Fast-Track Nonelective Laparoscopic Cholecystectomy is Safe and Feasible.

INTRODUCTION: Ample evidence exists to support the safety of fast-track discharge after elective laparoscopic cholecystectomy (LC), but there is currently no data available to support the safety of fast-tracking patients undergoing nonelective LC. We sought to determine whether fast-tracking patients undergoing nonelective LC is safe and feasible. METHODS: We performed a retrospective cohort review of 661 consecutive patients undergoing LC at a single teaching institution from April 2018 to January 2020. Subjects were divided into two groups: elective LC (ELC) and fast-track nonelective LC (FTLC). FTLC was defined as nonelective LC with total length of stay <36 h. Patients undergoing nonelective LC with length of stay exceeding 36 h were excluded. The primary outcome of interest was readmission within 30 d. The secondary outcomes included incidences of return to emergency department within 30 d, retained stone, bile leak, and wound infection. RESULTS: Of 661 LC, 185 (27%) were ELC and 476 (72%) were nonelective. FTLC included 121 (25%) of the nonelective LC. Preoperative characteristics were similar among the groups. On final pathology, chronic cholecystitis was predominant in both groups, but FTLC exhibited higher rates of acute cholecystitis (P < 0.0001). There was no significant difference in the primary outcome among groups: readmission within 30 d occurred in 6 (3%) ELC patients and 4 (3%) FTLC patients (P = 1.0). There were no significant differences in rates of return to emergency department within 30 d, retained stone, bile leak, or wound infection. CONCLUSIONS: With comparable postoperative complication rates to ELC, FTLC can be safely used in select patients. Additional studies are needed to determine preoperative predictors of FTLC suitability to prospectively identify appropriate patients.

In-Person Clinic Visits After Laparoscopic Cholecystectomy: Lessons Learned From COVID-19 Pandemic.

INTRODUCTION: The utility of routine in-person clinic appointments after laparoscopic cholecystectomy (LC) is uncertain, especially after the increase of telehealth visits during the COVID-19 pandemic. The purpose of this study was to evaluate the utility of routine in-person follow-up for patients undergoing LC prior to changes implemented during the pandemic and to determine whether a return to routine in-person follow-up is warranted. METHODS: We retrospectively reviewed follow-up encounters for all patients undergoing LC from April 2018 to February 2020. All patients were routinely scheduled for in-person postoperative clinic follow-up 2-4 wk after discharge. Follow-up was considered nonroutine if new studies or medications were ordered, the patient was referred to the emergency department or readmitted, or malignancy was identified on pathology review. RESULTS: Of 661 patients undergoing LC, 449 (68%) attended their scheduled in-person postoperative appointment and 212 (32%) did not. The postoperative appointment was nonroutine for 39 patients (9% of clinic attenders). Readmission occurred in 42 patients, with no differences between clinic attenders and nonattenders (P = 0.12). Furthermore, attending a postoperative clinic visit did not affect odds of readmission (odds ratio: 0.705, 95% confidence interval: 0.368, 1.351; P = 0.29). Readmission occurred on median day 9 after discharge in both groups. CONCLUSIONS: The incidence of nonroutine follow-up after LC is low, and attendance at follow-up clinic was not associated with reduced readmissions. A return to routinely scheduling in-person follow-up 2-4 wk after discharge may not be warranted. Telehealth visits within 1 wk of discharge after LC should be considered.

NSQIP Based Predictors of False Negative and Indeterminate Ultrasounds in Adults With Appendicitis.

BACKGROUND: It has been well established that ultrasound (US) is the initial screening tool for children with suspected acute appendicitis. However, computed tomography (CT) has become the standard screening modality for adults presenting with abdominal pain. A recent review of National Surgical Quality Improvement Program (NSQIP) data revealed US is being utilized as a screening modality in adults. We aimed to assess the diagnostic performance of US in evaluating adults with acute appendicitis. STUDY DESIGN: The American College of Surgeons NSQIP and NSQIP Procedure Targeted Data Files were accessed and examined for all patients in 2016 and 2017 who received an US and underwent an appendectomy. The US results were then correlated to the pathology in order to determine the diagnostic performance. Additionally, we identified predictors for indeterminate and false negative US results. RESULTS: Our study included 3607 appendectomy patients of which 1135 (30%) had an indeterminate US, 683 (18%) had an US not consistent with appendicitis, and 1789 (49%) had an US consistent with appendicitis. Sensitivity and Specificity were 74.3% and 53.0%, respectively. Positive Predictive Value (PPV) and Negative Predictive Value (NPV) were 95.9% and 12.2%, respectively. On regression analysis, clinically relevant predictors for false negative and indeterminate studies included age, sex, and BMI. CONCLUSIONS: Ultrasound is an effective initial imaging modality for acute appendicitis in the adult population. Females, age >30 y, and elevated BMI were more likely to have indeterminate or false negative results. These patients may benefit from CT as their initial screening test.

