Evolution of the Surgeon Volume / Patient Outcome Relationship

Adams et al. was the first to demonstrate an association between improved outcomes and provider experience in a 1973 study examining complication rates from coronary arteriograms.[1] In this study, a questionnaire was mailed to the directors of coronary arteriography laboratories throughout the US. They found that mortality was eight times higher in institutions performing fewer than 200 examinations per two-year period compared to institutions performing more than 800 examinations per two-year period. It was not until 1979, however, that efforts to systematically study outcomes in surgery were made by Luft and colleagues.[2] They demonstrated lower mortality rates at high-volume centers compared with low-volume centers for several high risk procedures, such as coronary artery bypass graft surgery (CABG) and vascular surgery. This landmark study set the stage for outcomes research in surgery. Over the past decade, additional studies have continued to show higher surgeon or hospital volumes to be associated with improved patient outcomes. [3-13] To what degree surgeon versus hospital volume each contribute to outcomes is controversial and depends on the procedure examined. Nevertheless, formal recommendations encouraging certain high-risk procedures be performed at high-volume hospitals began as early as 2000 by the Leapfrog group and other policy initiatives.[14, 15] Formal recommendations for surgeon volume, on the other hand, have been lacking. There has been mounting evidence, particularly in the last decade, that surgeon volume is associated with improved patient outcomes, independent of hospital volume. To what measure these data have influenced referral patterns from low- to high-volume surgeons is unknown

Retrograde intussusception seven years after a laparoscopic Roux-en-Y gastric bypass

Intussusception after Roux-en-Y gastric bypass is more common than previously believed. It usually occurs between one and three years post-operatively, though we present a case that presented with a retrograde intussusception necessitating bowel resection seven years after a laparoscpic Roux-en-Y gastric bypass. The diagnosis and etiological theories are discussed based on findings from the literature

Arterial embolization of retained kidney remnant following blunt traumatic injury: A case report

Introduction: There has been a recent trend toward nonoperative management of solid organ injuries with arteriography and embolization as alternatives to surgical exploration. We examine the use of arterial embolization in the management of a post-subtotal nephrectomy urinoma in a patient with severe renal injury secondary to blunt trauma. Methods: This case report has been reported in line with the CARE criteria [13]. Presentation of case: A 35-year-old female patient presented with a persistent urinoma after an incomplete nephrectomy for blunt renal trauma. Computed tomography scan of the abdomen demonstrated a 47 × 68 × 101 mm3 collection superior to the remnant of the resected right kidney. With persistence of the urinoma after placement of an 8 French drainage catheter, the patient was taken for arterial embolization of the lower renal artery for ablation of the kidney remnant. Discussion: Most kidney injuries with urinoma formation are treated successfully with supportive measures, however refractory cases require intervention. Arterial embolization has been used successfully in the treatment of traumatic pseudoaneurysms, arteriovenous fistulas, and some renal tumors. In this patient, we extended the use of embolization to infarct vessels of the functioning kidney remnant as an alternative to surgery. Post-embolization the patient recovered well with permanent resolution of the urinoma and short-term side effects limited to short-lived fever and lumbar pain. Conclusion: Arterial embolization should be considered as an alternative to surgery in cases of persistent urinoma following renal trauma with retained remnants

Correlation of venous lactate and time of death in emergency department patients with noncritical lactate levels and mortality from trauma

Background: Serum venous lactate (LAC) levels help guide emergency department (ED) resuscitation of patients with major trauma. Critical LAC level (CLAC, ≥4.0 mmol/L) is associated with increased disease severity and higher mortality in injured patients. The characteristics of injured patients with non-CLAC (NCLAC) (<4.0 mmol/L) and death have not been previously described. Objectives: (1) To describe the characteristics of patients with venous NCLAC and death from trauma. (2) To assess the correlation of venous NCLAC with time of death. Methods: A retrospective cohort study at an urban teaching hospital between 9/2011 and 8/2014. Inclusion: All trauma patients (all ages) who presented to the ED with any injury and met all criteria: (1) Venous LAC drawn at the time of arrival that resulted in an NCLAC level; (2) were admitted to the hospital; (3) died during their hospitalization. Exclusion: CLAC. Outcome: Correlation of NCLAC and time of death. Data were extracted from an electronic medical record by trained data abstractors using a standardized protocol. Cross-checks were performed on 10% of data entries and inter-observer agreement was calculated. Data were explored using descriptive statistics and Kaplan–Meier curves were created to define survival estimates. Data are presented as percentages with 95% confidence interval (CI) for proportions and medians with quartiles for continuous variables. Kaplan–Meier curves with differences in time to events based on LAC are used to analyze the data. Results: A total of 60 patients met the inclusion criteria. The median age was 52 years (quartiles: 30, 75) and 73% were male (age range 2–92). The median LAC in the overall cohort was 1.9 mmol/L (quartiles: 1.5, 2.1). Sixteen patients (27%) died during the first 24 h with 5 (31%) due to intracranial hemorrhage. The median survival time was 5.6 days (134.4 h) (95% CI: 2.3–12.6). Conclusions: In trauma patients with NCLAC who died during the index hospitalization, the median survival time was 5.6 days, approximately one-third of patients died within the first 24 h. These findings indicate that relying on a triage NCLAC level alone may result in underestimating injury severity and subsequent morbidity and mortality

