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1.
J Am Coll Surg ; 230(4): 720-723, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32035183
2.
Am J Surg ; 2020 Jan 20.
Artigo em Inglês | MEDLINE | ID: mdl-31983408

RESUMO

BACKGROUND: Readmission rates are an important metric because they enable an evaluation of care and affect Medicare funding. This study evaluates factors contributing to readmission after emergency general surgery. METHODS: The Virginia Health Information database was used to identify patients who had undergone the most common emergency general surgery procedures from 1/2011-6/2016. Analyses were performed for 30 and 90-day readmission. RESULTS: 121,223 records met initial inclusion criteria and 54,372 remained after exclusions. In 30 days there were 5050 readmissions and 7896 readmissions in 90 days. Factors significant in contributing to 30-day readmission were length of stay, discharge location, and several comorbidities. For 90-day readmission the same factors were significant with the addition of urgent vs emergency admission and insurance status as well as additional comorbidities. Discharge to rehab, SNF, or with home healthcare had particularly high rates of 90 day readmission. CONCLUSIONS: We identified factors that contribute to readmission after emergency general surgery providing targets for future interventions. Improved follow up for patients discharged with rehab or home health needs is our next step.

3.
J Trauma Acute Care Surg ; 88(1): e1-e21, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31626024

RESUMO

Uncontrolled exsanguination remains the leading cause of death for trauma patients, many of whom die in the pre-hospital setting. Without expedient intervention, trauma-associated hemorrhage induces a host of systemic responses and acute coagulopathy of trauma. For this reason, health care providers and prehospital personal face the challenge of swift and effective hemorrhage control. The utilization of adjuncts to facilitate hemostasis was first recorded in 1886. Commercially available products haves since expanded to include topical hemostats, surgical sealants, and adhesives. The ideal product balances efficacy, with safety practicality and cost-effectiveness. This review of hemostasis provides a guide for successful implementation and simultaneously highlights future opportunities.

7.
J Am Coll Surg ; 226(4): 623-627, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29307613

RESUMO

BACKGROUND: The acute care surgery (ACS) model has been widely implemented, with single institution studies demonstrating improved outcomes but multicenter studies questioning the efficiency. Acute care surgery programs care for sicker and more economically disadvantaged patients. This study compares outcomes between ACS and traditional models in the management of diverticulitis across an entire state. STUDY DESIGN: The Virginia Health Information administrative database for adults discharged with diverticulitis from January 2008 through September 2015, was reviewed. Patient characteristics were analyzed and compared between ACS and traditional models. Outcome differences were compared using logistic regression. RESULTS: We reviewed 23,943 admissions, with 2,330 (9.7%) patients cared for in ACS programs. The ACS patients were more likely to be uninsured (10.6% vs 6.8%, p < 0.0001) or covered by Medicaid (5.5% vs 3.4%, p < 0.0001), and the ACS hospitals cared for a higher percentage of minority patients than in the traditional programs (30.4% vs 19.8%, p < 0.0001). Operative rates were higher in ACS hospitals (14.7% vs 11.8%, p < 0.0001), as were rates of complicated diverticulitis (24.5% vs 20.3%, p < 0.0001). The ACS patients had significantly higher rates of comorbidities. After adjusting for patient comorbidities and demographics, ACS patients had a higher rate of complications (odds ratio [OR] 1.36, p = 0.0017). However, there was no difference in mortality, length of stay, or costs. When comparing only operative patients, there were no outcome differences after adjusting for patient factors. CONCLUSIONS: Acute care surgery patients present to the hospital with more severe disease, higher rates of medical comorbidities, and lower socioeconomic status. Once patient factors are accounted for, outcomes are equivalent for operative patients in either model. Acute care surgery hospitals provide high quality and efficient care to sicker and more complex patients than traditional programs.


Assuntos
Cuidados Críticos , Diverticulite/cirurgia , Doença Aguda , Adulto , Idoso , Diverticulite/complicações , Diverticulite/mortalidade , Feminino , Hospitalização , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores Socioeconômicos , Resultado do Tratamento , Virginia
8.
Am J Surg ; 215(6): 1055-1056, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29274885

RESUMO

The term, Festschrift, is defined as a volume of learned articles or essays by colleagues and admirers, serving as a tribute to a scholar. The recognition of LaSalle D. Leffall, Jr., M.D., F.A.C.S. adds credence to the merits of such a tribute.


Assuntos
Cirurgia Geral/história , Liderança , Sociedades Médicas/história , História do Século XX , História do Século XXI
12.
Am Surg ; 83(12): 1422-1426, 2017 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-29336766

RESUMO

Tertiary hospitals are increasingly called on by smaller hospitals and free-standing emergency rooms (ERs) to provide surgical care for complex patients. This study assesses patients transferred to an acute care surgery service. The ER and transfer center logs, as well as billing data, were reviewed for 12 months for all cases evaluated by acute care surgery. The charts were reviewed for demographics, comorbidities, and outcomes. A total of 111 transferred patients with complete data were identified, with 59 transferred from another hospital and 52 from a free-standing ER. The hospital transfer patients were older with more comorbidities, had a longer length of stay, and were more likely discharged to skilled care. There was no difference in the percent of patients requiring a procedure; however, significantly more procedures in the hospital transfer group were done by nonsurgical specialties Better infrastructure to monitor the impact of hospital transfers is warranted in the setting of the complex patient population transferred to tertiary hospitals.


