Use of non-technical skills can predict medical student performance in acute care simulated scenarios

Background

Though the importance of physician non-technical (NT) skills for safe patient care is recognized, NT skills of medical students, our future physicians, has received little attention. This study aims to investigate the relationship of medical student NT skills and clinical performance during acute care team simulation (ACTS).

Implementation of an acute care surgery service at an academic trauma center

Background

The establishment of acute care surgery is rapidly becoming a solution to meet emergency surgical needs. Challenges include competition for emergency surgery opportunities and the ability to economically sustain a practice.

Methods

Clinical activity was measured by reviewing the institutional and practice plan databases. Work relative value units and practice plan collection rates defined clinical activity and revenue.

Results

Operative procedures and intensive care unit activity accounted for 52% and 36% of activity, respectively. Although procedures on the digestive tract accounted for half of the operative activity, significant activity was observed in nearly all other systems. Overall clinical productivity remained constant but did demonstrate a 25% increase in operative work relative value units. Current billing activity supports 4.0 clinical full-time equivalents, but estimated collections would cover <73% of physician direct costs.

Conclusions

The authors describe the implementation of an acute care surgery service that combines trauma, emergency general surgery, and surgical critical care in an established academic surgery department. Developing a sustainable economic model must include income sources other than patient service revenue.     

Important role of acute care surgery during pandemic time

Pandemic impacts acute care surgery for diseases, such as gallbladder disease and acute appendicitis. At the early stage of coronavirus disease 2019 (COVID-19) pandemic, the case number of patients needing surgery decreased in hospitals from different countries. This decline was associated with the stay-home order and fear of getting COVID-19 infection. However, recent reports show that the case number for acute surgery returns to the normal level, which is comparable to that before the beginning of the pandemic. In addition, a variety of diseases show more severe than the cases before the pandemic, which might be caused by factors such as lack of regular follow-up and screening diagnosis and infection of viruses.     

Availability of acute care surgeons improves outcomes in patients requiring emergent colon surgery

Background

The need for emergent colon surgery is a common cause of severe sepsis/septic shock and mortality among surgical patients. We wanted to benchmark our outcomes against those of the National Surgical Quality Improvement Program (NSQIP). We hypothesized that having acute care surgeons to provide comprehensive perioperative care and rapid source control surgery would improve outcome.

Methods

We queried the 2005 to 2007 NSQIP dataset and our prospective database for patients with severe sepsis/septic shock requiring emergency colon surgery. Demographics, Acute Physiology and Chronic Health Evaluation II score, sepsis source, and hospital mortality data were obtained for all patients.

Results

Both cohorts were similar with regard to age and sex. The overall mortality rate for patients in our dataset was 28.3% compared with 40.1% in the NSQIP dataset (P = .06). The average Acute Physiology and Chronic Health Evaluation II score for our patients was 31 ± 8.2 with a predicted mortality rate of 73% (P < .0001 when compared with actual mortality rate of 28.3%).

Conclusions

Patients with severe sepsis/septic shock requiring emergent colon surgery have a high mortality rate. Delivery of comprehensive emergency surgical care by acute care surgeons appears to improve survival.     

Emergency valve surgery for infective endocarditis complicated by acute intracranial hemorrhage: A case report

IntroductionOptimal timing of surgical treatment for infective endocarditis (IE) complicated by intracranial hemorrhage remains controversial.Presentation of caseA 43-year-old man with IE received appropriate antibiotic therapy but had recurrence of cerebral infarction and intracranial hemorrhage (ICH). Emergency valve surgery was performed 2 days after ICH onset because of heart failure and recurrence of cerebral complications. Postoperatively, he showed no neurologic symptoms; neuroimaging showed no enlargement of ICH.DiscussionPostoperative risk of neurologic deterioration may be relatively lower than previously thought in patients with IE who undergo surgery within 1 month after ICH onset.ConclusionsEmergency surgery in patients with ICH is justified in cases of multiple indications for such small ICH. Further evaluation regarding the risk of subsequent hemorrhage in patients with ICH who require emergency valve surgery is warranted.     

