Featured Articles in Sep 2019

HIV Infection: Its Impact on Patients with Appendicitis in Botswana

 

Author list 

Alemayehu Ginbo Bedada, Marvin Hsiao, Georges Azzie

 

Abstract

Background

To compare the presentation, management, and outcome of HIV-positive patients with appendicitis to those of HIV-negative patients with appendicitis. Summary Background Data: The literature is limited regarding the impact of HIV infection on patients with appendicitis.

 

Methods

A retrospective review of patients with appendicitis and known HIV status admitted to Princess Marina Hospital, Gaborone, Botswana, aged 13 years and greater was performed from January 2013 to December 2015. Data on patient demographics, presentation, laboratory findings, management, and outcomes were analyzed.

 

Results

A total of 295 patients with appendicitis and known HIV status were identified, of which 119 (40.3%) were HIV positive. The median [IQR] ages for HIV-positive and HIV-negative patients were 34 [29–42] and 26 [20–33] years, respectively. The male-to-female ratio for the same two groups was 0.8:1 and 1.4:1, respectively. Presenting symptoms, signs, and white blood cell count were similar in both groups. HIV-positive patients had significantly higher overall (4.2 vs. 0.0%, p = 0.010) and postoperative (4.4 vs. 0.0%, p = 0.024) mortality rates. There was no significant difference in the total complication rate between HIV-positive and HIV-negative patients (13.2 vs. 7.9%, p = 0.192). Compared to HIV-positive patients with a CD4 count ≥200, patients with a CD4 count <200 have a significantly higher postoperative mortality rate (17.6 vs. 1.4%, p = 0.023) and a trend toward a higher total postoperative complication rate (31.3 vs. 10.8%, p = 0.054).

 

Conclusion

Within our setting, HIV infection, particularly with a CD4 <200, was correlated with significantly higher mortality in patients with acute appendicitis.

 

URL https://rdcu.be/bQczA


Has Symptom-Based Admission Replaced Diagnosis in the Emergency Department?

 

Author list 

Peter I. Kenner, Cecilia C. H. Wee, Dieter G. Weber

 

Abstract

Background

Classical medical teaching has made a clear distinction between signs and symptoms, and diagnosis. However, at the time of ward admission, a diagnosis may remain unclear. We propose administrative pressures during the admission process may have reduced the ability for pathological diagnosis. This may result in increased hospitalisation for investigation of signs and symptoms, rather than for treatment of clear diagnoses. We sought to further clarify this hypothesis and investigate changes in the nature of admissions during the last two decades in an adult emergency general surgery service.

 

Methods

A retrospective analysis of emergency general surgical admissions during four six-month time periods, between 2000 and 2018, was conducted. The six-month periods were spaced evenly during the 18-year study. Demographic information, emergency department length of stay, incidence of a pathological diagnosis on ward admission and accuracy of admission diagnosis were analysed.

 

Results

2763 patients were admitted in the four six-month time periods. A significant reduction in number of patients admitted with a pathological diagnosis was noted between the 2012 and 2018 study periods (p < 0.05), with 21.2% of patients admitted in 2018 for investigation of signs and symptoms. The incidence of an accurate admission diagnosis (as assessed by the discharge diagnosis) ranged from 62.3 to 63.6% and did not differ significantly by year.

 

Conclusion

Between 2012 and 2018, there was a significant increase in the number of emergency general surgical patients admitted for investigation of signs and symptoms. However, accuracy of admission diagnosis was unchanged during the study period.

 

URL https://rdcu.be/bQczW

 

 

 


Association of Surgical Volume and Quality Management in Thyroid Surgery

 

 

Author list 

Dominik A. Jakob, Philipp Riss, Christian Scheuba, Michael Hermann, Corina Kim-Fuchs, Christian A. Seiler, Martin A. Walter, Reto M. Kaderli

 

Abstract

Background

High-volume caseload in thyroid surgery is associated with lower postoperative complication rates resulting to better outcomes. The aim of the present study was to investigate the correlation of the departments’ annual number of thyroid surgeries on the adherence to consensus guidelines and on the implementation of measures for quality assurance.

 

Methods

In 2016, we sent an anonymous electronic survey with questions related to the perioperative management in thyroid surgery to all directors of departments in operative medicine in Switzerland and Austria. We compared the pre- and postoperative management with the summarized recommendations of the four most frequently used consensus guidelines. Analogously, we analyzed the implementation of six measures for quality assurance related to thyroid surgery for each participating department. Using logistic regression analysis, we evaluated the correlation of number of guidelines respected and number of measures for quality assurance with the departments’ annual number of surgeries performed. Furthermore, we evaluated the number of departments providing thyroid cancer surgery and their experience in neck dissection.

 

Results

The management corresponded in 64.0% to the summarized recommendations. Adherence to the summarized recommendations and implementation of measures for quality assurance were significantly more likely with increasing numbers of surgeries performed (p = 0.049 and p < 0.001). Ninety-two departments provided thyroid cancer surgery, whereas 12/92 (13.0%) were not able to perform central and/or lateral neck dissection.

