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Evaluation of the Collaborative Use of an Evidence-Based Care Bundle in Emergency Laparotomy
YesIMPORTANCE Patients undergoing emergency laparotomy have high mortality, but few
studies exist to improve outcomes for these patients.
OBJECTIVE To assess whether a collaborative approach to implement a 6-point care bundle
is associated with reduction in mortality and length of stay and improvement in the delivery
of standards of care across a group of hospitals.
DESIGN, SETTING, AND PARTICIPANTS The Emergency Laparotomy Collaborative (ELC) was a
UK-based prospective quality improvement study of the implementation of a care bundle
provided to patients requiring emergency laparotomy between October 1, 2015, and
September 30, 2017. Participants were 28 National Health Service hospitals and emergency
surgical patients who were treated at these hospitals and whose data were entered into the
National Emergency Laparotomy Audit (NELA) database. Post-ELC implementation
outcomes were compared with baseline data from July 1, 2014, to September 30, 2015.
Data entry and collection were performed through the NELA.
INTERVENTIONS A 6-point, evidence-based care bundle was used. The bundle included
prompt measurement of blood lactate levels, early review and treatment for sepsis, transfer
to the operating room within defined time goals after the decision to operate, use of
goal-directed fluid therapy, postoperative admission to an intensive care unit, and
multidisciplinary involvement of senior clinicians in the decision and delivery of perioperative
care. Change management and leadership coaching were provided to ELC leadership teams.
MAIN OUTCOME AND MEASURES Primary outcomes were in-hospital mortality, both crude
and Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality
and morbidity (P-POSSUM) risk-adjusted, and length of stay. Secondary outcomes were the
changes after implementation of the separate metrics in the care bundle.
RESULTS A total of 28 hospitals participated in the ELC and completed the project.
The baseline group included 5562 patients (2937 female [52.8%] and a mean [range] age of
65.3 [18.0-114.0] years), whereas the post-ELC group had 9247 patients (4911 female [53.1%]
and a mean [range] age of 65.0 [18.0-99.0] years). Unadjusted mortality rate decreased from
9.8% at baseline to 8.3% in year 2 of the project, and so did risk-adjusted mortality from a
baseline of 5.3% to 4.5% post-ELC. Mean length of stay decreased from 20.1 days during year
1 to 18.9 days during year 2. Significant changes in 5 of the 6 metrics in the care bundle were
achieved.
CONCLUSIONS AND RELEVANCE A collaborative approach using a quality improvement
methodology and a care bundle appeared to be effective in reducing mortality and length
of stay in emergency laparotomy, suggesting that hospitals should adopt such an approach
to see better patient outcomes and care delivery performance.This study was funded by The Health Foundation, United Kingdom, as part of a Scaling Up Award
Non-Functional Parathyroid Carcinoma: A Review of the Literature and Report of a Case Requiring Extensive Surgery
Parathyroid carcinoma is a rare malignancy, and only accounts for 0.5–2% of cases of primary hyperparathyroidism. Less than 10% of parathyroid carcinomas are non-functional, and as such, they have been rarely reported in the literature. Importantly, margin status at resection is related to prognosis, and only a handful of case reports of non-functional carcinoma note this important parameter. Here we report the first case of non-functional parathyroid carcinoma with negative margins, and review the literature on this rare entity. Whether functional or non-functional, parathyroid carcinoma can often be difficult to differentiate from benign parathyroid adenoma. While diagnosis has been based on clinical and histological criteria, recent data concerning the molecular underpinnings of parathyroid carcinoma may allow for improved accuracy in distinguishing benign and malignant parathyroid tumors
Challenges and Pitfalls in the Management of Parathyroid Carcinoma: 17-Year Follow-Up of a Case and Review of the Literature
A 29-year-old man presented to his primary care physician with nausea, severe weight loss and muscle weakness. He had a hard, fixed neck swelling. He was severely hypercalcaemic with 10-fold increased parathyroid hormone (PTH) concentrations. A diagnosis of primary hyperparathyroidism was established and the patient was referred for parathyroidectomy. At neck exploration, an enlarged parathyroid gland with invasive growth into the thyroid gland was found and removed, lymph nodes were cleared and hemithyroidectomy was performed. A suspected diagnosis of parathyroid carcinoma was confirmed histologically. Serum calcium and PTH levels normalised post-operatively, but hyperparathyroidism recurred within 3 years of surgery. Over the following 17 years, control of hypercalcaemia represented the most difficult challenge despite variable success achieved with repeated surgical interventions, embolisations, radiofrequency ablation of metastases and treatment with calcimimetics, bisphosphonates and haemodialysis using low-dialysate calcium. In this paper, we report the challenges and pitfalls we encountered in the management of our patient over nearly two decades of follow-up and review recent literature on the topic
Evaluation of appendicitis risk prediction models in adults with suspected appendicitis
Background
Appendicitis is the most common general surgical emergency worldwide, but its diagnosis remains challenging. The aim of this study was to determine whether existing risk prediction models can reliably identify patients presenting to hospital in the UK with acute right iliac fossa (RIF) pain who are at low risk of appendicitis.
