Decreasing 30-day surgical mortality in a VA Medical Center utilizing the ACS NSQIP Surgical Risk Calculator.

BACKGROUND: The Overton Brooks VA Medical Center Surgical Service had a high mortality. In an effort to reduce surgical mortality, we implemented a series of quality improvement interventions, including utilization of the ACS Surgical Risk Calculator to identify high-risk surgical patients for discussion in a multidisciplinary Pre-Operative Consultation Committee. METHODS: Retrospective study describing the implementation of a risk stratification intervention incorporating the ACS Surgical Risk Calculator Tool and a multidisciplinary Pre-Operative Consultation Committee to target high-risk patients. Measurement of 30 day surgical mortality and risk adjusted Observed to Expected (O/E) mortality ratio. RESULTS: From May 2013 to September 2014, 614 high-risk patients were selected utilizing the ACS Risk Calculator and presented at the Pre-Operative Consultation Committee. Following implementation of this risk stratification intervention, 30-day mortality decreased by 66% from 0.9% to 0.3%, and risk adjusted O/E mortality ratio decreased from 2.5 to 0.8. Among the high risk patients presented, there was no increase in referrals to other facilities. There was a significant increase in cases requiring further preoperative optimization, from 6.3% at the beginning of the study period to 17.5% at the end of the study period. CONCLUSIONS: Implementation of a preoperative risk stratification intervention utilizing the ACS Surgical Risk Calculator along with a multidisciplinary Pre-Operative Consultation Committee can be successfully accomplished, with a significant decrease in 30-day surgical mortality. This is the first published report of utilization of the ACS Risk calculator as part of a systematic quality improvement tool to decrease surgical mortality.

Improving staff perception of a safety climate with crew resource management training.

BACKGROUND: Communication failure is one of the top root causes in patient safety adverse events. Crew resource management (CRM) is a team building communication process intended to improve patient safety by improving team dynamics. First, to describe implementation of CRM in a Veterans Affair (VA) surgical service. Second, to assess whether staff CRM training is related to improvement in staff perception of a safety climate. MATERIAL AND METHODS: Mandatory CRM training was implemented for all surgical service staff at a VA Hospital at 0 and 12 mo. Safety climate questionnaires were completed by operating room staff at a baseline, 6 and 12 mo after the initial CRM training. RESULTS: Participants reported improvement on all 27 points on the safety climate questionnaire at 6 mo compared with the baseline. At 12 mo, there was sustained improvement in 23 of the 27 areas. CONCLUSIONS: This is the first published report about the effect of CRM training on staff perception of a safety climate in a VA surgical service. We demonstrate that CRM training can be successfully implemented widespread in a surgical program. Overall, there was improvement in 100% of areas assessed on the safety climate questionnaire at 6 mo after CRM training. By 1 y, this improvement was sustained in 23 of 27 areas, with the areas of greatest improvement being the performance of briefings, collaboration between nurses and doctors, valuing nursing input, knowledge about patient safety, and institutional promotion of a patient safety climate.

Gas Gangrene of the Diabetic Foot.

A 67-year old man presented with a painful left foot and a putrid odor. His past medical history was significant for poorly controlled diabetes mellitus, coronary artery disease, and peripheral vascular disease. His surgical history included a prior right below-knee amputation for a diabetic foot infection three years prior, and a left third toe amputation for osteomyelitis one month ago. He was an active smoker. His laboratory data revealed a white blood count of 22 k/uL and a blood glucose of 381 mg/dL. Physical exam demonstrated an erythematous and edematous left foot with subcutaneous crepitus along the plantar surface. Plain film x-rays of the left foot demonstrated gas pockets in the soft tissue and acute osteomyelitis (Figure 1). The patient was diagnosed with gas gangrene and was taken emergently to the operating room. In order to obtain source control of this life threatening infection, a left below-knee amputation was performed and broad spectrum empiric antibiotics were initiated immediately with vancomycin and piperacillin/tazobactam. Cultures were not obtained at the time of surgery and the organisms causing this infection are unknown. The patient survived and was discharged to a rehabilitation facility.

siRNA associated with immunonanoparticles directed against cd99 antigen improves gene expression inhibition in vivo in Ewing's sarcoma.

