Development of an emergency general surgery process improvement program

Background

The Joint Trauma System has demonstrated improved outcomes through coordinated research and process improvement programs. With fewer combat trauma patients, our military American College of Surgeons level 2 trauma center’s ability to maintain a strong trauma Process Improvement (PI) program has become difficult. As emergency general surgery (EGS) patients are similar to trauma patients, our Trauma and Acute Care Surgery (TACS) service developed an EGS PI program analogous to what is done in trauma. We describe the implementation of our novel EGS PI program and its effect on institutional PI proficiency.

Methods

An EGS registry was developed in 2013. Inclusion criteria were based on AAST published literature. In 2015, EGS registrar and PI coordinator positions were developed and filled with existing trauma staff. A formal EGS PI program began January 1, 2016. Pre- and post-program data was compared to determine the effect including EGS PI events had on increasing yield into our trauma PI program.

Results

In 2016, TACS saw 1001 EGS consults. Four hundred forty-four met criteria for registry inclusion. Eighty-two patients had 131 PI events; re-admission within 30 days, unplanned therapeutic intervention, and unplanned ICU admission were the most common events. Capture of EGS PI events yielded a 49% increase compared with 2015.

Conclusion

Overall patient volume and PI events post EGS PI program initiation exceeded those prior to implementation. These data suggest that extending trauma PI principles to EGS may be beneficial in maintaining inter-war military and/or lower volume trauma center readiness.

     

Apolipoprotein A-1 predicts coronary heart disease only at low concentrations of high-density lipoprotein cholesterol: an epidemiological study of Japanese-Americans

Conventional epidemiological and clinical studies of apolipoprotein A-1 and high-density lipoprotein-cholesterol have demonstrated, when examined jointly, that high-density lipoprotein is a better predictor of coronary heart disease. This strategy does not take into account known lipid metabolic relationships. A statistical approach that takes into account apolipoprotein A-1 being a constituent of the high-density lipoprotein particle is more appropriate. Among 1,177 Japanese-American men of the Honolulu Heart Program cohort free of disease at baseline (1980-1982), 182 new coronary heart disease cases developed over a 12-year follow-up period. After removing the linear relationship with high-density lipoprotein-cholesterol, a relative measure of apoliprotein A-1 concentration was derived. Based on joint conditions of "low" and "high" relative apoliprotein A-1 concentration and < or =40 and >40 mg/dl for the high-density lipoprotein-cholesterol distribution, four groupings were created. Among relative joint groupings of high/< or =40, low/< or =40, high/>40, and low/>40, respectively, the 12-year coronary heart disease incidence varied from 28.6, 18.2, 8.3, to 11.7 cases per 1,000 person-years. A test of statistical interaction was significant (P=0.028). Additional analyses revealed coronary heart disease cases were more likely among men with triglycerides > 190 mg/dl. Observed patterns of relationships among relative apoliprotein A-1 level, high-density lipoprotein cholesterol, and triglycerides with incident coronary heart disease are consistent with patterns noted in clinical, laboratory, and transgenic animal research more capable of elucidating mechanisms of disease causation. This epidemiological study suggests similar mechanisms may be operating at a population level, and may contribute to the public health burden of coronary heart disease.     

Effects of bone fracture and surgery on plasma myosin heavy chain fragments of skeletal muscle

OBJECTIVE: Myosin heavy chain (MHC) fragment is part of a structural or force-bearing protein expressed in the thick filament of muscle fibres. Since MHC fragment is a contractile protein, an increase in plasma MHC concentrations after muscle injury indicates degradation of the contractile apparatus. This study was conducted to determine whether MHC concentrations could be a tool in the assessment of tissue damage in patients with myoskeletal injuries. DESIGN: Prospective, controlled study. SETTING: A UK University National Health Service Centre. PATIENTS: Thirty-eight orthopedic patients, of whom 14 received surgical treatments within the 2-day study period. Patients were compared with 16 nonorthopedic control subjects. OUTCOME MEASURES: Serum levels of MHC, creatine kinase, cardiac troponin I (cTnI), and myoglobin were measured at the time of admission and 24 hours later. Data from patients undergoing surgical repairs were obtained 24 hours after surgery. A competitive radio-immunoassay for beta-type MHC was used. RESULTS: Plasma MHC concentration was higher in the patients than in the controls. The peak levels were observed 24 hours after injury or surgery (p < 0.05). cTnI concentrations were consistently below the assay detection limit of 0.3 microgram/L, thus excluding protein release from the heart muscle (cardiac beta-type MHC). Creatine kinase and myoglobin concentrations were significantly higher on admission in the non-surgical patients than in the surgically treated cases. CONCLUSIONS: Serum MHC levels could be a useful supplementary retrospective, prognostic or diagnostic tool in the study of myoskeletal disturbances involving muscle injury or bone fractures that result in membrane leakage of myoskeletal cells.     

