Impact on patient outcome of emergency department length of stay prior to ICU admission.

OBJECTIVE: The favorable evolution of critically ill patients is often dependent on time-sensitive care intervention. The timing of transfer to the intensive care unit (ICU) therefore may be an important determinant of outcomes in critically ill patients. The aim of this study was to analyze the impact upon patient outcome of the length of stay in the Emergency Care Department. DESIGN: A single-center ambispective cohort study was carried out. SETTING: A general ICU and Emergency Care Department (ED) of a single University Hospital. PATIENTS: We included 269 patients consecutively transferred to the ICU from the ED over an 18-month period. INTERVENTIONS: Patients were first grouped into different cohorts based on ED length of stay (LOS), and were then divided into two groups: (a) ED LOS ≤5h and (b) ED LOS >5h. VARIABLES: Demographic, diagnostic, length of stay and mortality data were compared among the groups. RESULTS: Median ED LOS was 277min (IQR 129-622). Patients who developed ICU complications had a longer ED LOS compared to those who did not (349min vs. 209min, p<0.01). A total of 129 patients (48%) had ED LOS >5h. The odds ratio of dying for patients with ED LOS >5h was 2.5 (95% CI 1.3-4.7). Age and sepsis diagnosis were the risk factors associated to prolongation of ED length of stay. CONCLUSIONS: A prolonged ED stay prior to ICU admission is related to the development of time-dependent complications and increased mortality. These findings suggest possible benefit from earlier ICU transfer and the prompt initiation of organ support.

[Detection of adverse events in thyroid and parathyroid surgery using trigger tool and Minimum Basic Data Set (MBDS)]. / Detección de eventos adversos en la cirugía tiroidea y paratiroidea utilizando la herramienta trigger y el Conjunto Mínimo de Datos Básicos (CMBD).

OBJECTIVES: To compare the ability of the trigger tool) and the Minimum Basic Data Set (MBDS) in detecting adverse events (AE) in hospitalized surgical patients with thyroid and parathyroid disease. METHODS: A descriptive, cross-sectional observational study, retrospective and cross-sectional study was conducted from May 2014 to April 2015 analysing retrospectively data on of patients submitted to thyroidectomy and parathyroidectomy in order to detect AE through the identification of triggers (an event often associated to an AE) and the MBDS. triggers and AE were located by systematic review of clinical documentation. The MBDS was got from the data base. Once an AE was detected, it was characterized. RESULTS: 203 AE were identified in 251 patients, being the 90.04% detected by trigger tool and 10.34% by MBDS. 126 patients had at least one AE (50.2%). Without the cases in which uncontrolled pain was the only AE, the percentage of patients that suffering AE was 38.65%. 187 AE were considered preventable and 16 AE were considered unpreventable. The trigger tool and the MBDS demonstrated a sensitivity of 91.27 and 13.49%, a specificity of 4.8 and 100%, a positive predictive value of 49,15 and 100%, and a negative predictive value of 35.29 and 53.42%, respectively. The triggers with more predictive power in AE detection were «antiemetic administration¼ and «calcium administration¼. CONCLUSIONS: Trigger tool shows higher sensitivity for detecting AE than the MBDS. All the detected AE were considered low severity and most of them were preventable.

Bariatric Surgery Waiting Lists in Spain.

Bariatric surgery is one of the most common general surgery procedures in countries that, like Spain, have public healthcare systems, but is also one of the procedures for which patients have to wait the longest. The Spanish Society of Obesity Surgery (SECO) conducted a survey to estimate the situation of bariatric surgery waiting lists in Spain's public hospitals and to gather information on a number of related aspects. METHODS: An online survey was sent to the members of the SECO. The survey received 137 visits, all via the click-through link provided, from 52 health centers (47 public and 5 private). The data collected were included in a database and later analyzed using the SPSS18.0 statistical software package. RESULTS: A total of 4724 patients were on bariatric surgery waiting lists (BWLs), at an average of 100 per public hospital. Sixty-eight percent had been waiting for more than 6 months. The mean delay per patient was 397 days, and the longest wait was 1661 days. A further 46.2% of respondents were able to recall cases of patients who in the past 5 years had suffered cardiovascular events with sequelae while awaiting surgery, and 21.2% recalled at least one fatal cardiovascular event in that time. CONCLUSION: Our data revealed an unacceptably long wait for obesity surgery. Notwithstanding the limitations and potential biases of our research, the long wait for surgery in our context inevitably has serious consequences for a potentially significant number of patients.