Characteristics and Outcomes of Individuals With Pre-existing Kidney Disease and COVID-19 Admitted to Intensive Care Units in the United States

Rationale &amp; objectiveUnderlying kidney disease is an emerging risk factor for more severe coronavirus disease 2019 (COVID-19) illness. We examined the clinical courses of critically ill COVID-19 patients with and without pre-existing chronic kidney disease (CKD) and investigated the association between the degree of underlying kidney disease and in-hospital outcomes.Study designRetrospective cohort study.Settings &amp; participants4,264 critically ill patients with COVID-19 (143 patients with pre-existing kidney failure receiving maintenance dialysis; 521 patients with pre-existing non-dialysis-dependent CKD; and 3,600 patients without pre-existing CKD) admitted to intensive care units&nbsp;(ICUs) at 68 hospitals across the United States.Predictor(s)Presence (vs absence) of pre-existing kidney disease.Outcome(s)In-hospital mortality (primary); respiratory failure, shock, ventricular arrhythmia/cardiac arrest, thromboembolic events, major bleeds, and acute liver injury (secondary).Analytical approachWe used standardized differences to compare patient characteristics (values&gt;0.10 indicate a meaningful difference between groups) and multivariable-adjusted Fine and Gray survival models to examine outcome associations.ResultsDialysis patients had a shorter time from symptom onset to ICU admission compared to other groups (median of 4 [IQR, 2-9] days for maintenance dialysis patients; 7 [IQR, 3-10] days for non-dialysis-dependent CKD patients; and 7 [IQR, 4-10] days for patients without pre-existing CKD). More dialysis patients (25%) reported altered mental status than those with non-dialysis-dependent CKD (20%; standardized difference=0.12) and those without pre-existing CKD (12%; standardized difference=0.36). Half of dialysis and non-dialysis-dependent CKD patients died within 28 days of ICU admission versus 35% of patients without pre-existing CKD. Compared to patients without pre-existing CKD, dialysis patients had higher risk for 28-day in-hospital death (adjusted HR, 1.41 [95% CI, 1.09-1.81]), while patients with non-dialysis-dependent CKD had an intermediate risk (adjusted HR, 1.25 [95% CI, 1.08-1.44]).LimitationsPotential residual confounding.ConclusionsFindings highlight the high mortality of individuals with underlying kidney disease and severe COVID-19, underscoring the importance of identifying safe and effective COVID-19 therapies in this vulnerable population

Obesity, inflammatory and thrombotic markers, and major clinical outcomes in critically ill patients with COVID‐19 in the US

Objective This study aimed to determine whether obesity is independently associated with major adverse clinical outcomes and inflammatory and thrombotic markers in critically ill patients with COVID‐19. Methods The primary outcome was in‐hospital mortality in adults with COVID‐19 admitted to intensive care units across the US. Secondary outcomes were acute respiratory distress syndrome (ARDS), acute kidney injury requiring renal replacement therapy (AKI‐RRT), thrombotic events, and seven blood markers of inflammation and thrombosis. Unadjusted and multivariable‐adjusted models were used. Results Among the 4,908 study patients, mean (SD) age was 60.9 (14.7) years, 3,095 (62.8%) were male, and 2,552 (52.0%) had obesity. In multivariable models, BMI was not associated with mortality. Higher BMI beginning at 25 kg/m2 was associated with a greater risk of ARDS and AKI‐RRT but not thrombosis. There was no clinically significant association between BMI and inflammatory or thrombotic markers. Conclusions In critically ill patients with COVID‐19, higher BMI was not associated with death or thrombotic events but was associated with a greater risk of ARDS and AKI‐RRT. The lack of an association between BMI and circulating biomarkers calls into question the paradigm that obesity contributes to poor outcomes in critically ill patients with COVID‐19 by upregulating systemic inflammatory and prothrombotic pathways