Pharmacological and surgical treatment of intracranial hypertension

Management of intracranial hypertension secondary to traumatic brain injury is crucial to optimizing outcomes. Use of pharmacological and/or surgical management is often needed to prevent secondary brain injury and its immediate and long-term effects. In addition to discussing medical and surgical options for approaching intracranial hypertension, this chapter will review its pathophysiology and discuss key aspects of intracranial pressure monitoring

Racial disparities in surgical outcomes: Does the level of resident surgeon play a role?

Background: Despite recognition of racial/ethnic surgical disparities, few studies have considered the role of surgical residents. This study aimed to elucidate whether disparities in postoperative outcomes are associated with the presence/level of surgical residents involved in procedures.Methods: Patients who were classified as having laparoscopic cholecystectomy, laparoscopic appendectomy, and open hernia repair in the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program database were compared by level of provider (junior residents postgraduate year 1-2, senior residents, attending alone) for differences in patient demographics, clinical case-mix, and postoperative outcome information by the use of descriptive statistics and multivariable logistic regression.Results: A total of 196,770 patients met inclusion criteria. Attendings performed 43.0% of operations alone (senior residents 37.5%, junior residents 20.1%), They operated on 44.1% white, 30.1% black, and 43.9% Hispanic patients compared with 35.5%, 48.7%, and 41.3% and 20.4%, 21.3%, and 14.8% for senior and junior residents, respectively. Compared with attendings alone, senior residents were more likely to operate on black patients (adjusted odds ratio [OR] 2.02, 95% confidence interval [95% CI] 1.95-2.09) and have major (OR 1.13, 95% CI 1.06-1.21) and minor complications (OR 1.20, 95% CI 1.11-1.31). Junior residents also were more likely to operate on black patients but did not experience significantly worse outcomes.Conclusion: Greater risk-adjusted odds of complications among patients treated by senior residents need to be carefully weighed given the group\u27s higher likelihood of operating on minority patients

Prioritizing qualitative research in surgery: A synthesis and analysis of publication trends

Background: Over the past 2 decades, researchers have recognized the value of qualitative research. Little has been done to characterize its application to surgery. We describe characteristics and overall prevalence of qualitative surgical research.Methods: We searched PubMed and CINAHL using surgery and 7 qualitative methodology terms. Four researchers extracted information; a fifth researcher reviewed 10% of abstracts for inter-rater reliability.Results: A total of 3,112 articles were reviewed. Removing duplicates, 28% were relevant (N = 878; κ = 0.70). Common qualitative methodologies included phenomenology (34.3%) and grounded theory (30.2%). Interviews were the most common data collection method (81.9%) of patients (64%) within surgical oncology (15.4%). Postdischarge was the most commonly studied topic (30.8%). Overall, 41% of studies were published in nursing journals, while 8% were published in surgical journals. More than half of studies were published since 2011.Conclusion: Results suggest qualitative surgical research is gaining popularity. Most is published in nonsurgical journals, however, utilizing only 2 methodologies (phenomenology, grounded theory). The surgical journals that have published qualitative research had study topics restricted to a handful of surgical specialties. Additional surgical qualitative research should take advantage of a greater variety of approaches to provide insight into rare phenomena and social context

Race and socioeconomic disparities in national stoma reversal rates

Background: Many temporary stomas are never reversed leading to significantly worse quality of life. Recent evidence suggests a lower rate of reversal among minority patients. Our study aimed to elucidate disparities in national stoma closure rates by race, medical insurance status, and household income. Methods: Five years of data from the Nationwide Inpatient Sample (2008 to 2012) was used to identify the annual rates of stoma formation and annual rates of stoma closure. Stomas labeled as permanent or those created secondary to colorectal cancers were excluded. Temporary stoma closure rates were calculated, and differences were tested with the chi-square test. Separate analyses were performed by race/ethnicity, insurance status, and household income. Nationally representative estimates were calculated using discharge-level weights. Results: The 5-year average annual rate of temporary stoma creation was 76,551 per year (46% colostomies and 54% ileostomies). The annual rate of stoma reversal was 50,155 per year that equated to an annual reversal rate of 65.5%. Reversal rates were higher among white patients compared with black patients (67% vs 56%, P \u3c .001) and among privately insured patients compared with uninsured patients (88% vs 63%, P \u3c .001). Reversal rates increased as the household income increased from 61% in the lowest income quartile to 72% in the highest quartile (P \u3c .001). Conclusions: Stark disparities exist in national rates of stoma closure. Stoma closure is associated with race, insurance, and income status. This study highlights the lack of access to surgical health care among patients of minority race and low-income statu

Evaluation of the Perceived Association Between Resident Turnover and the Outcomes of Patients Who Undergo Emergency General Surgery