Association between depression and hypertension using classic and revised blood pressure thresholds.

BACKGROUND: In a primary care population, the relationship between treatment of depression and hypertension (HTN) under the recently revised American College of Cardiology and American Heart Association HTN thresholds for diagnosing HTN is unknown. OBJECTIVE: To compare the association between changes in severity of co-occurring depression and HTN over time using the newly revised versus previous HTN guidelines. METHODS: In this retrospective cohort study, outpatients ≥18 years (n = 3018) with clinically significant depressive symptoms and elevated blood pressure at baseline were divided into a 'revised' guideline group (baseline blood pressure ≥130/80 mmHg), a 'classic' guideline group (≥140/90 mmHg) and a 'revised-minus-classic' group (≥130/80 and <140/90 mmHg). Depressive symptom change was assessed using the Patient Health Questionnaire-9 (PHQ-9). Correlations between changes in PHQ-9 scores and HTN levels by group over a 6- to 18-month observation period were assessed using robust regression analysis. RESULTS: There were demographic and clinical differences between groups. A total of 41% of study subjects (1252/3018) had a visit during the follow-up period where additional PHQ-9 and HTN results were available. Depressive symptom change was unrelated to change in blood pressure in the revised and revised-minus-classic groups. The classic HTN group demonstrated a clinically insignificant change in systolic blood pressure for each unit change in PHQ-9 score (ß = 0.23, P-value =0.02). CONCLUSIONS: Although a statistically significant association between reduced HTN levels and improvement in depressive symptoms was demonstrated under classic HTN guidelines, there was no clinically meaningful association between treatment of depression and improved HTN levels under either guideline.

Fixed-dose gabapentin augmentation in the treatment of alcohol withdrawal syndrome: a retrospective, open-label study.

Background: Lorazepam use in the treatment of alcohol withdrawal syndrome (AWS) is not without risk.Objective: This study compares AWS outcomes using a standard, symptom-triggered lorazepam dosing protocol (control group) and symptom-triggered lorazepam dosing augmented with a gabapentin loading dose and taper (GABA group).Methods: Consecutive, non-randomized adults (n = 982; 64.0% male) undergoing treatment for AWS were included in this retrospective, open-label study. Symptom-triggered lorazepam dosing was informed by scores on the Clinical Institute Withdrawal Assessment-Alcohol, revised (CIWA-Ar). Gabapentin augmentation utilized an initial loading dose (900 mg) and a three-day taper. Outcomes included average symptom severity per treatment hour and average lorazepam dose per treatment hour. Average time in the protocol by group, stratified by highest CIWA-Ar score, was examined as a secondary outcome. A priori group differences were controlled statistically.Results: GABA patients were older and exhibited somewhat more severe withdrawal symptoms than controls. After controlling for confounders, gabapentin augmentation did not significantly lower average lorazepam dosing per treatment hour or withdrawal symptom severity per treatment hour. Compared to controls, overall withdrawal symptoms diminished somewhat more rapidly for GABA patients experiencing low or moderate-level withdrawal symptoms; however, severe withdrawal symptoms remitted more slowly in the GABA group. Results should be interpreted in light of the uncontrolled nature of group assignment and other confounders.Conclusions: Compared to symptom-triggered lorazepam dosing alone, gabapentin augmentation did not produce better outcomes during treatment of acute AWS. These results do not support the use of scheduled gabapentin as an augmentation to benzodiazepines during inpatient treatment of AWS.

Reimbursement for Hip Fractures: The Impact of Varied Current Procedural Terminology Coding Using Relative Value Units.

