Effect of a Boarding Restriction Protocol on Emergency Department Crowding

PurposeAccess block due to the lack of hospital beds causes crowding of emergency departments (ED). We initiated the “boarding restriction protocol” that limits the time of stay in the ED for patients awaiting hospitalization to 24 hours from arrival. The purpose of this study was to determine the effect of the boarding restriction protocol on ED crowding.Materials and MethodsThe primary outcome was ED occupancy rate, which was calculated as the ratio of the number of occupying patients to the total number of ED beds. Time factors, such as length of stay (LOS), treatment time, and boarding time, were investigated.ResultsThe mean of the ED occupancy rate decreased from 1.532±0.432 prior to implementation of the protocol to 1.273±0.353 after (p<0.001). According to time series analysis, the absolute effect caused by the protocol was -0.189 (-0.277 to -0.110) (p=0.001). The proportion of patients with LOS exceeding 24 hours decreased from 7.6% to 4.0% (p<0.001). Among admitted patients, ED LOS decreased from 770.7 (421.4–1587.1) minutes to 630.2 (398.0–1156.8) minutes (p<0.001); treatment time increased from 319.6 (198.5–482.8) minutes to 344.7 (213.4–519.5) minutes (p<0.001); and boarding time decreased from 298.9 (109.5–1149.0) minutes to 204.1 (98.7–545.7) minutes (p<0.001). In pre-protocol period, boarding patients accumulated in the ED during the weekdays and resolved on Friday, but this pattern was alleviated in post-period.ConclusionThe boarding restriction protocol was effective in alleviating ED crowding by reducing the accumulation of boarding patients in the ED during the weekdays.     

Clinical outcome of preemptive kidney transplantation in patients with diabetes mellitus

End-stage renal disease (ESRD) caused by diabetic nephropathy is increasing throughout the world. The survival of diabetic patients treated by transplantation has improved nowadays. Although recent studies have demonstrated preemptive kidney transplantation to be associated with better graft survival in CKD patients, the effect of pre-transplantation dialysis on graft outcomes among diabetic ESRD patients is unclear. This analysis summarized our experience with preemptive kidney transplantation in diabetic ESRD patients by retrospectively comparing 70 such patients transplanted between 1995 and 2009. These 70 patients were divided into two groups: 30 patients underwent preemptive and the other 40 transplantation after maintenance hemodialysis or peritoneal dialysis. We compared graft survivals, acute rejection episodes, postoperative complications, and delayed graft function rates. The 10-year patient survival of 100% in the preemptive group was similar to that of the nonpreemptive group (85%, P = .11). But the 10 year graft survival was higher among the preemptive than the nonpreemptive group (100% vs 75%, P = .02). Pre-transplantation modality did not affect graft survival. Therefore, preemptive kidney transplantation should be applied to eligible patients with diabetic ESRD.     

Hemangiopericytoma of the Greater Omentum

A 41-year-old Chinese woman was admitted to our hospital with epigastric pain. Computed tomography detected a heterogeneous enhancement tumor fed by the left gastroepiploic artery in the left lower quadrant and cholelithiasis. Excision of the tumor in the greater omentum and cholecystectomy were performed laparoscopically. Histological findings confirmed a diagnosis of hemangiopericytoma with low-grade malignancy. To our knowledge, hemangiopericytoma of the greater omentum is very rare, and only 12 cases were reported in English literature. We report a case of hemangiopericytoma arising in the greater omentum and review the literature.     

Conventional laparoscopic adrenalectomy versus laparoscopic adrenalectomy through mono port

A standard procedure for single-port laparoscopic adrenal surgery has not been established. We retrospectively investigated intraoperative and postoperative outcomes after laparoscopic adrenalectomy through mono port (LAMP) and conventional laparoscopic adrenalectomy to assess the feasibility of LAMP. Between March 2008 and December 2009, 22 patients underwent adrenalectomy at the Department of Surgery, Kangbuk Samsung Hospital. Twelve patients underwent conventional laparoscopic adrenalectomy and 10 patients underwent LAMP. The same surgeon performed all the surgeries. The 2 procedures were compared in terms of tumor size, operating time, time to resumption of a soft diet, length of hospital day, and postoperative complications. The 2 groups were similar in terms of tumor size (30.08 vs. 32.50 mm, P=0.796), mean operating time (112.9 vs. 127 min, P=0.316), time to resumption of a soft diet (1.25 vs. 1.30 d, P=0.805), and length of hospital day (4.08 vs. 4.50 d, P=0.447). Despite 1 patient in the LAMP group experiencing ipsilateral pleural effusion as a postoperative complication, this parameter was similar for the 2 groups (P=0.195). Perioperative mortality, blood transfusion, and conversion to open surgery did not occur. Perioperative outcomes for LAMP were similar to those for conventional laparoscopic adrenalectomy. LAMP appears to be a feasible option for adrenalectomy.     

