The impact of race on outcomes following emergency surgery: an American College of Surgeons National Surgical Quality Improvement Program assessment

Background

Despite significant evolutions in health care, outcome discrepancies exist among demographic cohorts. We sought to determine the impact of race on emergency surgery outcomes.

Methods

This is a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database (2005 through 2009) for all patients aged ≥16 years undergoing emergency abdominal surgery. Primary outcomes included morbidity and mortality.

Results

We identified 75,280 patients (mean age 48.2 ± 19.9 years, 51.7% female; 79% white, 9.9% black, 5.0% Hispanic, 3.7% Asian, 1.3% American Indian or Alaskan, .2% Pacific Islander). Annual rates of emergency operations ranged from 7.3% to 8.5% (P = .22). The overall complication (18.6%) and mortality rate (4.6%) was highest in the black population (24.3%, 5.3%) followed by whites (18.7%, 4.6%), with the lowest rate in Hispanic (11.7%, 1.8%) and Pacific Islander populations (10.2%, 1.8%; P < .001). Compared with whites, blacks had a 1.25-fold (1.17 to 1.34; P < .001) increased risk of complications, but similar mortality (P = .168). When combining minorities, overall complications were 1.059-fold (1.004 to 1.12; P = .034) higher, however, mortality was reduced 1.7-fold (1.07 to 1.34; P = .001).

Conclusions

Following emergency abdominal surgery, minority race is independently associated with increased complications and reduced mortality.     

Outpatient burn data: An untapped resource

Introduction

The National Burn Repository (NBR) currently only contains inpatient data from participating United States burn centres. However, the majority of the patients treated in burn centres are managed as outpatients. Unfortunately, this significant demographic is not represented in the NBR annual report. The purpose of this study is to compare the difference in aetiology and demographics between inpatient and outpatient burn patients. In addition, the workload demands for data entry of inpatient and outpatient records in the burn registry will be compared.

Methods

Outpatient and inpatient burn data at an American Burn Association-Verified Burn Center were prospectively collected during fiscal year 2008. Data collected included age, burn size and aetiology of burn. Aetiology was also stratified by age group. Inpatient data were compared with outpatient data with Fisher's exact test. The amount of time taken to enter inpatients’ and outpatients’ data parameters in the TRACS v5.0 database was also recorded.

Results

Data were collected for 241 inpatients and for 543 outpatients during fiscal year 2008. No significant differences in gender or race were found between the two groups. When comparing demographics, outpatients tended to be younger (26 ± 19 years vs. 32 ± 22 years, p = 0.01) with a smaller burn size (2.5 ± 7% vs. 6.8 ± 12%, p < 0.001) and a lower frequency of full-thickness burns (17% vs. 41%, p < 0.001).Of the patients managed as an outpatient, a total 29.7% were eventually admitted to the hospital. Just over half of those (16.7%) initially managed in the outpatient setting were admitted for a planned surgical procedure. The other 13% were admitted for pain control and wound-care issues.Injury was more likely to be caused by flame in inpatients (p < 0.001). Scald injuries were more common in the outpatient setting (34% vs. 27%), but this difference did not reach statistical significance (p = 0.079). Outpatients were more likely to be injured with a contact burn (p < 0.0001). Outpatient injury was more likely to be work-related than inpatient injury (p = 0.0497), but less likely to be related to recreational activity (p = 0.006) or arson/abuse/assault (p = 0.0158). An experienced TRACSv5.0 user required 11 ± 0.6 min to enter an inpatient record and 6 ± 0.6 min to enter an outpatient record in the system (p = 0.002).

Conclusions

Inpatient injury is more likely to be caused by flame, whereas outpatient injury is more likely to be caused by scald and contact burns. Work-related burn is more likely to be treated in the outpatient setting. Outpatient burn data also take less time to enter. Since significant differences in aetiology exist, outpatient data should be reported separately from inpatient data in order to understand the full spectrum of burn aetiology. The NBR and other registries should be modified to track outpatient burn data and outcomes.     

The incremental benefit of two quadrant lavage for peritoneal cytology at staging laparoscopy for oesophagogastric adenocarcinoma

Background

Patients with positive peritoneal cytology from oesophagogastric cancer have a poor prognosis. The purpose of this study was to compare lavage cytology from the pelvis alone with the pelvis and subphrenic areas at staging laparoscopy in patients with potentially resectable oesophagogastric adenocarcinoma.

Methods

Between November 2006 and November 2010, all patients with operable oesophagogastric adenocarcinoma on spiral CT considered fit for surgical resection underwent staging laparoscopy. Subphrenic and pelvic peritoneal lavage for cytology was performed followed by laparoscopic biopsy of any visible peritoneal disease. Patients were divided into groups: macroscopic peritoneal metastases (P+), no macroscopic peritoneal disease with negative cytology (P?C?), no macroscopic peritoneal disease with positive pelvic cytology (P?PC+), no macroscopic peritoneal disease with positive subphrenic cytology (P?SC+), or both (P?PSC+).

