American journal of surgery最新文献

Background: Access to schedules, protocols, and learning materials needs to be convenient and fast. Smartphones have become the default pathway for information access. The purpose of this study was to understand the impact of a smartphone application (app) on residency workflow and education.

Methods: After app development, a survey was conducted before and after implementation using Likert scales.Student's t-test was used for analysis.

Results: Pre-app, 76 ​% of faculty did not know the resident on call compared to 50 ​% post implementation (p ​< ​0.01). Pre-app, management algorithms required internet search; post-app no searching was required (p ​< ​0.05). Post-app, a printed call schedule became unnecessary and hospital operator calls decreased from daily to occasionally for residents and almost never for faculty (p ​< ​0.01).

Conclusions: A smartphone application has proven to be beneficial for consolidating resources and workflow to improve resident training and patient care.

Background: Reported outcomes after appendectomy during pregnancy remain inconclusive, and the risk for preterm delivery is not necessarily procedure-related.

Methods: This retrospective cohort study included 185 pregnant women who underwent appendectomy during pregnancy and gave birth between 2005 and 2022, compared using a 3:1 ratio to 555 parturients who did not undergo surgery. clinical, obstetrical and neonatal outcomes were analyzed.

Results: Laparoscopic appendectomy was the most common procedure (117/185; 63.2 ​%) whereas 68/185 (36.8 ​%) had open appendectomy. Pathological findings revealed that 141/185 cases (76.2 ​%) had an inflamed appendix, while 44/185 (23.8 ​%) were classified as having a "white appendix" (negative appendectomy). Preterm delivery occurred more frequently in the appendectomy group [22/185 (11.9 ​%) vs 30/555 (5.4 ​%), p ​= ​0.003] with even higher incidence in negative appendectomies compared to inflamed appendix cases [9/44 (20.5 ​%) vs 13/141 (9.2 ​%), p ​= ​0.044]. Multivariate analysis identified appendectomy (but not an inflamed appendix) as the sole significant risk factor for preterm birth (odds ratio 2.3, CI 1.26-4.15, p ​= ​0.006).

Conclusion: Preterm delivery correlates with negative appendectomies. Careful assessment is essential to avoid unnecessary surgical interventions during pregnancy.

Background: The National Comprehensive Cancer Care Network (NCCN) provides recommendations for patients with colorectal cancer. Concordance with evidence-based guidelines improves outcomes. Our objectives were to 1) examine rates of guideline non-concordance in a large vertically integrated health system; 2) examine factors associated with non-concordant care, and 3) identify geographical patterns of non-concordant care.

Methods: Colorectal cancer patients were identified from a single-state 16 hospital health-system cancer registry diagnosed between 2011 and 2021. We defined major (MAJ) and minor (MIN) quality indicators of guideline-concordance based on NCCN guidelines. Regression methods were used to identify predictors of major quality criteria non-concordance. County-level mapping was used to identify geographical locations of the highest rates of non-concordance.

Results: Overall, 2324 patients with colon and rectal cancer were analyzed. There was a complete guideline concordance (an absence of guideline non-concordance) rate of 24.7​% (n ​= ​573), MIN only guideline non-concordance rate of 63.3​% (n ​= ​1471), and MAJ non-concordance rate of 12.4​% (n ​= ​280). Predictors of MAJ non-concordance for colon cancer were stage, >1 Charleson-Deyo Score, >60 days from diagnosis to treatment, and >1 hospital network used for care. Predictors of MAJ non-concordance for rectal cancer were >60 days from diagnosis to treatment, and >1 facility used for care. Marion county had the highest rates of non-concordance for colon and rectal cancer.

Conclusion: The majority of colon and rectal cancer patients in a large health system received guideline concordant major quality indicators, however 12​% of patients do not. An identifiable geographical location with the highest rates of non-concordance and its associated factors serves as a target for future quality improvement.

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) may benefit patients with severe subdiaphragmatic traumatic hemorrhage. This study compares outcomes in patients with penetrating abdominal vascular injury treated with REBOA versus those managed without REBOA.

Methods: Using the Trauma Quality Improvement Program (TQIP) database, we identified adult patients with penetrating abdominal vascular injury from 2017 to 2022. Propensity scores matched REBOA patients 1:3 with non-REBOA patients. The primary outcome was in-hospital mortality, with secondary outcomes including 24-h mortality, transfusion needs, and complications such as acute kidney injury (AKI), deep vein thrombosis (DVT), pulmonary embolism (PE), lower extremity compartment syndrome, fasciotomy, amputation, and femoral artery repair.

Results: Two hundred ninety-three REBOA patients were matched with 879 non-REBOA patients. REBOA patients had higher in-hospital mortality (46.8 ​% vs 36.3 ​%, p ​= ​0.002), packed-red blood cell (PRBC) transfusion requirements within 4 ​h (median 15.3 vs 8.2, p ​< ​0.001), AKI (8.5 ​% vs 4.7 ​%, p ​= ​0.013), fasciotomy (6.5 ​% vs 3.6 ​%, p ​= ​0.039), amputation (3.4 ​% vs 1.4 ​%, p ​= ​0.025), and femoral artery repair (3.4 ​% vs 0.6 ​%, p ​< ​0.001). In a subgroup analysis of patients without severe extra-abdominal injuries, REBOA was associated with higher in-hospital mortality (49.7 ​% vs. 38.2 ​%, p ​= ​0.013) and increased packed red blood cell (PRBC) transfusion requirements (median 14.1 vs. 8.3 units, p ​< ​0.001).