IMPORTANCE: Inpatient palliative care improves symptom management and patient satisfaction with care and reduces hospital costs in seriously ill patients. However, the role of palliative care in the treatment of patients undergoing surgery (surgical patients) remains poorly defined. OBJECTIVE: To characterize the content, design, and results of interventions to improve access to palliative care or the quality of palliative care for surgical patients. EVIDENCE REVIEW: This systematic review was conducted according to PRIMSA guidelines. Articles were identified through searches of PubMed, PsycINFO, EMBASE, and CINAHL as well as manual review of references. Eligible articles included experimental, quasi-experimental, and observational studies published in English from January 1, 1994, through October 31, 2014, in which patient outcomes of palliative care interventions for adult surgical patients were reported. Data on the study setting, design, intervention, participants, and results were extracted from the final study set and analyzed from December 22, 2014, to February 7, 2015. FINDINGS: A total of 3838 abstracts were identified and screened by 2 reviewers, 77 articles were reviewed in full text, and 25 articles (22 unique interventions involving 8575 unique patients) met the study criteria. Interrater agreement was good (κ = 0.78). Nine single-institution retrospective cohort studies, 7 single-institution prospective cohort studies, 7 single-institution randomized clinical studies, and 2 multicenter randomized clinical studies were included. Nineteen of the 23 single-site studies were performed at academic hospitals. Given the heterogeneity of study methods and measures, meta-analysis was not possible. Preoperative decision-making interventions were associated with decreased mortality in 4 studies. Three studies reported improved quality of communication; 4, improved symptom management; and 7, decreased use of health care resources and decreased cost. However, many studies were small, performed in academic settings, and methodologically flawed and did not measure clinically meaningful outcomes. CONCLUSIONS AND RELEVANCE: The sparse evidence regarding interventions to introduce or improve palliative care for surgical patients is further limited by methodologic flaws. Rigorous evaluations of standardized palliative care interventions measuring meaningful patient outcomes are needed

Surgeons’ perceptions toward providing care for diverse patients: The need for cultural dexterity training

Objective: We sought to understand the experiences of surgical residents and faculty with treating culturally diverse patients, and identify recommendations for establishing and implementing structured cultural competency training. Summary background data: Cultural competency training for medical professionals could reduce healthcare disparities, yet is currently not a standard part of surgical residency training. Few studies have explored the perspectives of surgical residents and faculty on the skills needed to provide cross-cultural care. Study design: A purposeful sample of surgical residents and faculty from 4 academic institutions was recruited for semistructured qualitative interviews. We developed an in-depth interview guide and performed interviews to thematic saturation. Interviews were audio-recorded, transcribed, and analyzed using grounded theory methodology. Results: We interviewed 16 attending surgeons and 15 surgical residents. Participant demographics were: male (51.6%), White (58.1%), Black (9.7%), Asian (22.5%), and Hispanic (9.7%). Four main themes emerged from the data: 1) aspects of culture that can inform patient care; 2) specific cultural challenges related to surgical care, including informed consent, pain management, difficult diagnoses and refusal of treatment, emergency situations, and end-of-life issues; 3) need for culturally competent care in surgery to navigate cultural differences; 4) perceived challenges and facilitators to incorporating cultural competency into the current training paradigm. Conclusions: Surgeons identified the need to provide better cross-cultural care and proposed tenets for training. Based on these findings, we suggest the development and dissemination of a cultural dexterity training program that will provide surgeons with specific knowledge and skills to care for patients from diverse sociocultural background

Effect of an equal-access military health system on racial disparities in colorectal cancer screening

Background: Racial disparities in colorectal cancer (CRC) screening are frequently attributed to variations in insurance status. The objective of this study was to ascertain whether universal insurance would lead to more equitable utilization of CRC screening for black patients in comparison with white patients.Methods: Claims data from TRICARE (insurance coverage for active, reserve, and retired members of the US Armed Services and their dependents) for 2007-2010 were queried for adults aged 50 years in 2007, and they were followed forward in time for 4 years (ages, 50-53 years) to identify their first lower endoscopy and/or fecal occult blood test (FOBT). Variations in CRC screening were compared with descriptive statistics and multivariate logistic regression.Results: Among the 24,944 patients studied, 69.2% were white, 20.3% were black, 4.9% were Asian, and 5.6% were other. Overall, 54.0% received any screening: 83.7% received endoscopy, and 16.3% received FOBT alone. Compared with whites, black patients had higher screening rates (56.5%) and had 20% higher risk-adjusted odds of being screened (95% confidence interval [CI], 1.11-1.29). Asian patients had a likelihood of screening similar to that of white patients (odds ratio [OR], 1.06; 95% CI, 0.92-1.23). Females (OR, 1.20; 95% CI, 1.10-1.33), active-duty personnel (OR, 1.15; 95% CI, 1.06-1.25), and officers (OR, 1.28; 95% CI, 1.18-1.37) were also more likely to be screened.Conclusion: Within an equal-access, universal health care system, black patients had higher rates of CRC screening in comparison with prior reports and even in comparison with white patients within the population. These findings highlight the need to understand and develop meaningful approaches for promoting more equitable access to preventative care. Moreover, equal-access, universal health insurance for both the military and civilian populations can be presumed to improve access for underserved minorities