Barriers to metabolic bariatric surgery in adolescents: results of a qualitative study

BackgroundIt is estimated that 4.5 million youth in the United States have severe obesity (SO). Metabolic and bariatric surgery (MBS) is the most effective and longitudinally durable treatment for adolescents with SO, but only an estimated 1600 adolescents undergo the procedure annually.ObjectiveTo understand patients’ perceptions and experiences with the barriers to MBS as an adolescent.SettingThis research was conducted at Children’s Hospital Colorado, an urban academic medical center, and the University of Colorado Anschutz School of Medicine and Sanford Research, a rural medical center.MethodsWe conducted 14 qualitative interviews with individuals who received MBS between the ages of 19 and 25 years in the last 5 years regarding the barriers to MBS they experienced as an adolescent. A formal qualitative analysis was conducted using the constant comparative techniques of grounded theory generally guided by Anderson’s behavioral model of health service use.ResultsWe identified 3 principal groups of barriers related to (1) a lack of information that MBS was an option and the absence of discussions about MBS with medical providers while an adolescent, (2) a lack of access to MBS primarily related to insurance coverage, costs, and family-related issues, and (3) a general stigma around MBS as a treatment for obesity.ConclusionThis study suggests that the primary barriers to MBS for adolescents with SO are related to a general lack of information about MBS, social stigma, and access issues related to costs that decrease or limit access.     

加速康复外科方案和标准治疗方案对腹部手术患者术后急性肾损伤影响的比较Meta分析

目的 通过Meta分析比较加速康复外科(ERAS)方案和标准治疗方案对腹部手术患者术后急性肾损伤(AKI)的影响.方法 通过PubMed、Embase、Cochrane Library数据库和参考文献列表进行检索,识别从建库至2020年9月符合纳入标准的相关研究.采用风险比(RR)、均数差(MD)和相应的95％可信区间...     

手助腹腔镜外科技术在腹部外科中的应用(附113例报告)

目的:探讨手助腹腔镜外科(hand-assisted laparoscopic surgery,HALS)技术在复杂外科手术中的应用价值。方法:2002年2月至2006年12月应用HALS技术治疗113例患者,对临床相关指标,如手术时间、术中出血量、术后并发症等进行观察和分析。结果:113例患者中,110例获得成功,术后并发症发生率为5.45%,无死亡病例。结论:HALS技术可提高复杂腹腔镜手术的效率和安全性,并在一定程度上保留了微创手术创伤小、康复快的优势。     

Non-immune mediated thrombocytopenia caused by thromboprophylaxis for the perioperative care of urological surgery: A case report and review of the literature

IntroductionHeparin-induced thrombocytopenia (HIT) is a rare but serious condition due to heparin use for treating thromboprophylaxis, regardless of the dosage. Here, we present a case of non-immune thrombocytopenia caused by thromboprophylaxis for urological surgery, which is sometimes difficult to discriminate from immune-mediated thrombocytopenia.Presentation of caseA 55-year-old man with renal cancer underwent portless endoscopic radical nephrectomy through a single small incision and was subsequently administered unfractionated heparin as well as mechanical devices to prevent venous thromboembolism. On postoperative day 2, a subcutaneous hemorrhage developed around the surgical site and the lower abdomen, and the platelet count simultaneously decreased to 50% of the baseline value. We suspected HIT and immediately conducted the 4Ts score examination. The 4Ts score was 3 points (low probability), and the result of the platelet factor 4-heparin complex antibody assay was negative. The patient was diagnosed with non-immune mediated thrombocytopenia. We took precaution by discontinuing heparin, which fortunately did not result in any adverse effects, and this led to platelet count normalization.DiscussionDue to the rarity of HIT, it is difficult to distinguish HIT from non-immune mediated thrombocytopenia.ConclusionThis article emphasizes that early and accurate diagnosis of postoperative thrombocytopenia is important for accurate therapy. Hence, all surgeons should know that the HIT diagnosis is based on clinical and serologic findings.     

Vascular surgery patients in intensive care: a bi-national cohort study over 15 years

Background

To describe the characteristics and outcomes of patients admitted to Intensive Care following vascular surgery, and their subsequent usage of Intensive Care resources, over a 15-year period in Australia and New Zealand.

Methods

This was a retrospective, bi-national study of 69 676 adult patients admitted to 179 Intensive Care Unit (ICUs) following vascular surgery between January 2005 and December 2019, using the Australian and New Zealand Intensive Care Society Adult Patient Database.