BACKGROUND: Many orthopedic practices routinely code hip fracture hemiarthroplasty as Current Procedural Terminology (CPT) 27125 even though 27236 is the correct CPT code. Our objective is to determine the financial impact this simple mistake has on surgeon reimbursement. METHODS: Our data comprised cases assigned International Classification of Diseases, Tenth Revision code S72.001A through S72.035A and CPT code 27125 or 27236 within the American College of Surgeons National Surgical Quality Improvement Program 2016-2017 database. Relative value units (RVUs) per CPT code and the Centers for Medicare and Medicaid Services reported that RVU conversion factor of $36.0896 per 1 RVU was used to calculate reimbursement per case. The dollar difference and percent difference per case was then calculated between cases assigned CPT code 27125 and those assigned 27236. RESULTS: Our total sample consisted of 12,287 National Surgical Quality Improvement Program cases. Of those, 4185 (34%) were cases of a hip fracture treated with hemiarthroplasty that were incorrectly coded as CPT code 27125. That error in coding results in a decrease in reimbursement of $35.01 per case, a 5.51% difference. CONCLUSION: Since the current healthcare reimbursement model relies solely on CPT codes to determine RVUs, it is imperative that orthopedic surgeons understand the financial impact of incorrect coding. Although correct coding of hemiarthroplasty procedures for hip fractures is an easy task to fix in the future, we hope that through this study a greater emphasis is placed on coding in orthopedic surgery.

HEART Score Risk Stratification of Low-Risk Chest Pain Patients in the Emergency Department: A Systematic Review and Meta-Analysis.

STUDY OBJECTIVE: The objectives of this systematic review and meta-analysis are to appraise the evidence in regard to the diagnostic accuracy of a low-risk History, ECG, Age, Risk Factors, and Troponin (HEART) score for prediction of major adverse cardiac events in emergency department (ED) patients. These included 4 subgroup analyses: by geographic region, the use of a modified low-risk HEART score (traditional HEART score [0 to 3] in addition to negative troponin results), using conventional versus high-sensitivity troponin assays in the HEART score, and a comparison of different post-ED-discharge patient follow-up intervals. METHODS: We searched MEDLINE, EBSCO, Web of Science, and Cochrane Database for studies on the diagnostic performance of low-risk HEART scores to predict major adverse cardiac events among ED chest pain patients. Two reviewers independently screened articles for inclusion, assessed the quality of studies with both an adapted Quality Assessment of Diagnostic Accuracy Studies version 2 tool and an internally developed tool that combined components of the Quality in Prognostic Studies; Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies; and Grading of Recommendations Assessment, Development and Evaluation. Pooled sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratios were calculated. RESULTS: There were 25 studies published from 2010 to 2017, with a total of 25,266 patients included in the final meta-analysis, of whom 9,919 (39.3%) were deemed to have low-risk HEART scores (0 to 3). Among patients with low-risk HEART scores, short-term major adverse cardiac events (30 days to 6 weeks) occurred in 2.1% of the population (182/8,832) compared with 21.9% of patients (3,290/15,038) with non-low-risk HEART scores (4 to 10). For patients with HEART scores of 0 to 3, the pooled sensitivity of short-term major adverse cardiac event predictions was 0.96 (95% confidence interval [CI] 0.93 to 0.98), specificity was 0.42 (95% CI 0.36 to 0.49), positive predictive value was 0.19 (95% CI 0.14 to 0.24), negative predictive value was 0.99 (95% CI 0.98 to 0.99), positive likelihood ratio was 1.66 (95% CI 1.50 to 1.85), and negative likelihood ratio was 0.09 (95% CI 0.06 to 0.15). Subgroup analysis showed that lower short-term major adverse cardiac events occurred among North American patients (0.7%), occurred when modified low-risk HEART score was used (0.8%), or occurred when high-sensitivity troponin was used for low-risk HEART score calculations (0.8%). CONCLUSION: In this meta-analysis, despite its use in different patient populations, the troponin type used, and timeline of follow-up, a low-risk HEART score had high sensitivity, negative predictive value, and negative likelihood ratio for predicting short-term major adverse cardiac events, although risk of bias and statistical heterogeneity were high.

Common step-wise interventions improved primary care clinic visits and reduced emergency department discharge failures: a large-scale retrospective observational study.