Laparoscopic surgical management and clinical characteristics of ovarian fibromas

Objective:

This study aims to analyze the clinical characteristics and diagnostic features of ovarian fibromas and to evaluate the efficacy and safety of laparoscopic surgery for ovarian fibromas.

Methods:

We reviewed the records of 47 consecutive women who underwent laparoscopic or laparotomic surgeries and whose final histopathological diagnoses were ovarian fibroma, cellular fibroma, or fibrothecoma from January 1999 to August 2010.

Results:

During the study period, 49 tumors were removed from 47 women including 27 ovarian fibromas, 19 fibrothecomas, and 3 cellular fibromas. The preoperative diagnoses were ovarian fibroma in 25 women (53.2%) and uterine myoma in 16 women (34.0%). A high serum CA 125 level (>35U/mL) was observed in 15 women, and serum CA 125 level was significantly higher in women with ascites (P=<0.001). The tumors were removed surgically in all women, using the laparotomic approach in 16 women (34.0%) and the laparoscopic approach in 31 women (66.0%). The laparoscopic surgery had the advantages of shorter hospital stay and faster return of bowel activities compared to laparotomy.

Conclusions:

Ovarian fibromas are often misdiagnosed as uterine myomas, and sometimes mistaken for a malignant tumor of the ovary preoperatively. Laparoscopic surgery can be an effective and safe surgical approach for managing ovarian fibromas.     

Analysis of anatomical variations of bone and vascular structures around the posterior atlantal arch using three-dimensional computed tomography angiography

OBJECT: The current study evaluates the incidence of anatomical variations of the V(3) segment of the vertebral artery (VA) and the posterior arch of the atlas (C-1). Failure to appreciate these types of anatomical variations can cause catastrophic injury to the VA during posterior approaches to the upper cervical spine. METHODS: In the present study, the authors analyzed the records of 1013 Korean patients who underwent computed tomography (CT) angiography to evaluate the incidence of anomalous variations in the third segment of the VA and to determine the incidence and morphometric characteristics of any detected posterior ponticuli. The authors also hoped to determine any specific imaging features that might indicate a VA anomaly around the craniovertebral junction. RESULTS: The mean age of the patients was approximately 55.7 years and the prevalence of a posterior ponticulus was 15.6%. The incidence rate of a posterior ponticulus in the male population was 19.3%, whereas in the female population it was 12.8%. The incomplete type of posterior ponticulus was more common than the complete type. The mean age of the patients with an incomplete posterior ponticulus (55.7 years) was significantly younger (p = 0.018) than the mean age of patients with a complete posterior ponticulus (57.6 years). The incidence rate of a persistent first inter-segmental artery was 4.7% and the incidence rate of a fenestrated VA was 0.6%. The area of the C-1 transverse foramen on the abnormal side was significantly smaller than that of the contralateral normal side. CONCLUSIONS: The shape of the C-1 posterior arch and the third segment of the VA are heterogeneous. Therefore, preoperative radiological studies should be performed to identify any anatomical variations. Using preoperative 3D CT angiography, we can precisely identify an anomalous VA and significantly reduce the risk of VA injury.     

Contemporary outcomes after superficial femoral artery angioplasty and stenting: the influence of TASC classification and runoff score

OBJECTIVE: A recent randomized trial suggested nitinol self-expanding stents (SES) were associated with reduced restenosis rates compared with simple percutaneous transluminal angioplasty (PTA). We evaluated our results with superficial femoral artery (SFA) SES to determine whether TransAtlantic InterSociety Consensus (TASC) classification, indication for intervention, patient risk factors, or Society of Vascular Surgery (SVS) runoff score correlated with patency and clinical outcome, and to evaluate if bare nitinol stents or expanded polytetrafluoroethylene (ePTFE) covered stent placement adversely impacts the tibial artery runoff. METHODS: A total of 109 consecutive SFA stenting procedures (95 patients) at two university-affiliated hospitals from 2003 to 2006 were identified. Medical records, angiographic, and noninvasive studies were reviewed in detail. Patient demographics and risk factors were recorded. Procedural angiograms were classified according to TASC Criteria (I-2000 and II-2007 versions) and SVS runoff scores were determined in every patient; primary, primary-assisted, secondary patency, and limb salvage rates were calculated. Cox proportional hazard model was used to determine if indication, TASC classification, runoff score, and comorbidities affected outcome. RESULTS: Seventy-one patients (65%) underwent SES for claudication and 38 patients (35%) for critical limb ischemia (CLI). Average treatment length was 15.7 cm, average runoff score was 4.6. Overall 36-month primary, primary-assisted, and secondary rates were 52%, 64%, and 59%, respectively. Limb salvage was 75% in CLI patients. No limbs were lost following interventions in claudicants (mean follow-up 16 months). In 24 patients with stent occlusion, 15 underwent endovascular revision, only five (33%) ultimately remained patent (15.8 months after reintervention). In contrast, all nine reinterventions for in-stent stenosis remained patent (17.8 months). Of 24 patients who underwent 37 endovascular revisions for either occlusion or stenosis, eight (35%) had worsening of their runoff score (4.1 to 6.4). By Cox proportional hazards analysis, hypertension (hazard ratio [HR] 0.35), TASC D lesions (HR 5.5), and runoff score > 5 (HR 2.6) significantly affected primary patency. CONCLUSIONS: Self-expanding stents produce acceptable outcomes for treatment of SFA disease. Poorer patency rates are associated with TASC D lesions and poor initial runoff score; HTN was associated with improved patency rates. Stent occlusion and in-stent stenosis were not entirely benign; one-third of patients had deterioration of their tibial artery runoff. Future studies of SFA interventions need to stratify TASC classification and runoff score. Further evaluation of the long-term effects of SFA stenting on tibial runoff is needed.     