Assuntos
Transferência de Pacientes , Procedimentos Cirúrgicos Operatórios , Atenção Terciária à Saúde , Comorbidade , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade
13.
J Surg Educ ; 73(5): 851, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27397416
15.
JAMA Surg ; 151(8): 768-70, 2016 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-27096328

RESUMO

This Special Communication summarizes the key points raised at the Society of Surgical Chairs mentorship panel sessions held at the 2014 and 2015 annual meetings of the society. Highlights of these expert panel discussions include senior chairs' insights into successfully dealing with increasingly complex academic medical organizations and horizontal department management expectations in the context of the arrival of the Millennial Generation into the work force. Three key tenets of effective surgery leadership that arose from these sessions deal with the importance of (1) collaboration and cooperativity, (2) humanized relationships and mentorship, and (3) operational efficiency. Overall, the panel consensus for the future of surgery leadership was optimistic while recognizing that the demands of chairmanship are considerable.


Assuntos
Comportamento Cooperativo , Eficiência , Cirurgia Geral/organização & administração , Relações Interpessoais , Liderança , Congressos como Assunto , Humanos , Mentores
16.
JAMA Surg ; 151(6): 554-63, 2016 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-26982380

RESUMO

Health care disparities (differential access, care, and outcomes owing to factors such as race/ethnicity) are widely established. Compared with other groups, African American individuals have an increased mortality risk across multiple surgical procedures. Gender, sexual orientation, age, and geographic disparities are also well documented. Further research is needed to mitigate these inequities. To do so, the American College of Surgeons and the National Institutes of Health-National Institute of Minority Health and Disparities convened a research summit to develop a national surgical disparities research agenda and funding priorities. Sixty leading researchers and clinicians gathered in May 2015 for a 2-day summit. First, literature on surgical disparities was presented within 5 themes: (1) clinician, (2) patient, (3) systemic/access, (4) clinical quality, and (5) postoperative care and rehabilitation-related factors. These themes were identified via an exhaustive preconference literature review and guided the summit and its interactive consensus-building exercises. After individual thematic presentations, attendees contributed research priorities for each theme. Suggestions were collated, refined, and prioritized during the latter half of the summit. Breakout sessions yielded 3 to 5 top research priorities by theme. Overall priorities, regardless of theme, included improving patient-clinician communication, fostering engagement and community outreach by using technology, improving care at facilities with a higher proportion of minority patients, evaluating the longer-term effect of acute intervention and rehabilitation support, and improving patient centeredness by identifying expectations for recovery. The National Institutes of Health and American College of Surgeons Summit on Surgical Disparities Research succeeded in identifying a comprehensive research agenda. Future research and funding priorities should prioritize patients' care perspectives, workforce diversification and training, and systematic evaluation of health technologies to reduce surgical disparities.


Assuntos
Pesquisa Biomédica , Disparidades em Assistência à Saúde , National Institutes of Health (U.S.) , Qualidade da Assistência à Saúde , Sociedades Médicas , Procedimentos Cirúrgicos Operatórios , Competência Cultural , Acesso aos Serviços de Saúde , Disparidades em Assistência à Saúde/etnologia , Humanos , Relações Médico-Paciente , Cuidados Pós-Operatórios , Padrões de Prática Médica , Fatores Socioeconômicos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/reabilitação , Estados Unidos
17.
J Trauma Acute Care Surg ; 80(6): 870-6, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-26886001

RESUMO

BACKGROUND: The pattern of law enforcement-related injuries of police and civilians in the United States is unknown. METHODS: Data were aggregated from the Federal Bureau of Investigations, the Bureau of Justice Statistics, the Centers for Disease Control (CDC) Web-based Injury Statistics Query and Reporting System, and the Nationwide Inpatient Sample (NIS) from 2003 to 2011. Law enforcement-related injuries in the CDC Web-based Injury Statistics Query and Reporting System and the NIS were identified using E-codes 970-976, which are meant to identify "injuries inflicted by the police or other law-enforcing agents, including military on duty, in the course of arresting or attempting to arrest lawbreakers, suppressing disturbances, maintaining order, and other legal action." RESULTS: The CDC reported a total of 715,118 nonfatal injuries and 3,156 fatal injuries from 2003 to 2011. In contrast, for the same period, the NIS identified a total of 3,958 patients, ranging from 348 to 572 per year. Among the injured, 1,548 (48.0%) were white, 866 were black (26.8%), and 605 were Hispanic (18.8%); 1,011 patients (25.5%) were injured by firearms, while 2,304 (58.2%) experienced blows or manhandling. Firearm-injured hospitalized patients are more likely to be male, black or Hispanics, and in the age group of 18 years to 39 years. CONCLUSION: The majority of law enforcement-related injuries are among white or black young men. Hispanic patients are more likely to be injured by a firearm than struck. When injured by firearm, white and black patients are more likely to die compared with Hispanic patients. Unfortunately, data about these injuries are scattered across multiple data systems. A uniform national system to aggregate these data sources is needed to better understand the scope of the problem, for both law enforcement personnel and civilians. LEVEL OF EVIDENCE: Epidemiologic study, level III.


