Stereotactic Body Radiation Therapy (SBRT) for Liver Metastasis: Early Experience with the Cyberknife Robotic Radio-Surgery System

Background: The liver is a common site for malignant metastases. Surgical metastatic resection, ablative therapies, and external beam radiation therapy (EBRT) all have advantages and limitations. Preliminary reports reveal SBRT treats hepatic metastases with limited toxicities. We reviewed our institution’s SBRT experience for the treatment of liver metastases to assess toxicity and outcomes.Methods: Hepatic metastases treated with SBRT were retrospectively reviewed from 2008-2010. Computed tomography (CT) identified tumor volume prior to SBRT, local recurrence and out-of-field progression after SBRT. Study endpoints were local recurrence, toxicity, and overall survival.Results: Thirty-three patients had 37 liver metastases treated with a median SBRT dose of 30Gy. Median follow-up was 8.1 months. Five lesions (13.5%) locally recurred after a median of 10.6 months. Seventeen patients had out-of-field progression (15 liver, 6 systemic) after a median of 5.1 months. Overall 23.5-month survival was 45.5%. Five patients reported nausea and seven reported pain after SBRT. There were no grade 4-5 toxicities or cases of liver failure.Conclusion: SBRT is safe and well tolerated in patients with hepatic metastases. SBRT offers a local therapy with limited toxicities to patients with lesions not amenable to traditional ablative, surgical, or regional therapies

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

UTILITY OF COMPUTED TOMOGRAPHY RECONSTRUCTED THORACOLUMBAR SPINAL IMAGING IN BLUNT TRAUMA.

OBJECTIVES: Fractures of the thoracolumbar(TL) spine are common and may cause neurologic damage, pain, and reduced quality of life. CT TL reconstructions from CT chest/abdomen/pelvis(CAP) are used to identify TL fractures, however their benefit over CAP imaging is unclear. We hypothesized that reformatted TL images do not identify additional clinically significant injuries or change outcomes. METHODS: Retrospective data were collected 2016-2021 from trauma patients at a level-1 trauma center. All patients ≥18 years old, with TL fractures on CT CAP with/without CT TL reformats were included. Clinically significant TL fractures were defined as requiring operative fixation, brace, or spinal rehabilitation. A binary classification model was created to assess the diagnostic utility of CTCAP compared to CTTL in predicting clinically significant fractures in patients who underwent CT CAP/TL. RESULTS: There were 828 patients with TL fractures, 634 had both CT CAP/CT TL (CAPTL) and 194CTCAP only (CAP). There were 134(16%) clinically significant TL fractures (14(7.2%) CT CAP vs120(18.9%) CT CAPTL,p \u3c 0.001). There were no differences among unstable fractures, fractures on MRI only, mortality, or neurologic deficits on discharge between CAPTL and CAP(p \u3e 0.05). Among clinically significant fractures, CAPTL was not associated with increased MRI utilization, surgery, spinal brace, or spinal cord rehabilitation(p \u3e 0.05). Among clinically insignificant fractures, CAPTL was associated with increased MRIs, LOS, and ICU LOS (p \u3c 0.05). CAPTL was also an independent predictor of increased MRIs (OR5.79,CI2.29-14.65,p \u3c 0.01) and spine consultation (OR2.39,CI1.64-3.67,p \u3c 0.01). More CTCAP/TL were performed in those with clinically significant fractures; however, CTCAP was equivalent to CTTL for detection of fractures(p \u3e 0.05). CONCLUSION: CTCAP alone is sufficient to identify clinically significant TL fractures. While the addition of TL reformatted imaging minimizes missed injuries, it is associated with increased hospital length of stay and MRI resource utilization. Therefore, careful consideration is needed for appropriate CT TL patient selection. STUDY TYPE: Original Research. LEVEL OF EVIDENCE: Level IV/Diagnostic Test

Fever in the ICU: A Predictor of Mortality in Mechanically Ventilated COVID-19 Patients.

PURPOSE: While fever may be a presenting symptom of COVID-19, fever at hospital admission has not been identified as a predictor of mortality. However, hyperthermia during critical illness among ventilated COVID-19 patients in the ICU has not yet been studied. We sought to determine mortality predictors among ventilated COVID-19 ICU patients and we hypothesized that fever in the ICU is predictive of mortality. MATERIALS AND METHODS: We conducted a retrospective cohort study of 103 ventilated COVID-19 patients admitted to the ICU between March 14 and May 27, 2020. Final follow-up was June 5, 2020. Patients discharged from the ICU or who died were included. Patients still admitted to the ICU at final follow-up were excluded. RESULTS: 103 patients were included, 40 survived and 63(61.1%) died. Deceased patients were older {66 years[IQR18] vs 62.5[IQR10], ( CONCLUSIONS: This is one of the first studies to identify ICU hyperthermia as predictive of mortality in ventilated COVID-19 patients. Additional predictors included male sex, age, and acidosis. With COVID-19 cases increasing, identification of ICU mortality predictors is crucial to improve risk stratification, resource management, and patient outcomes

Critical care pharmacy practice advancement recommendations on direct patient care activities: An opinion of the American College of Clinical Pharmacy Critical Care Practice and Research Network