Results

The proportion of ICU bed days used by vascular surgery patients decreased during the study period from 3.6% in 2005 to 2.9% in 2019 (P < 0.001). The cohort had a median age of 73 years, and were most frequently admitted after a carotid endarterectomy (22%) or elective open aneurysm repair (20%). A total of 5.2% of patients did not survive to discharge. Mean annual adjusted mortality decreased during the study period from 6.1% in 2005 to 3.7% in 2019 (P < 0.001). Multiple factors were associated with higher mortality, including gender, hospital case volume and hospital type.

Conclusions

Between 2005 and 2019 survival for vascular surgery patients requiring ICU admission in Australia and New Zealand improved. During the same time the proportion of ICU bed days used by these patients decreased.     

社区医护人员实施居家安宁疗护促进及阻碍因素的质性研究

目的 了解社区医护人员实施居家安宁疗护的促进及阻碍因素，为有效推进居家安宁疗护提供依据。 方法 采用描述性质性研究方法，以目的抽样法选取昆明市2所社区卫生服务中心的13名医护人员进行半结构访谈，采用内容分析法整理、分析资料。 结果 提炼出社区医护人员实施居家安宁疗护促进及阻碍因素2个主题，促进因素主题的3个亚主题包括意识到居家安宁疗护的重要性、容易与居民取得联系、患者有居家安宁疗护的需求；阻碍因素主题的4个亚主题包括政策支持因素、医护人员因素、患方因素、风险因素。 结论 社区医护人员实施居家安宁疗护的促进及阻碍因素是多维度的，应重视政府、社区医护人员、患者和家属共同参与居家安宁疗护的重要性，构建符合我国国情的居家安宁疗护服务模式。     

腹腔镜手术治疗急性结石性胆囊炎396例报告

目的:总结腹腔镜手术治疗急性结石性胆囊炎的临床经验。方法:回顾分析为396例急性结石性胆囊炎患者行腹腔镜胆囊切除术的临床资料。结果:364例成功完成手术3,2例中转开腹。手术时间28～110 min,平均58 min,术中出血量10～100 ml,术后无严重并发症发生,患者均痊愈出院。结论:急性结石性胆囊炎行腹腔镜胆囊切除术安全可行。     

Critical care usage after major gastrointestinal and liver surgery: a prospective,multicentre observational study

Background

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

Constructing an episode of care from acute hospitalization records for studying effects of timing of hip fracture surgery

Episodes of care defined by the event of hip fracture surgery are widely used for the assessment of surgical wait times and outcomes. However, this approach does not consider nonoperative deaths, implying that survival time begins at the time of procedure. This approach makes treatment effect implicitly conditional on surviving to treatment. The purpose of this article is to describe a novel conceptual framework for constructing an episode of hip fracture care to fully evaluate the incidence of adverse events related to time after admission for hip fracture. This admission‐based approach enables the assessment of the full harm of delay by including deaths while waiting for surgery, not just deaths after surgery. Some patients wait until their conditions are optimized for surgery, whereas others have to wait until surgical service becomes available. We provide definitions, linkage rules, and algorithms to capture all hip fracture patients and events other than surgery. Finally, we discuss data elements for stratifying patients according to administrative factors for delay to allow researchers and policymakers to determine who will benefit most from expedited access to surgery. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:197–204, 2016.     

脊髓损伤患儿父母照顾体验的质性研究

目的 深入了解脊髓损伤患儿父母的照顾体验,为促进其身心健康提供参考。方法 采用现象学研究方法,以立意抽样法抽取11名脊髓损伤患儿的父母进行半结构化访谈,运用Colaizzi分析法归纳主题。结果 提炼出4个主题,分别为承受照顾负荷、心理体验复杂、适应角色改变并提高照顾技能、渴望家庭和社会支持。结论 脊髓损伤患儿父母的照顾负荷较重,存在负性心理,医护人员需重视评估患儿父母照顾感受,并提供积极的心理干预指导,必要时提供适当的社会支持,以减轻其照顾负荷,改善其心理状况。     

胆源性胰腺炎行腹腔镜胆囊切除术及手术时机（附78例报告）

目的：探讨急性胆源性胰腺炎腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）的可行性及手术时机选择。方法：回顾分析急性胆源性胰腺炎78例患者在两周内行LC的临床资料和治疗结果。结果：全组患者均行LC,8例术中粘连较重,经仔细分离,平均手术时间约90min,其余手术难度不大,平均手术时间40min,术后无并发症发生,均治愈出院。随访1年,无一例胰腺炎复发。结论：胆源性胰腺炎患者行LC应选择在两周内,手术安全可行。