Aesthetic reconstruction of lower leg defects using a new anterolateral lower leg perforator flap.

Our objective in this study was to report on the successful clinical use of a new perforator flap obtained from the proximal quarter of the anterolateral lower leg. Eight patients had the procedure either as a result of trauma (seven patients) or to treat Marjolin's ulcer (one patient). During the procedure, a line was drawn from the anterior fibular head to the anterior lateral malleolus. Then, using Doppler, a septocutaneous perforator from the fibular head to the proximal quarter point of the line was identified. The subfascial dissection was continued to the detected perforator. Along the perforator in the anterior intermuscular (peroneal) septum, a deep dissection was performed. The perforator was then separated and the flap harvested. The septocutaneous perforator was the perforator of the superficial peroneal nerve accessory artery in three cases, the perforator of the superior lateral peroneal artery in one case, and the perforator originating directly from the anterior tibial artery in four cases. Seven of eight cases were treated successfully. The results obtained were satisfactory, both aesthetically and functionally. This flap is a valuable alternative to the various perforator flaps from the lower leg. This flap has the advantage of being very thin, which makes it suitable for reconstruction of defects in the foot, ankle, pretibial area, and knee. However, one limitation of this procedure is that the diameter of the perforator was approximately 0.6-1.2 mm.     

Surgical completeness of robotic thyroidectomy: a prospective comparison with conventional open thyroidectomy in papillary thyroid carcinoma patients

Background

Using the da Vinci^® robotic system, surgeons can complete secure thyroidectomy without noticeable neck scarring. This study compared the surgical completeness of transaxillary robotic thyroidectomy (RT) with conventional open procedures (OT) in treating papillary thyroid carcinoma (PTC) patients.

Materials and methods

From April 2009 through February 2011, 94 PTC patients underwent total thyroidectomy with central compartment neck dissection (CCND) at Yonsei University College of Medicine. All patients received 1.1 GBq radioactive iodine (RAI) ablation, post-therapy whole-body scans (TxWBS), and diagnostic WBS (DxWBS) 1 year later. We prospectively compared patient clinicopathologic characteristics and surgical completeness between the two groups.

Results

Fifty-one patients underwent OT and 43 underwent RT. Mean age was significantly younger in the RT group. Tumor size, capsular-invasion frequency, multifocality, bilaterality, and central nodal metastasis were not different between the two groups. The number of retrieved nodes during CCND did not significantly differ between the groups. There was no significant difference between the OT and RT groups in stimulated thyroglobulin levels acquired during TxWBS and DxWBS. The RAI uptake ratios at TxWBS were significantly higher in the RT group compared with the OT group; however, follow-up DxWBS showed no difference in RAI uptake ratios. Also, the ablation success rate was similar between the two groups. There were no abnormal findings in follow-up neck ultrasonography in either group.

Conclusion

Remnant thyroid tissue ablation after transaxillary RT was successfully managed by 1.1 GBq RAI. RT showed similar surgical completeness versus conventional OT, and provides a safe and feasible surgical option for PTC patients.     

Static Langer's line and wound contraction rates according to anatomical regions in a porcine model

This study investigated wound contraction rates according to anatomical regions and wound morphology according to skin tension line in a micropig porcine model. Of the four animals used, skin tension morphology was determined in one pig. In the remaining three pigs, six pairs of full‐thickness skin excisions were created on the dorsum (six square and six circular). The wounds were grouped, Wounds #1 through #5, according to the skin tension line and anatomical regions: Wounds #1 and #2, cephalic; Wounds #4 and #5, caudal; and Wound #3, center. Wound sizes and contraction rates were calculated for 28 days. A static tension topography of the micropig dorsum was obtained. Excisional wounds deformed along the local tension vector and healed in this fashion. Wound contraction rates were significantly higher for cephalic wounds (p = 0.004). No significant difference in wound contraction rates were observed between square and circular wounds. Final wound morphology was related to the local tension vector and initial wound shape. Cephalic wounds contracted more quickly. Further studies are needed to characterize scar formation after primarily closed surgical wounds in relation to the newly established skin tension topography and to elucidate the mechanism behind the variable wound contraction rates in the cephalocaudal gradient.