BACKGROUND: It is critical to understand whether providing health insurance coverage, assigning a dedicated Primary Care Physician (PCP), and arranging timely post-Emergency Department (ED) clinic follow-up can improve compliance with clinic visits and reduce ED discharge failures. We aim to determine the benefits of providing these common step-wise interventions and further investigate the necessity of urgent PCP referrals on behalf of ED discharged patients. METHODS: This is a single-center retrospective observational study. All patients discharged from the ED over the period Jan 1, 2015 through Dec 31, 2017 were included in the study population. Step-wise interventions included providing charity health insurance, assigning a dedicated PCP, and providing ED follow-up clinics. PCP clinic compliance and ED discharge failures were measured and compared among groups receiving different interventions. RESULT: A total of 227,627 patients were included. Fifty-eight percent of patients receiving charity insurance had PCP visits in comparison to 23% of patients without charity insurance (p < 0.001). Seventy-seven percent of patients with charity insurance and PCP assignments completed post-ED discharge PCP visits in comparison to only 4.5% of those with neither charity insurance nor PCP assignments (p < 0.001). CONCLUSIONS: Step-wise interventions increased patient clinic follow-up compliance while simultaneously reducing ED discharge failures. Such interventions might benefit communities with similar patient populations.

Patient Partnership Tools to Support Medication Safety in Community-Dwelling Older Adults: Protocol for a Nonrandomized Stepped Wedge Clinical Trial.

BACKGROUND: Preventable harms from medications are significant threats to patient safety in community settings, especially among ambulatory older adults on multiple prescription medications. Patients may partner with primary care professionals by taking on active roles in decisions, learning the basics of medication self-management, and working with community resources. OBJECTIVE: This study aims to assess the impact of a set of patient partnership tools that redesign primary care encounters to encourage and empower patients to make more effective use of those encounters to improve medication safety. METHODS: The study is a nonrandomized, cross-sectional stepped wedge cluster-controlled trial with 1 private family medicine clinic and 2 public safety-net primary care clinics each composing their own cluster. There are 2 intervention sequences with 1 cluster per sequence and 1 control sequence with 1 cluster. Cross-sectional surveys will be taken immediately at the conclusion of visits to the clinics during 6 time periods of 6 weeks each, with a transition period of no data collection during intervention implementation. The number of visits to be surveyed will vary by period and cluster. We plan to recruit patients and professionals for surveys during 405 visits. In the experimental periods, visits will be conducted with two partnership tools and associated clinic process changes: (1) a 1-page visit preparation guide given to relevant patients by clinic staff before seeing the provider, with the intention to improve communication and shared decision-making, and (2) a library of short educational videos that clinic staff encourage patients to watch on medication safety. In the control periods, visits will be conducted with usual care. The primary outcome will be patients' self-efficacy in medication use. The secondary outcomes are medication-related issues such as duplicate therapies identified by primary care providers and assessment of collaborative work during visits. RESULTS: The study was funded in September 2019. Data collection started in April 2023 and ended in December 2023. Data was collected for 405 primary care encounters during that period. As of February 15, 2024, initial descriptive statistics were calculated. Full data analysis is expected to be completed and published in the summer of 2024. CONCLUSIONS: This study will assess the impact of patient partnership tools and associated process changes in primary care on medication use self-efficacy and medication-related issues. The study is powered to identify types of patients who may benefit most from patient engagement tools in primary care visits. TRIAL REGISTRATION: ClinicalTrials.gov NCT05880368; https://clinicaltrials.gov/study/NCT05880368. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/57878.

Implementation of a Preoperative Huddle at a Level 1 Trauma Center.

OBJECTIVE: Medical errors resulting in patient harm still occur at an alarmingly high rate. Surgery is a high-risk area that can frequently result in patient harm if errors occur. There is a need for standardization of communication and processes to decrease errors. We sought to determine whether the implementation of a preoperative huddle at our hospital could standardize communication and decrease medical errors. METHODS: A unique preoperative huddle was developed and implemented at a level 1 trauma center. We reviewed data before and after the implementation of the preoperative huddle including patient surveys and comments, the percentage of on-time operating room (OR) starts, OR turnover times, and the number of sentinel events. RESULTS: After huddle implementation, we observed a trend of improvement in our patient survey results on patient's perception that the doctors/nurses explained the procedure understandably after huddle implementation. There was a statistically yet limited clinically significant increase in OR turnover time from 37 to 40 minutes (P < 0.001). There was also an increase in on-time OR starts from 37% to 45% (P < 0.001). We observed a decrease in the number of sentinel events, with only 1 occurring each year since implementation. CONCLUSIONS: A preoperative huddle was successfully implemented at a level 1 trauma hospital and helped standardize communication without significantly disrupting workflow. To our knowledge, this method of preoperative huddling has not been previously described in the literature.