An updated position paper on critical care pharmacy services recommends the development of new clinical programs. However, proposed pragmatic strategies for critical care pharmacy practice advancement are lacking. The purpose of this position paper is to develop consensus recommendations aimed at direct patient care activities for the advancement of critical care pharmacy practice. A 24-member task force of critical care pharmacists, physicians, and nurses participated in a Recommendation Development Phase and Consensus-building Phase (using a Delphi method) to produce the final critical care practice advancement recommendations. Proposed recommendations of pragmatic medication management opportunities with an advanced scope of practice involving pharmacist prescriptive authority for initiating, modifying, or discontinuing drug therapy and medication monitoring were developed. Task force participants anonymously voted on each proposed recommendation using a fivepoint Likert scale (1 = strongly agree, 2 = agree, 3 = neutral, 4 = disagree, and 5 = strongly disagree). Recommendations failing to achieve consensus (≥70% agreement on “strongly agree”/“agree” votes) were revised for subsequent voting. Task force response rates during the first and second voting rounds were 71% (n = 17) and 79% (n = 19), respectively. A total of 57 (93.4%) of the 61 proposed practice advancement recommendations achieved consensus of which 88.5% (n = 54) met consensus after the first round. Consensus recommendations involved the critical care pharmacist initiating (n = 15), modifying (n = 22), or discontinuing (n = 9) drug therapy, and ordering relevant laboratory values or tests to optimize drug therapy (n = 11). One recommendation failing consensus was not revised for additional voting given the impracticality of achieving agreement. Fifty-seven of the proposed 61 recommendation statements (93%) achieved the consensus threshold after two rounds of voting by an interprofessional expert panel. These recommendations provide a conceptual framework for promoting novel critical care pharmacist prescriptive authority over specific aspects of direct patient care. Implementation challenges and barriers, further described in this paper, must be explored at the institutional level for acceptance

Screening and intervention for intimate partner violence at trauma centers and emergency departments: an evidence-based systematic review from the Eastern Association for the Surgery of Trauma

Background Intimate partner violence (IPV) is a serious public health issue with a substantial burden on society. Screening and intervention practices vary widely and there are no standard guidelines. Our objective was to review research on current practices for IPV prevention in emergency departments and trauma centers in the USA and provide evidenced-based recommendations.Methods An evidence-based systematic review of the literature was conducted to address screening and intervention for IPV in adult trauma and emergency department patients. The Grading of Recommendations, Assessment, Development and Evaluations methodology was used to determine the quality of evidence. Studies were included if they addressed our prespecified population, intervention, control, and outcomes questions. Case reports, editorials, and abstracts were excluded from review.Results Seven studies met inclusion criteria. All seven were centered around screening for IPV; none addressed interventions when abuse was identified. Screening instruments varied across studies. Although it is unclear if one tool is more accurate than others, significantly more victims were identified when screening protocols were implemented compared with non-standardized approaches to identifying IPV victims.Conclusion Overall, there were very limited data addressing the topic of IPV screening and intervention in emergency medical settings, and the quality of the evidence was low. With likely low risk and a significant potential benefit, we conditionally recommend implementation of a screening protocol to identify victims of IPV in adults treated in the emergency department and trauma centers. Although the purpose of screening would ultimately be to provide resources for victims, no studies that assessed distinct interventions met our inclusion criteria. Therefore, we cannot make specific recommendations related to IPV interventions.PROSPERO registration number CRD42020219517

The Emergency Surgery Score accurately predicts the need for postdischarge respiratory and renal support after emergent laparotomies: A prospective EAST multicenter study

The Emergency Surgery Score (ESS) was recently validated as an accurate mortality risk calculator for emergency general surgery. We sought to prospectively evaluate whether ESS can predict the need for respiratory and/or renal support (RRS) at discharge after emergent laparotomies (EL).This is a post hoc analysis of a 19-center prospective observational study. Between April 2018 and June 2019, all adult patients undergoing EL were enrolled. Preoperative, intraoperative, and postoperative variables were systematically collected. In this analysis, patients were excluded if they died during the index hospitalization, were discharged to hospice, or transferred to other hospitals. A composite variable, the need for RRS, was defined as the need for one or more of the following at hospital discharge: tracheostomy, ventilator dependence, or dialysis. Emergency Surgery Score was calculated for all patients, and the correlation between ESS and RRS was examined using the c-statistics method.From a total of 1,649 patients, 1,347 were included. Median age was 60 years, 49.4% were men, and 70.9% were White. The most common diagnoses were hollow viscus organ perforation (28.1%) and small bowel obstruction (24.5%); 87 patients (6.5%) had a need for RRS (4.7% tracheostomy, 2.7% dialysis, and 1.3% ventilator dependence). Emergency Surgery Score predicted the need for RRS in a stepwise fashion; for example, 0.7%, 26.2%, and 85.7% of patients required RRS at an ESS of 2, 12, and 16, respectively. The c-statistics for the need for RRS, the need for tracheostomy, ventilator dependence, or dialysis at discharge were 0.84, 0.82, 0.79, and 0.88, respectively.Emergency Surgery Score accurately predicts the need for RRS at discharge in EL patients and could be used for preoperative patient counseling and for quality of care benchmarking.Prognostic and epidemiological, level III