High Acuity of Postoperative Consults to Emergency General Surgery at an Urban Safety Net Hospital.

BACKGROUND: Emergency general surgery (EGS) has high rates of morbidity, mortality, and readmission. Therefore, it might be expected that an EGS service fields many consultations for postoperative patients. However, with the known overutilization of emergency department visits for nonurgent conditions, we hypothesized most postoperative consults received by an EGS service would be nonurgent and could be appropriately managed as an outpatient. METHODS: We reviewed all EGS consults at a single urban safety net hospital over a 12-month period, screening for patients who had undergone surgery in the previous 12 mo. This included consultations from the emergency room and inpatient setting. Demographics, admission status, procedures performed, and other details were abstracted from the chart and Vizient reports. Consultation questions were categorized and then reviewed by an expert panel to determine if conditions could have been managed as an outpatient. RESULTS: The EGS service received a total of 1112 consults, with 99 (9%) for a postoperative condition. Overall, 85% of postoperative consults were admitted after consultation, 19% underwent surgery and 21% underwent a procedure with gastroenterology or interventional radiology. Expert review classified slightly over one-third (36%) of consults as nonurgent. CONCLUSIONS: Most postoperative consults seen at our urban safety net hospital represent true morbidity that required admission, intervention, or surgery. Despite this high acuity, one-third of postoperative consults could have been managed as an outpatient. Efforts to improve discharge instructions and set patient expectations could limit unnecessary postoperative emergency department visits.

Periodic Estrogen Receptor-Beta Activation: A Novel Approach to Prevent Ischemic Brain Damage.

In women, the risk for cerebral ischemia climbs rapidly after menopause. At menopause, production of ovarian hormones; i.e., progesterone and estrogen, slowly diminishes. Estrogen has been suggested to confer natural protection to premenopausal women from ischemic stroke and some of its debilitating consequences. This notion is also strongly supported by laboratory studies showing that a continuous chronic 17ß-estradiol (E2; a potent estrogen) regimen protects brain from ischemic injury. However, concerns regarding the safety of the continuous intake of E2 were raised by the failed translation to the clinic. Recent studies demonstrated that repetitive periodic E2 pretreatments, in contrast to continuous E2 treatment, provided neuroprotection against cerebral ischemia in ovariectomized rats. Periodic E2 pretreatment protects hippocampal neurons through activation of estrogen receptor subtype beta (ER-ß). Apart from neuroprotection, periodic activation of ER-ß in ovariectomized rats significantly improves hippocampus-dependent learning and memory. Difficulties in learning and memory loss are the major consequence of ischemic brain damage. Periodic ER-ß agonist pretreatment may provide pharmacological access to a protective state against ischemic stroke and its debilitating consequences. The use of ER-ß-selective agonists constitutes a safer target for future research than ER-α agonist or E2, inasmuch as it lacks the ability to stimulate the proliferation of breast or endometrial tissue. In this review, we highlight ER-ß signaling as a guide for future translational research to reduce cognitive decline and cerebral ischemia incidents/impact in post-menopausal women, while avoiding the side effects produced by chronic E2 treatment.