Management of symptomatic cholelithiasis: a systematic review.

BACKGROUND: Symptomatic cholelithiasis is a common surgical disease and accounts for half of the over one million cholecystectomies performed in the USA annually. Despite its prevalence, only one prior systematic review has examined the evidence around treatment strategies and it contained a narrow scope. The goal of this systematic review was to analyze the clinical effectiveness of treatment options for symptomatic cholelithiasis, including surgery, non-surgical therapies, and ED pain management strategies. METHODS: Literature search was performed from January 2000 through June 2020, and a narrative analysis was performed as studies were heterogeneous. RESULTS: We identified 12 publications reporting on 10 trials (9 randomized controlled trials and 1 observational study) comparing treatment methods. The studies assessed surgery, observation, lithotripsy, ursodeoxycholic acid, electro-acupuncture, and pain-management strategies in the emergency department. Only one compared surgery to observation. CONCLUSION: This work presents the existing data and underscores the current gap in knowledge regarding treatment for patients with symptomatic cholelithiasis. We use these results to suggest how future trials may guide comparisons between the timing of surgery and watchful waiting to create a set of standardized guidelines. Providing appropriate and timely treatment for symptomatic cholelithiasis is important to streamline care for a costly and prevalent disease. TRIAL REGISTRATION: PROSPERO Protocol Number: CRD42020153153.

Identifying vulnerable populations with symptomatic cholelithiasis at risk for increased health care utilization.

BACKGROUND: Gallstones are a common problem in the United States with many patients suffering from symptomatic cholelithiasis (SC). Patients with SC may first present to the emergency department ED) and are often discharged for elective follow-up; however, it is unknown what system and patient factors are associated with increased risk for ED revisits. This study aimed to assess longitudinal ED utilization and cholecystectomy for patients with SC and identify patient, geographic, and hospital characteristics associated with ED revisits, specifically race/ethnicity and insurance status. METHODS: Patients discharged from the ED with SC between July 1, 2016, and December 31, 2017, were identified from California administrative databases and followed for 1 year. Emergency department revisits and cholecystectomy after discharge were examined using logistic regression, clustering standard errors by hospital. Models adjusted for patient, geographic, and hospital variables using census and hospital administrative data. RESULTS: Cohort included 34,427 patients who presented to the ED with SC and were discharged. There were 18.8% of the patients that had one or more biliary-related ED revisits within 1 year. In fully adjusted models, non-Hispanic Black patients had higher odds for any ED revisit (adjusted odds ratio 1.23; 95% confidence interval, 1.09-1.39) and for two more ED revisits (adjusted odds ratio 1.48; 95% confidence interval, 1.20-1.82). Insurance type was also associated with ED revisits. CONCLUSION: Non-Hispanic Black patients experienced higher utilization of health care resources for SC after adjusting for other patient, geographic and hospital variables. Strategies to mitigate these disparities may include the development of standardized protocols regarding the follow-up and education for SC. Implementation of such strategies can ensure equitable treatment for all patients. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Delay to Surgery for Patients with Symptomatic Cholelithiasis: Retrospective Analysis of an Administrative California Database after Discharge from the Emergency Department.

BACKGROUND: Timely receipt of surgery should be available for all patients. Few studies have examined differences in the treatment of symptomatic cholelithiasis (SC), a common surgical problem, based on race/ethnicity or insurance status. This study aimed to identify differences in repeat emergency department (ED) use and wait time to cholecystectomy for SC. STUDY DESIGN: Patients discharged from the ED with SC between July 1, 2016, and December 31, 2017, were identified from California administrative databases and followed for 1 year. Repeat ED use and wait time to elective and nonelective cholecystectomy after ED discharge were examined using logistic and negative binomial regression models. RESULTS: The final cohort analyzed 13,596 patients who underwent cholecystectomy within 1 year from index ED visit for SC. In adjusted analysis, non-Hispanic Black patients had higher odds for repeat ED use for biliary-related conditions before elective surgery and experienced longer waits for cholecystectomy (across several measures of wait times) compared with non-Hispanic White patients. Similar findings were seen for Medicaid and self-pay compared with privately insured patients. For example, self-pay patients had more than double the odds of experiencing repeat ED use while waiting for elective cholecystectomy compared with privately insured patients (adjusted odds ratio 2.49, 95% CI 1.88-3.31). CONCLUSION: Patients with SC receiving cholecystectomy within 1 year from index ED visit were more likely to have repeat ED use and longer waits to surgery based on their race/ethnicity and insurance status, even after adjusting for other measures of access. We identify a vulnerable population at risk for differences in treatment for a common surgical pathology.

The Impact of Primary Care Physicians on the Surgical Presentation and Outcomes of Colorectal Cancer in Vulnerable Populations.

BACKGROUND: Multiple socioeconomic and clinical factors have been implicated in the health disparities that exist amongst vulnerable populations with colorectal cancer. Efforts have been directed toward addressing these factors to improve outcomes. We evaluate the impact of primary care physicians (PCP) on the surgical presentation and outcomes of colorectal cancer at a safety-net hospital. METHODS: A retrospective chart review of 331 patients diagnosed with colorectal adenocarcinoma between 2014 and 2020 at a single-institution urban county medical center. RESULTS: The cohort was predominantly male (59%) and Hispanic (52.1%). Thirty-two percent of patients had a PCP at time of diagnosis. Patients with PCPs compared to those without PCPs had significantly lower rates of acute presentation (perforation or obstruction) (17.0 vs 38.1%, P < .001), higher rates of surgical resection (83.0 vs 70.7%, P = .016), and were less likely to have metastatic disease at presentation (20.4 vs 33.5%, P = .02). Overall, having a PCP also improved probability of survival (HR 1.36, P < .04). CONCLUSION: Having a PCP at the time of colorectal cancer diagnosis is associated with improved outcomes in a safety-net population, with significant differences in surgical presentation and resection.