Effect of an equal‐access military health system on racial disparities in colorectal cancer screening

Background: Racial disparities in colorectal cancer (CRC) screening are frequently attributed to variations in insurance status. The objective of this study was to ascertain whether universal insurance would lead to more equitable utilization of CRC screening for black patients in comparison with white patients.Methods: Claims data from TRICARE (insurance coverage for active, reserve, and retired members of the US Armed Services and their dependents) for 2007-2010 were queried for adults aged 50 years in 2007, and they were followed forward in time for 4 years (ages, 50-53 years) to identify their first lower endoscopy and/or fecal occult blood test (FOBT). Variations in CRC screening were compared with descriptive statistics and multivariate logistic regression.Results: Among the 24,944 patients studied, 69.2% were white, 20.3% were black, 4.9% were Asian, and 5.6% were other. Overall, 54.0% received any screening: 83.7% received endoscopy, and 16.3% received FOBT alone. Compared with whites, black patients had higher screening rates (56.5%) and had 20% higher risk-adjusted odds of being screened (95% confidence interval [CI], 1.11-1.29). Asian patients had a likelihood of screening similar to that of white patients (odds ratio [OR], 1.06; 95% CI, 0.92-1.23). Females (OR, 1.20; 95% CI, 1.10-1.33), active-duty personnel (OR, 1.15; 95% CI, 1.06-1.25), and officers (OR, 1.28; 95% CI, 1.18-1.37) were also more likely to be screened.Conclusion: Within an equal-access, universal health care system, black patients had higher rates of CRC screening in comparison with prior reports and even in comparison with white patients within the population. These findings highlight the need to understand and develop meaningful approaches for promoting more equitable access to preventative care. Moreover, equal-access, universal health insurance for both the military and civilian populations can be presumed to improve access for underserved minorities

From understanding to action: Interventions for surgical disparities

Background: Health care disparities are a well-documented phenomenon. Despite the development and implementation of multiple interventions, disparities in surgery have proven persistent. Thought to arise from a combination of patient, provider, and system-level factors, the objective of this study was to identify what is currently known about factors that influence surgical disparities and elucidate possible interventions to address them across four intervention-based themes: (1) condition-specific targeted interventions; (2) increased reliance on quantitative factors; (3) doctor-patient communication; and (4) cultural humility. Data sources: Articles were abstracted from PubMed, EMBASE, and the Cochrane Library using controlled keyword vocabulary. Conclusions: There are various forms of interventions to address surgical disparities, spanning knowledge from disparate fields. Promising efforts have emerged towards the successful alleviation of disparities. In order to move the field of surgery from understanding of disparities towards actions to mitigate them, continued development of meaningful quality improvement initiatives are neede

Surgeons\u27 Perceptions Toward Providing Care for Diverse Patients: The Need for Cultural Dexterity Training

OBJECTIVE: We sought to understand the experiences of surgical residents and faculty with treating culturally diverse patients, and identify recommendations for establishing and implementing structured cultural competency training. SUMMARY BACKGROUND DATA: Cultural competency training for medical professionals could reduce healthcare disparities, yet is currently not a standard part of surgical residency training. Few studies have explored the perspectives of surgical residents and faculty on the skills needed to provide cross-cultural care. STUDY DESIGN: A purposeful sample of surgical residents and faculty from 4 academic institutions was recruited for semistructured qualitative interviews. We developed an in-depth interview guide and performed interviews to thematic saturation. Interviews were audio-recorded, transcribed, and analyzed using grounded theory methodology. RESULTS: We interviewed 16 attending surgeons and 15 surgical residents. Participant demographics were: male (51.6%), White (58.1%), Black (9.7%), Asian (22.5%), and Hispanic (9.7%). Four main themes emerged from the data: 1) aspects of culture that can inform patient care; 2) specific cultural challenges related to surgical care, including informed consent, pain management, difficult diagnoses and refusal of treatment, emergency situations, and end-of-life issues; 3) need for culturally competent care in surgery to navigate cultural differences; 4) perceived challenges and facilitators to incorporating cultural competency into the current training paradigm. CONCLUSIONS: Surgeons identified the need to provide better cross-cultural care and proposed tenets for training. Based on these findings, we suggest the development and dissemination of a cultural dexterity training program that will provide surgeons with specific knowledge and skills to care for patients from diverse sociocultural backgrounds