 

Conclusion

Consensus guidelines are insufficiently implemented within thyroid surgery, and quality management is associated with surgical volume.

 

URL https://rdcu.be/bQcBe

 


Bilateral Risk-Reducing Mastectomies with Implant-Based Reconstructions Followed Long Term

 

Author list 

Karin Isaksson, Brita Arver, Matteo Bottai, Andreas Pettersson, Marie Wickman, Kerstin Sandelin

 

Abstract

Background

Bilateral risk-reducing mastectomy (BRRM) is the most effective method to prevent breast cancer in genetically predisposed women and is often performed concomitantly with breast reconstruction. The reconstruction time varies and corrective surgeries are common.

 

Methods

This study evaluated 185 consecutive cases of BRRM and immediate breast reconstruction with implants with regard to surgical outcome and resource consumption. With an 18-year observation period, it was possible to compare permanent expander implants (PEIs) with permanent fixed volume implants (PIs).

 

Results

A minimum follow-up of 2 years for all participants but one was achieved. Seventy-five percent (n = 138) of the women received PEI and 25% (n = 47) PI. In a multivariate analysis including age, BMI (<25, ≥25), smoking (yes, no), implant type (PEI, PI), incision technique, operation time and specimen weight <350 g, ≥350 g), only BMI ≥25 was associated with an increased risk of an early complication (OR 7.1, 95% CI 2.44–20.4). As expected, there was a significant difference in median reconstruction time between PEI and PI (12.4 vs. 1.0 months, p < 0.001). The cumulative reoperation-free 2-year survival was significantly higher in the PI than in the PEI group (81% vs. 26%, p < 0.001).

 

Conclusion

Implant-based reconstruction remains a valid option after BRRM in high-risk women. Whenever possible (low BMI and small breast volume without severe ptosis), permanent fixed volume implants can be safely recommended and are resource saving in comparison with permanent expander implants.

 

URL https://rdcu.be/bQcBp

 

 


Chronic Postoperative Opioid Use: A Systematic Review

 

Author list 

Ashley Hinther, Omar Abdel-Rahman, Winson Y. Cheung, May Lynn Quan, Joseph C. Dort

 

Abstract

Background

There are a number of studies in the literature that describe the prevalence, causes, and factors associated with chronic postoperative opioid use, but there is a lack of synthesis of the literature to guide clinicians in optimally managing postoperative pain while avoiding opioid dependence. Thus, the goal of this study was to perform a systematic review of the literature to investigate the prevalence of chronic postoperative opioid use and the associated risk factors.

 

Materials and methods

A systematic search was performed using Ovid Medline and Embase according to PRISMA guidelines. Data were collected on the following outcomes of interest: prevalence of opioid use at 3, 6, and 12 months postoperatively, and risk factors associated with chronic postoperative opioid use.

 

Results

Forty-three articles were included in the final analysis. The mean prevalence of chronic postoperative opioid use in all populations at 3, 6, and 12 months postoperatively was 30.5%, 25.6%, and 25.2%, respectively. The prevalence of patients who developed chronic opioid use at 3, 6, and 12 months postoperatively was 10.4%, 8.5%, and 9.8%, respectively. Forty of the articles analyzed risk factors associated with chronic postoperative opioid use. The most common associated risk factor identified was preoperative opioid use with 27 articles demonstrating a significant association with chronic postoperative opioid use.

 

Discussion

The current opioid crisis is in part secondary to the prevalence of chronic opioid use following surgery. This study identified associated risk factors with chronic postoperative opioid use, which may help identify patients at risk for developing chronic postoperative opioid use.

 

URL https://rdcu.be/bQcAm

 

 

 


A Systematic Review on the Synoptic Operative Report Versus the Narrative Operative Report in Surgery

 

Author list 

Özgür Eryigit, Floyd W. van de Graaf, Johan F. Lange

 

Abstract

Background

Proper documentation is an essential part of patient safety and quality of care in the surgical field. Surgical procedures are traditionally documented in narrative operative reports which are subjective by nature and often lack essential information. This systematic review will analyze the added value of the newly emerged synoptic reporting technique in the surgical setting.

 

Methods

A systematic review was conducted to compare the completeness and the user-friendliness of the synoptic operative report to the narrative operative report. A literature search was performed in EMBASE, Ovid MEDLINE, Web of Science, Cochrane CENTRAL, and Google Scholar for studies published up to April 6, 2018. The Newcastle–Ottawa Scale was utilized for the risk of bias assessment of the included articles. PROSPERO registration number was: CRD42018093770.

 

Results

Overall and subsection completion of the operative report was higher in the synoptic operative report. The time until completion of the operative report and the data extraction time were shorter in the synoptic report. One exception was the specific details section concerning the operative procedure, as this was generally reported more frequently in the narrative report. The use of mandatory fields in the synoptic report resulted in more completely reported operative outcomes with completion percentages close to 100%.

 

Conclusions

The synoptic operative report generally demonstrated a higher completion rate and a much lower time until completion compared to the traditional narrative operative report. A hybrid approach to the synoptic operative report will potentially yield better completion rates and higher physician satisfaction.

 

URL https://rdcu.be/bQcAc

 

 


 

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