Assuntos
Aplicação da Lei , Ferimentos e Lesões/epidemiologia , Adolescente , Adulto , Idoso , Grupos Étnicos/estatística & dados numéricos , Feminino , Armas de Fogo , Homicídio/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos/epidemiologia , Violência/estatística & dados numéricos , Ferimentos e Lesões/etnologia
19.
Am Surg ; 81(8): 798-801, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26215242

RESUMO

Reliance on CT imaging in the evaluation of low-impact blunt trauma is a major source of radiation exposure, cost, and resource utilization. This study sought to determine if torso (chest and abdomen) CT could be avoided in patients with ground level falls. This was a retrospective chart review of patients admitted to the trauma service between January 2013 and April 2014. The mechanism of injury was ground level fall or fall from sitting. Patient demographics, physical examination (PE) findings, imaging results, length of stay, and complications were reviewed. History and physical data were based on chief resident or attending documentation. A significant thoracic injury was defined as a hemothorax, a pneumothorax, greater than three rib fractures, or aortic injury. A significant abdominal injury was defined as a solid organ injury, an intra-abdominal hematoma, a hollow viscus injury, aortic injury, or a urologic injury. The trauma service evaluated 156 patients. Nine patients were excluded for intubation or Glasgow Coma Scale (GCS) < 13. Of the 147 remaining, mean age was 69 years, mean GCS was 14.8. A chest CT was obtained in 111 (76%). Eight (7%) had a significant thoracic injury. All patients with significant thoracic injury had positive examination findings. No patient with a normal PE was found to have a significant thoracic injury (negative predictive value of 100%). An abdominal CT was obtained in 86 (59%). Five (6%) were found to have a significant abdominal injury. All patients who had a significant radiographic injury had an abnormal PE (negative predictive value of 100%). In conclusion, thorough history and physical in the trauma bay allow the clinician to obtain selective torso CT imaging. Routine torso CT warrants re-evaluation in low-impact injury mechanisms as there appears to be little benefit compared with the resource utilization and expense.


Assuntos
Traumatismos Abdominais/diagnóstico por imagem , Acidentes por Quedas , Traumatismos Torácicos/diagnóstico por imagem , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Procedimentos Desnecessários/estatística & dados numéricos , Ferimentos não Penetrantes/diagnóstico por imagem , Traumatismos Abdominais/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Redução de Custos , Análise Custo-Benefício , Feminino , Seguimentos , Hospitais Gerais , Humanos , Escala de Gravidade do Ferimento , Masculino , Anamnese , Pessoa de Meia-Idade , Segurança do Paciente , Exame Físico/métodos , Postura , Valor Preditivo dos Testes , Radiografia Abdominal/economia , Radiografia Abdominal/estatística & dados numéricos , Radiografia Torácica/economia , Radiografia Torácica/estatística & dados numéricos , Estudos Retrospectivos , Traumatismos Torácicos/diagnóstico , Tomografia Computadorizada por Raios X/economia , Centros de Traumatologia , Procedimentos Desnecessários/economia , Virginia , Ferimentos não Penetrantes/diagnóstico
20.
Am Surg ; 81(4): 336-40, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25831176

RESUMO

The objective of this study was to investigate the feasibility of using ultrasound (US) in place of portable chest x-ray (CXR) for the rapid detection of a traumatic pneumothorax (PTX) requiring urgent decompression in the trauma bay. All patients who presented as a trauma alert to a single institution from August 2011 to May 2012 underwent an extended focused assessment with sonography for trauma (FAST). The thoracic cavity was examined using four-view US imaging and were interpreted by a chief resident (Postgraduate Year 4) or attending staff. US results were compared with CXR and chest computed tomography (CT) scans, when obtained. The average age was 37.8 years and 68 per cent of the patients were male. Blunt injury occurred in 87 per cent and penetrating injury in 12 per cent of activations. US was able to predict the absence of PTX on CXR with a sensitivity of 93.8 per cent, specificity of 98 per cent, and a negative predictive value of 99.9 per cent compared with CXR. The only missed PTX seen on CXR was a small, low anterior, loculated PTX that was stable for transport to CT. The use of thoracic US during the FAST can rapidly and safely detect the absence of a clinically significant PTX. US can replace routine CXR obtained in the trauma bay and allow more rapid initiation of definitive imaging studies.


Assuntos
Pneumotórax/diagnóstico , Radiografia Torácica/métodos , Tomografia Computadorizada por Raios X , Centros de Traumatologia , Ferimentos e Lesões/diagnóstico por imagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Viabilidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Pneumotórax/etiologia , Valor Preditivo dos Testes , Curva ROC , Reprodutibilidade dos Testes , Estudos Retrospectivos , Índices de Gravidade do Trauma , Ultrassonografia , Ferimentos e Lesões/complicações , Adulto Jovem
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