Understanding the effect of direct-acting antiviral therapy on weight in patients with chronic hepatitis C.

BACKGROUND: Direct-acting antivirals (DAAs) have revolutionized treatment for HCV. Compared to interferon-based therapies, DAAs achieve higher rates of sustained virologic response, with more tolerable side effects. Nonetheless, interferon-based therapies have the potential to cause weight loss, and literature documenting the impact of DAAs on weight is limited. Appetite suppression may occur with chronic HCV. It is plausible that DAAs may indirectly cause weight gain given their ability to cause rapid virologic suppression, leading to improved hepatic function. METHODS: A retrospective chart review identified 220 patients who initiated DAA therapy between 1 February 2019, and 29 February 2020. Patients 18 years and older who completed therapy with a DAA were included in the study if they had a documented initial weight (weight on the day therapy was initiated) and final weight (weight 12 weeks after therapy completion). Change in weight was assessed as the primary outcome. Comorbidities with the potential to impact weight were assessed as confounders. RESULTS: Multiple variables were analyzed and baseline BMI was the only factor that influenced a change in weight (P = 0.016). Patients with a higher BMI at baseline experienced statistically significant weight gain. Weight was increased by 0.14 kg per unit of BMI (95% CI: 0.026, 0.25). Patient demographics relating to age and gender, progression of cirrhosis and concurrent comorbidities had no statistically significant impact on change in weight. CONCLUSION: Weight changes after treatment with a DAA may be related to the individual's weight prior to treatment.

Follow-up Evaluation of Medial Clear Space and Talar Tilt After Bimalleolar Equivalent Fracture Fixation Without Primary Deltoid Repair.

BACKGROUND: We sought first to determine the efficacy of lateral ankle fixation alone in maintenance of medial clear space and talar valgus in bimalleolar equivalent ankle fractures not receiving primary deltoid repair, and second to assess perceived outcomes via the Foot and Ankle Outcome Score. To our knowledge, no study has quantified the reduction of medial clear space and talar valgus in bimalleolar equivalent ankle fractures receiving lateral ankle fixation alone. METHODS: We compared preoperative, initial postoperative, and greater than 1-year follow-up radiographs of medial clear space and talar valgus in individuals who received lateral ankle fixation alone in bimalleolar equivalent ankle fractures. Subjective outcomes were measured via the Foot and Ankle Outcome Score. RESULTS: Thirty-seven patients participated in the study and showed a statistically significant reduction of medial clear space and restoration of talar position, and maintenance with this fixation method during follow-up in patients with bimalleolar equivalent ankle fractures. Adjunctively, patients perceived their outcomes to be satisfactory, as demonstrated by the results of the Foot and Ankle Outcome Score. CONCLUSIONS: We aimed to assess the efficacy of lateral ankle fixation in the maintenance of medial clear space and talar valgus reduction at midterm follow-up. Although some authors contend that primary deltoid repair in bimalleolar equivalent ankle fractures is warranted, these midterm study results suggest that isolated lateral ankle fixation is adequate for medial ankle stabilization in bimalleolar equivalent fractures, and thus primary deltoid repair is not indicated.

Simple Nephrectomy in a Tertiary Care Safety Net Hospital-Patient Characteristics, Causes, Cost, and Renal Function Implications.