Conclusions: In penetrating abdominal vascular injuries, REBOA was associated with worse outcomes.

Introduction: Trauma team performance, measured by the non-technical skills scale T-NOTECHS, has been shown to impact patient outcomes. We assess how personnel movements affect non-technical skills and time of resuscitation(TOR) using trauma video review.

Methods: A prospective study of blunt and/or penetrating trauma activations recorded between May and November 2023 ​at a Level-I trauma center. Regressions controlling for confounders were used to measure the association between foot traffic and the outcomes of interest¹: TOR² T-NOTECHS score(Smith et al., 2015; Mackenzie et al., 2007; Maiga et al., 2024; Vella et al., 2024; Pucher et al., 2014; Dumas et al., 2020; Succar et al., 2024; Steinemann et al., 2012; Andersson et al., 2012; Conrad et al., 2010; Lies and Zhang, 2015) .5-155-15 RESULTS: We identified 77 trauma activations, with 40 ​%(n ​= ​32/77) penetrating injuries. There was a median of 17[14-18] individuals at the start of trauma activations. During resuscitations, individuals entered the room a median of 12[8-18] times and exited the room 17[11-22] times. The median TOR was 8[6-10] min and the median T-NOTECHS was 7[6-8]. Regression analysis showed foot traffic was independently associated with increased TOR(β 0.34, p-value <0.01) and worse total T-NOTECHS score(β 0.06, p ​< ​0.01).

Conclusions: Higher foot traffic is associated with poorer team performance and delays in resuscitation. Future directions should further explore environmental and personal factors that may impede performance metrics.

Background: Pregnant trauma patients present unique challenges in terms of assessment and management. This study assesses the impact of traumatic injuries on pregnant patients using a national trauma database.

Methods: ACS-TQIP (2020-2021) identified traumatically injured females aged ≥15 and ​≤ ​55. Propensity score matching compared pregnant and not-pregnant patients. Primary outcome was mortality, with secondary outcomes including length of stay (LOS), emergency department and discharge disposition, interventions, and complications.

Results: Of 947,000 traumatically injured females, 8421 (0.9 ​%) were pregnant. Pregnant patients (6.0 ​%) sustained firearm injuries more than not-pregnant patients (5.4 ​%) (p ​= ​0.02). Pregnant patients had more severe thoracic (47.2%vs.9.4 ​%) and abdominal injuries (7.1%vs.4.8 ​%) compared to not-pregnant patients (p ​< ​0.001). Among pregnant patients, 5.6 ​% had preterm labor, 2.6 ​% had cesarean sections, and 1.9 ​% had abortions. After matching, there was no significant difference in mortality between both groups (p ​= ​0.40). Pregnant patients had longer ICU LOS (p ​< ​0.05) and higher rates of unplanned return to ICU (p ​< ​0.05).

Conclusions: Pregnant patients are more often victims of firearm violence, sustaining critical thoracic and abdominal injuries. These injuries demand increased interventions, introduce complications, and can be fatal.

Introduction: Patients with rectal cancer face a potentially life-limiting disease with multi-modal treatment options conferring substantial symptom burdens. Treatment decisions frequently require trade-offs and input from a multidisciplinary team: ideal cases for shared decision-making. Using qualitative analysis, we characterized the content of communication between surgeons and patients who have rectal cancer.

Methods: We performed secondary analysis of audio-recorded clinic visits of patients with rectal cancer (n ​= ​18) with colorectal surgeons (n ​= ​8) at 5 academic centers. Four coders used inductive content analysis with an analytical emphasis on communication about decision-making.

Results: Surgeons focused on communicating technical details of potential treatment pathways. Patients sought information around prognosis, functional changes, long-term recovery, and next steps. Surgeons laid groundwork for shared decision-making; patient goals were not routinely clarified. Decisions were typically deferred due to uncertainty and missing information needed to determine appropriate treatment options.

Conclusions: Our findings suggest avenues for surgeons to enhance communication around rectal cancer decision-making: acknowledging uncertainty and providing concrete information when able, focusing on topics such as prognosis, tradeoffs, and long-term recovery, and clarifying patient preferences.

Introduction: This study aims to assess various models of psychological debriefing, their benefits, and the impact of their implementation on medical trainees & healthcare professionals' stress management skills, mental well-being, and clinical performance.

Methods: This review queried PubMed, ProQuest, Web of Science, and Google Scholar databases for articles regarding psychological debriefing in medical education published through May 2024. Included studies that assessed the utilization, implementation, and effectiveness of various psychological debriefing models in the hospital setting among nursing staff, medical trainees, and attending physicians. Outcomes evaluated were successful debriefing models, associated benefits, and attendees' attitudes toward implementation.

Results: Sixteen studies were included. In all psychological debriefing models, attendees had improved coping skills following a challenging clinical scenario and supported the future use of these sessions. However, several barriers to the success of these sessions like untrained facilitators and insufficient time devoted have been noted.

Conclusion: Psychological debriefing sessions assisted attendees cope with stressful situations, improved self-confidence, and advocate for themselves. Different models of psychological debriefing can be implemented depending on the resources of each facility.