Symptomatic Cholelithiasis: Do Minority Patients Experience Delays to Surgery?

BACKGROUND: Cholecystectomy is one of the most common surgeries and the majority are performed to treat symptomatic cholelithiasis (SC). While surgery is often elective, poor access or delays in care may lead to urgent cases, which are potentially associated with higher complication rates. This study aims to determine if minority patients with SC have higher rates of urgent cholecystectomy and postoperative complications. MATERIALS AND METHODS: Analysis of patients undergoing cholecystectomy for SC utilizing American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) from 2017 to 2019. Primary outcome was acuity of cholecystectomy (i.e., urgent versus elective). Secondary outcomes were any post-operative complication and length of stay. RESULTS: Patients who underwent cholecystectomy for SC between 2017 to 2019 (N: 13,390) were analyzed. Hispanic and non-Hispanic Black patients had higher odds of undergoing urgent surgery as compared to non-Hispanic White patients, and Hispanics had over twice the odds (adjusted odds ratio (aOR), 2.16; 95% CI 1.93-2.43), adjusting for age, sex, and comorbidities. Having urgent surgery was associated with higher odds for developing any postoperative complication and experiencing longer length of stay. After adjusting for urgency of surgery, Non-Hispanic Black and Asian patients were at risk for higher postoperative length of stay. CONCLUSIONS: Hispanic and non-Hispanic Black patients were more likely to undergo urgent cholecystectomy as compared to non-Hispanic White patients for SC. Urgent surgery was independently associated with a higher complication rate and longer length of stay. Further characterization of the delays to surgery that lead to these differences are critical to prevent further treatment disparities.

Perioperative Pain Management Issues Unique to Older Adults Undergoing Surgery: A Narrative Review.

INTRODUCTION: The older population is growing and with this growth there is a parallel rise in the operations performed on this vulnerable group. The perioperative pain management strategy for older adults is unique and requires a team-based approach for provision of high-quality surgical care. METHODS: Literature search was performed using PubMed in addition to review of relevant protocols and guidelines from geriatric, surgical, and anesthesia societies. Systematic reviews and meta-analyses, randomized trials, observational studies, and society guidelines were summarized in this review. MANAGEMENT: The optimal approach to a pain management strategy for older adults undergoing surgery involves addressing all phases of perioperative care. For example, preoperative assessment of a patient's cognitive function and presence of chronic pain may impact the pain management plan. Consideration should be also given to intraoperative strategies to improve pain control and minimize both the dose and side effects from opioids (e.g. regional anesthetic techniques). Postoperative pain control (e.g. under or over treatment of pain) may impact the development of elderly-specific complications such as postoperative delirium and functional decline. Finally, pain management does not stop after the older adult patient leaves the hospital. Both discharge planning and post-operative clinic follow-up provide important opportunities for collaboration and intervention. CONCLUSIONS: An opioid-sparing pain management strategy for older adults can be accomplished with a comprehensive and collaborative interdisciplinary strategy addressing all phases of perioperative care.

Question Design Affects Students' Sense-Making on Mathematics Word Problems.

Mathematics word problems provide students with an opportunity to apply what they are learning in their mathematics classes to the world around them. However, students often neglect their knowledge of the world and provide nonsensical responses (e.g., they may answer that a school needs 12.5 buses for a field trip). This study examined if the question design of word problems affects students' mindset in ways that affect subsequent sense-making. The hypothesis was that rewriting standard word problems to introduce inherent uncertainty about the result would be beneficial to student performance and sense-making because it requires students to reason explicitly about the context described in the problem. Middle school students (N = 229) were randomly assigned to one of three conditions. In the standard textbook condition, students solved a set of six word problems taken from current textbooks. In the modified yes/no condition, students solved the same six problems rewritten so the solution helped answer a "yes" or "no" question. In the disfluency control condition, students solved the standard problems each rewritten in a variety of fonts to make them look unusual. After solving the six problems in their assigned condition, all students solved the same three "problematic" problems designed to assess sense-making. Contrary to predictions, results showed that students in the modified yes/no condition solved the fewest problems correctly in their assigned condition problem set. However, consistent with predictions, they subsequently demonstrated more sense-making on the three problematic problems. Results suggest that standard textbook word problems may be able to be rewritten in ways that mitigate a "senseless" mindset.

Partial knowledge in the development of number word understanding.

A common measure of number word understanding is the give-N task. Traditionally, to receive credit for understanding a number, N, children must understand that N does not apply to other set sizes (e.g. a child who gives three when asked for 'three' but also when asked for 'four' would not be credited with knowing 'three'). However, it is possible that children who correctly provide the set size directly above their knower level but also provide that number for other number words ('N + 1 givers') may be in a partial, transitional knowledge state. In an integrative analysis including 191 preschoolers, subset knowers who correctly gave N + 1 at pretest performed better at posttest than did those who did not correctly give N + 1. This performance was not reflective of 'full' knowledge of N + 1, as N + 1 givers performed worse than traditionally coded knowers of that set size on separate measures of number word understanding within a given timepoint. Results support the idea of graded representations (Munakata, Trends in Cognitive Sciences, 5, 309-315, 2001.) in number word development and suggest traditional approaches to coding the give-N task may not completely capture children's knowledge.