Methods
A systematic search was completed to identify all existing appendicitis risk prediction models. Models were validated using UK data from an international prospective cohort study that captured consecutive patients aged 16–45 years presenting to hospital with acute RIF in March to June 2017. The main outcome was best achievable model specificity (proportion of patients who did not have appendicitis correctly classified as low risk) whilst maintaining a failure rate below 5 per cent (proportion of patients identified as low risk who actually had appendicitis).
Results
Some 5345 patients across 154 UK hospitals were identified, of which two‐thirds (3613 of 5345, 67·6 per cent) were women. Women were more than twice as likely to undergo surgery with removal of a histologically normal appendix (272 of 964, 28·2 per cent) than men (120 of 993, 12·1 per cent) (relative risk 2·33, 95 per cent c.i. 1·92 to 2·84; P < 0·001). Of 15 validated risk prediction models, the Adult Appendicitis Score performed best (cut‐off score 8 or less, specificity 63·1 per cent, failure rate 3·7 per cent). The Appendicitis Inflammatory Response Score performed best for men (cut‐off score 2 or less, specificity 24·7 per cent, failure rate 2·4 per cent).
Conclusion
Women in the UK had a disproportionate risk of admission without surgical intervention and had high rates of normal appendicectomy. Risk prediction models to support shared decision‐making by identifying adults in the UK at low risk of appendicitis were identified
Carotid endarterectomy relieves pulsatile tinnitus associated with severe ipsilateral carotid stenosis
Objectives. Pulsatile tinnitus is a rare and often disabling condition. Pulsatile tinnitus sometimes occurs in patients with severe atherosclerotic carotid stenosis. It is uncertain whether carotid endarterectomy (CEA) relieves pulsatile tinnitus in patients with severe carotid stenosis. Design, Materials and Methods. This is a retrospective study of 14 patients with pulsatile tinnitus who underwent CEA. Demographic and clinical features and pre-operative duplex results were recorded. Operative results in this group were assessed. Results. CEA relieved symptoms of pulsatile tinnitus in 10 out of 14 cases (70%). Of 10 patients that had lateralisable tinnitus and ipsilateral surgery, 9 (90%) reported symptomatic improvement. Conclusions. CEA is effective in improving pulsatile tinnitus in patients with unilateral symptoms and severe ipsilateral carotid stenosis
The Challenge of Antimicrobial Resistance in Managing Intra-Abdominal Infections
In recent years, there has been a worldwide increase in infections caused by microorganisms resistant to multiple antimicrobial agents. Methods: In the past few decades, an increased prevalence of infections caused by antibiotic-resistant pathogens, including Enterococcus spp., carbapenem-resistant Pseudomonas aeruginosa and Acinetobacter baumannii, extended-spectrum β-lactamase (ESBL)-producing Escherichia coli and Klebsiella spp., carbapenemase-producing Klebsiella pneumoniae, and resistant Candida spp., also has been observed among intra-abdominal infections (IAIs). Results: The increasing prevalence of multi-drug resistance is responsible for a substantial increase in morbidity and mortality rates associated with IAIs. Conclusions: It is necessary for every surgeon treating IAIs to understand the underlying epidemiology and clinical consequences of antimicrobial resistance. Emergence of drug resistance, combined with the lack of new agents in the drug development pipeline, indicates that judicious antimicrobial management will be necessary to preserve the utility of the drugs available currently