Transient Receptor Potential Channels in Microglia: Roles in Physiology and Disease

Microglia modulate the nervous system cellular environment and induce neuroprotective and neurotoxic effects. Various molecules are involved in these processes, including families of ion channels expressed in microglial cells, such as transient receptor potential (TRP) channels. TRP channels comprise a family of non-selective cation channels that can be activated by mechanical, thermal, and chemical stimuli, and which contribute to the regulation of intracellular calcium concentrations. TRP channels have been shown to be involved in cellular processes such as osmotic regulation, cytokine production, proliferation, activation, cell death, and oxidative stress responses. Given the significance of these processes in microglial activity, studies of TRP channels in microglia have focused on determining their roles in both neuroprotective and neurotoxic processes. TRP channel activity has been proposed to play an important function in neurodegenerative diseases, ischemia, inflammatory responses, and neuropathic pain. Modulation of TRP channel activity may thus be considered as a potential therapeutic strategy for the treatment of various diseases associated with alterations of the central nervous system (CNS). In this review, we describe the expression of different subfamilies of TRP channels in microglia, focusing on their physiological and pathophysiological roles, and consider their potential use as therapeutic targets in CNS diseases.     

Human pharmacology of 6-[D-alpha-(3-guanylureido)-phenylacetamido]-penicillanic acid (BL-P1654)

BL-P1654 is a new alpha-substituted ureido penicillin which has broad-spectrum activity. Doses of 0.5 and 1.0 g administered by rapid intravenous injection produce mean peak serum concentrations of 40.7 and 80.8 mug/ml, respectively. The same doses administered by 1-h intravenous infusions produce mean peak serum concentrations of 22.6 and 47 mug/ml, respectively. The mean serum concentrations from 1 to 6 h after onset of administration of the drug are the same for both schedules. The mean serum concentration at 6 h after the rapid intravenous injection of 0.5- and 1.0-g doses of BL-P1654 are 3.4 and 5.4 mug/ml, respectively. A dose of 1.0 g every 4 h maintains a serum concentration of about 15 mug/ml. About 50 to 65% of the BL-P1654 is excreted in the urine during the first 6 h.     

Arteriovenous access: managing common problems

The creation and maintenance of hemoaccess occupies a significant portion of most vascular and general surgery practices. In this article, the methods used to detect hemoaccess at risk for failure and the endovascular and surgical techniques used to prolong or restore their patency are reviewed. Also, the management of hemoaccess infection, aneurysmal degeneration, false aneurysm formation, and symptomatic arterial steal syndrome are described.     

Two-site immunoenzymometric assay for the 52-kDa cathepsin D in cytosols of breast cancer tissues

We developed a solid-phase two-site immunoenzymometric assay (IEMA) of the estrogen-induced 52-kDa cathepsin D (EC 3.4.23.5) and its processed forms (48-kDa and 34-kDa proteins) in cytosols of breast cancer tissues, using two monoclonal antibodies directed against two different epitopes of these antigens. The first antibody is bound to a polystyrene microtiter well; the second is labeled with alkaline phosphatase. The assay involves a simultaneous incubation of the antigen with both antibodies, because we observed signal loss during sequential incubations. Alkaline phosphatase was chosen because other enzymes (peroxidase, beta-galactosidase) were inhibited by cytosol extraction buffers. The measurable range of 52-kDa-related proteins is from 0.3 to 6 nmol/L with precision (CVs) within and between runs of 3.9% and 15.8%, respectively. The sensitivity, accuracy, and rapid turnaround time of the two-site IEMA should facilitate the clinical evaluation of this new marker in oncology.