OBJECTIVE: To evaluate factors associated with simple nephrectomy at a safety net hospital with a diverse patient population and large catchment area. Simple nephrectomy is an underreported surgery. Performance of simple nephrectomy may represent a failure of management of underlying causes. METHODS: We performed a retrospective review of simple nephrectomies performed at a major urban safety net hospital from 2014 to 2019. Detailed demographic, surgical, and renal functional outcomes were abstracted. We assessed the medical and social factors leading to performance of simple nephrectomy and report contemporaneous perception of preventability of the simple nephrectomy by the surgeon. RESULTS: Eighty-five patients underwent simple nephrectomy during the study period; 55% were non-white, 77% were women, and the median age at time of surgery was 46 years. The most common medical factors contributing to simple nephrectomy were stone disease in 55.3%, followed by retained ureteral stent (30.6%) and stricture (30.6%). The most common social factors were lack of insurance (58.5%), substance abuse issues (32.3%), mental health issues (24.6%), and immigration status (18.5%). In 38.8% of cases, the provider felt the surgery was preventable if medical factors leading to simple nephrectomy were properly addressed. CONCLUSIONS: Simple nephrectomy is a common surgery in the safety net hospital setting. Both medical and sociologic factors can lead to simple nephrectomy, and awareness of these factors can lead efforts to mitigate them. This review has led to the implementation of strategies to minimize occurrences of retained stents in our patients.

Novel Investigation of the Deep Band of the Lateral Plantar Aponeurosis and Its Relationship With the Lateral Plantar Nerve.

BACKGROUND: We describe a thick fascial band arising from the medial aspect of the lateral plantar aponeurosis diving deep into the forefoot crossing over a branch of the lateral plantar nerve. Because a review of current literature resulted in limited and outdated sources, we sought to first determine the frequency of this fascial band and the location where it crosses the lateral plantar nerve and, second, discuss the clinical applications these anatomical findings could have. METHODS: 50 pairs of cadaveric feet (n = 100) were dissected to investigate for presence of the fascial band and its interaction with the lateral plantar nerve. Images were taken of each foot with the fascial band. ImageJ was used to take 2 measurements assessing the relationship of the tuberosity of the base of the fifth metatarsal to where the nerve crossed deep to the fascial band. RESULTS: Overall, 38% of the feet possessed the fascial band. It was found unilaterally in 10 pairs and bilaterally in 14 pairs. On average, the point at which the lateral plantar nerve passed deep to the fascial band was 2.0 cm medial and 1.7 cm anterior to the tuberosity of the base of the fifth metatarsal. CONCLUSION: When present, the deep band of the lateral plantar aponeurosis (PA) was consistently found to be crossing the lateral plantar nerve. The discovery of the location where this most commonly occurs has not been previously reported and adds an interesting dimension that elevates an anatomical study to one that has clinical potential. CLINICAL RELEVANCE: The established target zone gives a precise location for where the relationship between the deep band of the lateral PA and the lateral plantar nerve exists when evaluating the foot. The target zone provides a potential springboard for future investigations concerning said relationship clinically.

Identifying diverse concepts of discharge failure patients at emergency department in the USA: a large-scale retrospective observational study.

OBJECTIVES: Identifying patients who are at high risk for discharge failure allows for implementation of interventions to improve their care. However, discharge failure is currently defined in literature with great variability, making targeted interventions more difficult. We aim to derive a screening tool based on the existing diverse discharge failure models. DESIGN, SETTING AND PARTICIPANTS: This is a single-centre retrospective cohort study in the USA. Data from all patients discharged from the emergency department were collected from 1 January 2015 through 31 December 2017 and followed up within 30 days. METHODS: Scoring systems were derived using modified Framingham methods. Sensitivity, specificity and area under the receiver operational characteristic (AUC) were calculated and compared using both the broad and restricted discharge failure models. RESULTS: A total of 227 627 patients were included. The Screening for Healthcare fOllow-Up Tool (SHOUT) scoring system was derived based on the broad and restricted discharge failure models and applied back to the entire study cohort. A sensitivity of 80% and a specificity of 71% were found in SHOUT scores to identify patients with broad discharge failure with AUC of 0.83 (95% CI 0.83 to 0.84). When applied to a 3-day restricted discharge failure model, a sensitivity of 86% and a specificity of 60% were found to identify patients with AUC of 0.79 (95% CI 0.78 to 0.80). CONCLUSION: The SHOUT scoring system was derived and used to screen and identify patients that would ultimately become discharge failures, especially when using broad definitions of discharge failure. The SHOUT tool was internally validated and can be used to identify patients across a wide spectrum of discharge failure definitions.