Pathologic intrathyroidal parathyroid glands.

BACKGROUND: Parathyroid glands originate from the third and fourth branchial pouches and migrate caudally to their final positions. Aberrations during migration result in anomalous locations. Intrathyroidal location is not common. METHODS: We reviewed cervical explorations performed from 1974 to 1993 in hyperparathyroidism patients. RESULTS: We found pathological intrathyroidal glands in six patients. Three patients had adenomas (left superior, left inferior and right inferior glands). The hyperplastic glands were left inferior in one patient and right inferior in the remaining two. Intraoperative diagnosis was made in three cases in which palpation of the thyroid gland showed a nodule that was suspected to be the parathyroid missing gland. In three patients it was a finding in thyroidectomy or hemithyroidectomy specimens, two of them with associated thyroid nodular disease. CONCLUSIONS: Ipsilateral thyroidotomy on the side of a palpable thyroid mass or blind hemithyroidectomy are justified if a presumably pathological intrathyroidal gland is suspected, when all other sites in the neck have been excluded.

[Intraoperative serum parathyroid hormone measurement in the surgical treatment of hyperparathyroidism]. / Utilidad de las determinaciones intraoperatorias de la parathormona plasmática en la cirugía del hiperparatiroidismo.

BACKGROUND: PTH(1-84) short half life permits us to monitor parathyroidectomy efficacy, confirming complete resection after unilateral surgical approach in some cases of primary hyperparathyroidism. Nevertheless, this utility has been tested in controlled clinical trials and there is no agreement regarding the extraction of samples, their processing and interpretation of results. PATIENTS AND METHODS: In 18 consecutive patients operated on for primary or secondary hyperparathyroidism, serum PTH(1-84) concentrations were assessed at different times before, during and after partial (in 11 patients with multiglandular illness) and total resections. RESULTS: Initial PTH(1-84) concentrations very largely in different pre-resection samples, and these variations significantly affect post-resection percentage reduction. Plasmatic clearance of PTH(1-84) after incomplete resection follows a decreasing exponential curve towards new equilibrium concentrations. The difference is significant comparing with concentrations following complete resection only 5 minutes after, but the 95% intervals with a confidence level of 90% of confidence are exclusive only for determinations after 120 minutes. CONCLUSIONS: The decrement of serum PTH(1-84) concentrations to 20% of the preresection levels 120 minutes after an adenomectomy confirms the complete removal of all pathologic parathyroid tissue. A less sharp decrement must be investigated and may justify an early surgical revision.

[Impact of imaging tests on the negative appendectomy rate]. / Impacto de los métodos de diagnóstico por imagen en la apendicectomía de urgencia.

INTRODUCTION: Negative appendectomies and perforated appendectomies have traditionally been quality indicators in surgery. The aim of this study is to analyze the emergency appendectomies in our hospital regarding the use of imaging tests and a review of the literature to analyze the quality of diagnosis in acute appendicitis. MATERIAL AND METHODS: Retrospective study including all patients operated on for suspected acute appendicitis at a single institution for one year (2007). Data gathered from histology and imaging tests reports. Analysis of the histology results, imaging test used and its diagnostic accuracy. Comparison with quality levels published in the international literature. RESULTS: A total of 394 patients were included in the study, the overall rate of negative appendectomy was 9.6%. Abdominal ultrasound (AU) was performed on 54.6% of patients and abdominal CT-scan on 10.2% of them, and 4.2% of the patients had both tests. AU positive predictive value was 82%. CT-scan positive predictive value was 97%. CONCLUSION: The negative appendectomy rate (9.6%) in our centre shows values lower than the published ones in historical series but superior to the one published recently in the USA. The use of imaging tests in our hospital is lower than the one published in the USA, although similar to data reported in other European countries.