Ewing's sarcoma is a rare, mostly pediatric bone cancer that presents a chromosome abnormality called EWS/Fli-1, responsible for the development of the tumor. In vivo, tumor growth can be inhibited specifically by delivering small interfering RNA (siRNA) associated with nanoparticles. The aim of the work was to design targeted nanoparticles against the cell membrane glycoprotein cd99, which is overexpressed in Ewing's sarcoma cells to improve siRNA delivery to tumor cells. Biotinylated poly(isobutylcyanoacrylate) nanoparticles were conceived as a platform to design targeted nanoparticles with biotinylated ligands and using the biotin-streptavidin coupling method. The targeted nanoparticles were validated in vivo for the targeted delivery of siRNA after systemic administration to mice bearing a tumor model of the Ewing's sarcoma. The expression of the gene responsible of Ewing's sarcoma was inhibited at 78% ± 6% by associating the siRNA with the cd99-targeted nanoparticles compared with an inhibition of only 41% ± 9% achieved with the nontargeted nanoparticles.

Eliminating Critical Incident Tracking Network Patient Safety Events at a Veterans Affairs Institution Through Crew Resource Management Training.

The objective of this study was to determine whether rates of Critical Incident Tracking Network (CITN) patient safety adverse events change after implementation of crew resource management (CRM) training at a Veterans Affairs (VA) hospital. CRM training was conducted for all surgical staff at a VA hospital. Compliance with briefing and debriefing checklists was assessed for all operating room procedures. Tracking of adverse patient safety events utilizing the VA CITN events was performed. There was 100% adherence to performance of briefings and debriefings after initiation of CRM training. There were 3 CITN events in the year prior to implementation of CRM training; following CRM training, there have been zero CITN events. Following CRM training, CITN events were eliminated, and this has been sustained for 2.5 years. This is the first study to demonstrate the impact of CRM training on CITN events, specifically, in a VA medical center.

Odontomas: un reto para el tratamiento interdisciplinario del paciente de ortodoncia / Odontomas: a challenge for the interdisciplinary treatment of the orthodontic patient

El objetivo del presente trabajo es describir las técnicas para el diagnóstico y tratamiento de 3 casos clínicos de odontoma en pacientes ortodóncicos. En el caso 1, se trató a un paciente masculino de 17 años, que acudió para interconsulta con el servicio de ortodoncia, ya que no había erupcionado el canino superior izquierdo y el primer premolar superior izquierdo. El estudio anatomopatológico reveló odontoma complejo con áreas pindborgoides y acumulación de células fantasma. En al caso 2 se trató a un paciente femenino de 15 años. El estudio anatomopatológico reveló odontoma complejo. En el caso 3, se trató a un paciente masculino de 28 años que acudió a rehabilitación integral de su boca, y fue derivado a la cátedra de ortodoncia. En la radiografía panorámica se observó una imagen compatible con odontoma. Se remitió una muestra a anatomía patológica que confirmó el diagnóstico de odontoma. Conclusión: el conocimiento adecuado de las características clínicas, radiológicas y patológicas es necesario para un correcto diagnóstico y tratamiento. Es importante el trabajo interdisciplinario ortodoncista - cirujano para tratar estos casos (AU)

The objective of this work is to describe the techniques for the diagnosis and treatment of 3 clinical cases of odontoma in orthodontic patients. In case 1, a 17-year-old male patient was treated who came for consultation with the orthodontic service, since the upper left canine and the upper left first premolar had not erupted. Pathological study revealed complex odontoma with pindborgoid areas and accumulation of ghost cells. In case 2, a 15-year-old female patient was treated. The anatomopathological study revealed a complex odontoma. In case 3, a 28-year-old male patient was treated who attended comprehensive rehabilitation of his mouth and was referred to the orthodontic department. In the panoramic radiography, an image compatible with odontoma was observed. A sample was sent to pathological anatomy, which confirmed the diagnosis of odontoma. Conclusion: Adequate knowledge of the clinical, radiological and pathological characteristics is necessary for a correct diagnosis and treatment. Interdisciplinary orthodontist-surgeon work is important to treat these cases (AU)

99mTc-Depreotide chest SPECT demonstrates pulmonary metastases from renal cell carcinoma.

99mTc-Depreotide has been used on single pulmonary nodules to identify somatostatin receptor-positive lung cancer. We report that pulmonary metastases of a 78-y-old man with postradical nephrectomy for renal cell carcinoma were detected by (99m)Tc-depreotide chest SPECT. Thus, (99m)Tc-depreotide chest SPECT can be used to diagnose secondary lung cancer, such as pulmonary metastases from renal cell carcinoma with somatostatin receptor-positive tumor, other than primary lung cancer. Depending on whether the (99m)Tc-depreotide was positive for pulmonary metastases, the patient underwent an appropriate therapy without further invasive procedures.