the authors compared patient demographics, mechanism of injury, and associated injuries between children sustaining blunt trauma with and without a thoracic aortic injury. Factors independently associated with this injury were identified using multivariate methods. RESULTS: Among 26,940 children with a blunt mechanism of injury, 34 (0.1%) children sustained a thoracic aortic injury, 14 (41%) of whom died. Thoracic aortic injuries were independently associated with age, injury sustained as an occupant in a motor vehicle crash, and severe injuries (Abbreviated Injury Scale value of > or =3) involving the head, thorax (other than aorta), abdomen, and lower extremities. CONCLUSIONS: Older children involved in a motor vehicle crash with severe head, torso, and lower extremity injuries are a group at high risk for injury to the thoracic aorta. These easily identifiable risk factors may facilitate more rapid identification of this rare and potentially fatal injury.

Variability in trauma center outcomes for patients with moderate intracranial injury.

BACKGROUND: The variability of outcome between Trauma Centers has not been extensively studied as a possible avenue for performance improvement. Trauma Center variability in severity-adjusted survival for patients with moderate intracranial injury (MII) was studied in order to determine the association of MII-related process of care variables with outcomes. The analytic results were supplemented with peer review of MII patients with unexpected outcomes and identified potential process of care variables. METHODS: A retrospective cohort study was undertaken based on data submitted to a statewide trauma center database from July '95 through June '98. MII patients had one or more selected ICD-9-CM codes with an AIS-90 severity score of 3 or 4 but no higher. Severity adjustment was done using case matching and a logistic function based New Model that appropriately accounts for patients intubated on Emergency Department arrival. MII-related process of care variables derived from the database were identified and their relationship with outcome were evaluated individually and using multivariate methods. Trauma center personnel conducted standardized peer reviews. RESULTS: The study included data from 6765 patients treated at 26 trauma centers. Two centers (2PZW) had significantly more survivors than expected by both severity adjustment methods. Three had significantly fewer survivors than expected (3NZW). By several measures, patients treated in the 2PZW centers were more seriously injured and older than those in the 3NZW centers. CT of the head performed in the treating hospital was the only process of care variable associated with outcome in multivariate evaluations. Peer review also found little association between process of care variables and patient outcomes. However, peer review reported that 23.7% of unexpected deaths identified by case matching or the New Model were preventable or potentially preventable. Peer review also identified as medically unnecessary significant percentages of patients with unexpectedly long stays in hospital (26.4%) or in ICU (17.3%) identified by case matching. Nearly 45% of unexpected complications were judged preventable or potentially preventable. CONCLUSIONS: Two severity adjustment methods identified significant variability in trauma center outcomes for patients with MII. The difference in outcomes between the centers with better than expected (2PZW) and poorer than expected outcomes (3NZW) was substantial. Peer review identified significant opportunities for reducing unexpected deaths, stays in hospital and in ICU, and the occurrence of complications. Trauma registry data and peer reviews found little relationship between available process of care variables and patient outcomes. This study should stimulate discussions to understand reasons for outcome variability and ways to reduce it.