Results

A total of 316 staging laparoscopy procedures were performed; 245 patients (78 %) were P?C?, 28 (9 %) were P+, and 43 (14 %) were P?C+, of whom 29 (9 %) were P?PSC+, 10 (3 %) were P?SC+, and 4 (1 %) were P?PC+. Pelvic cytology alone had 76.7 % sensitivity for peritoneal disease, and subphrenic cytology alone had 90.7 % sensitivity.

Conclusions

Peritoneal lavage for cytology at staging laparoscopy has an incremental benefit for staging oesophagogastric adenocarcinoma in the absence of macroscopic metastatic disease. Subphrenic washings have the highest yield of positive results. Performing isolated pelvic washings for cytology will understage 23.3 % of patients with microscopic peritoneal disease. The routine use of subphrenic in combination with pelvic lavage for cytology at staging laparoscopy in patients with oesophagogastric adenocarcinoma has an incremental benefit in detecting cytology-positive disease over either pelvic or subphrenic cytology alone.     

Factors influencing the acquisition of Stenotrophomonas maltophilia infection in cystic fibrosis patients

BackgroundStenotrophomonas maltophilia is one of the most common multi-drug resistant organisms causing pulmonary infections in CF patients. It is unknown whether S. maltophilia infection follows the same pattern and shares similar risk factors for acquisition as described for Pseudomonas aeruginosa.MethodsWe examined all clinical events from 1997 to 2008 in the Toronto CF Database to identify risk factors for the acquisition of S. maltophilia and to define distinct patterns of infection.ResultsWe followed 601 patients over 12 years, during which time one quarter of subjects had at least one positive culture for S. maltophilia; the incidence rate was slightly higher in children (11.6/100 person years) compared with adults (10.6/100 person years). Using multi-variable Cox proportional hazards models, steeper rate of FEV₁ decline was a significant risk factor for S. maltophilia acquisition, whereas new infections were less likely to occur with greater oral antibiotic use and a history of Burkholderia cepacia complex infection.ConclusionsThis study illustrates the evolution of S. maltophilia infection over time in a large cohort of adults and children with CF. Younger CF patients, and those with greater lung function decline were at increased risk of S. maltophilia infection. The use of oral antibiotics to maintain lung function may be a way of decreasing the risk of infection. However, the optimal management of CF patients with persistent S. maltophilia infection is not yet known and requires further studies.     

Factors shaping community structure of endophytic fungi–evidence from the Pinus-Viscum-system

Endophytic fungal communities have been shown to be highly diverse in almost every host plant species analyzed so far. However, the factors shaping their compositions are largely unknown. To elucidate the impact of various factors, 10 independent replicates of DNA extracts from each of 17 surface-sterilized leaf and stem samples were analyzed by pyrosequencing of fungal ITS1 rRNA gene amplicons. Altogether, 154 fungal OTUs (operational taxonomic units), represented by 953,385 sequences, were found in at least 2 samples from Viscum album ssp. austriacum and/or its host Pinus sylvestris. Deviating from earlier, cultivation-based assessments, the communities were dominated by OTUs related to the genus Mortierella and OTUs not assignable to a certain fungal phylum. However, Ascomycota were still the most diverse group in terms of OTU richness and already hypothesized organ and host preferences of certain endophytic Xylariaceae isolated from the Pinus-Viscum-system could be confirmed. Host species and organ type were also the major factors shaping the detected fungal communities. The two plant species clearly differed according to the endophytic fungal communities, but only stems and needles of Pinus were inhabited by significantly different fungal assemblages. Interestingly, only the 1 and 3 year old stem sections differed according to the endophytic fungal community, while differently aged leaves of both plants were indistinguishable in this regard. Size of the organs had no impact on fungal communities in Pinus, but shorter internodes and smaller leaves showed at least a tendency to differ from the corresponding larger organs in Viscum. Fungal communities also differed slightly between the two sampling sites, lying 200 km apart, and between the three sampling campaigns. Because the samples were drawn within 15 days, this finding indicates that seasonal shifts clearly outweigh aging effects in host plant with perennial leaves. The results therefore provide strong evidence against a linear development of the endophytic fungal communities in Pinus sylvestris and Viscum album over the years. The communities seem to establish themselves already in the year the respective organs emerge. Further study is required to clarify whether they predominantly establish anew each year, or if the core community persists throughout subsequent years. The most abundant endophytic OTUs are known from soil and/or dead plant material and are supposed to represent latent decomposers. The study reveals for the first time that host and/or organ preferences of putatively saprotrophic fungi are predominantly responsible for compositional differences in the endophytic fungal communities between host plants and organs. While the analyses are shown to provide rather robust results, the significance of genetic abundance, as revealed by high-throughput sequencing analyses, remains an unsettled issue. This is discussed in detail, as well as the challenges in assigning taxonomic names to OTUs.