1. The document discusses various sources of data for benchmarking surgical outcomes, including public reporting programs, public use administrative databases, and clinical registries. It notes limitations of using administrative data including problems with accuracy, completeness, and clinical precision of coding.
2. Clinical registries like the National Surgical Quality Improvement Program (NSQIP) and the Society of Thoracic Surgeons database are described as better sources of benchmarking data as they provide risk-adjusted outcomes while protecting individual hospital and surgeon confidentiality.
3. Limitations of all surgical benchmarking sources include small sample sizes, lack of generalizability between databases, and lack of external auditing to ensure accuracy and completeness of submitted data.
This document summarizes an article about volunteer surgeons providing care to wounded soldiers in Iraq and Afghanistan. It discusses the senior visiting surgeon program established by the American College of Surgeons that allows surgeons to volunteer their time. The volunteer rotation described involved caring for patients at Landstuhl Regional Medical Center in Germany as part of the complex medical evacuation process bringing wounded soldiers from war zones to the United States for further treatment and recovery.
1) The document discusses the management of pregnant patients requiring surgery or experiencing trauma. It notes special considerations for pregnant patients, including physiological changes and the need to care for both mother and fetus.
2) In trauma situations, the initial focus is stabilizing the mother to benefit both patients. Penetrating injuries often directly threaten the fetus while blunt trauma poses less direct risk, usually resulting in placental abruption or preterm labor.
3) Surgical decisions must weigh fetal viability against maternal stability, with non-urgent cases delayed if possible. Monitoring includes fetal heart monitoring and ultrasound to detect issues like abruption.
This document summarizes key points about surgical treatment of early rectal cancer and care of elderly surgical patients. It discusses that radical resection for early rectal cancer achieves excellent local control but has risks, while local excision may be preferable but has a higher local recurrence rate. Adjuvant therapy after local excision may help address this. It also notes that the elderly population is growing and physiologic changes with aging, like cardiac function decline, must be considered in surgical planning and risk assessment for elderly patients. Functional status is more important than age alone.
A C S0105 Postoperative Management Of The Hospitalized Patientmedbookonline
This document discusses postoperative management of surgical patients. It describes the different levels of postoperative care including same-day surgery, the surgical floor, telemetry ward, and intensive care unit. Factors determining a patient's disposition include their preoperative health, procedure performed, and postoperative clinical status. The document also discusses common postoperative orders related to tubes, drains, oxygen therapy, and wound care to guide nursing staff.
1) The document discusses the case of a 38-year-old Hindu male patient from Visakhapatnam presenting with a 2x1cm ulcer on the right lateral border of his tongue.
2) It describes his medical history including a history of ill-fitting dentures and dying during an MRI evaluation due to an allergic reaction to contrast.
3) The oncologist discusses potential treatment options with the patient including radiation therapy to preserve his tongue and avoid surgery, as well as interviews with ENT specialists and a dentist.
Protons Compared to Photons in Pediatric PatientsDanielle Buswell
Proton radiation therapy may reduce risks of late side effects compared to photon therapy for pediatric patients with medulloblastoma. Proton therapy decreases exit dose which can cause toxicities like heart problems, hearing loss, and neurocognitive deficits. Studies found proton therapy resulted in fewer neurocognitive deficits and lower risks of secondary cancers. While proton therapy may have better outcomes, its higher cost must be considered compared to photon therapy for each patient.
The document provides guidelines for the perioperative management of patients with obstructive sleep apnea (OSA). It defines OSA and discusses its prevalence. The guidelines were developed through a rigorous process including a literature review and input from experts. The guidelines aim to improve perioperative care and reduce risks for patients with OSA undergoing procedures. Recommendations are made regarding preoperative assessment and risk stratification of patients, as well as postoperative monitoring and care.
Duke OHNS Lumbar Drain AN Poster 44x44 vfinalMatthew Crowson
- The study examines whether the pre-operative use of a lumbar drain reduces post-operative cerebrospinal fluid leaks in patients undergoing acoustic neuroma resection.
- 282 patients were included in the study, with 220 receiving a pre-operative lumbar drain and 62 not receiving one. No significant difference was found in CSF leak rates between the two groups.
- While CSF leaks are a common complication, the routine use of pre-operative lumbar drains is not recommended due to the 5.3% complication rate associated with lumbar drain use and no evidence that it decreases CSF leak rates.
This document summarizes an article about volunteer surgeons providing care to wounded soldiers in Iraq and Afghanistan. It discusses the senior visiting surgeon program established by the American College of Surgeons that allows surgeons to volunteer their time. The volunteer rotation described involved caring for patients at Landstuhl Regional Medical Center in Germany as part of the complex medical evacuation process bringing wounded soldiers from war zones to the United States for further treatment and recovery.
1) The document discusses the management of pregnant patients requiring surgery or experiencing trauma. It notes special considerations for pregnant patients, including physiological changes and the need to care for both mother and fetus.
2) In trauma situations, the initial focus is stabilizing the mother to benefit both patients. Penetrating injuries often directly threaten the fetus while blunt trauma poses less direct risk, usually resulting in placental abruption or preterm labor.
3) Surgical decisions must weigh fetal viability against maternal stability, with non-urgent cases delayed if possible. Monitoring includes fetal heart monitoring and ultrasound to detect issues like abruption.
This document summarizes key points about surgical treatment of early rectal cancer and care of elderly surgical patients. It discusses that radical resection for early rectal cancer achieves excellent local control but has risks, while local excision may be preferable but has a higher local recurrence rate. Adjuvant therapy after local excision may help address this. It also notes that the elderly population is growing and physiologic changes with aging, like cardiac function decline, must be considered in surgical planning and risk assessment for elderly patients. Functional status is more important than age alone.
A C S0105 Postoperative Management Of The Hospitalized Patientmedbookonline
This document discusses postoperative management of surgical patients. It describes the different levels of postoperative care including same-day surgery, the surgical floor, telemetry ward, and intensive care unit. Factors determining a patient's disposition include their preoperative health, procedure performed, and postoperative clinical status. The document also discusses common postoperative orders related to tubes, drains, oxygen therapy, and wound care to guide nursing staff.
1) The document discusses the case of a 38-year-old Hindu male patient from Visakhapatnam presenting with a 2x1cm ulcer on the right lateral border of his tongue.
2) It describes his medical history including a history of ill-fitting dentures and dying during an MRI evaluation due to an allergic reaction to contrast.
3) The oncologist discusses potential treatment options with the patient including radiation therapy to preserve his tongue and avoid surgery, as well as interviews with ENT specialists and a dentist.
Protons Compared to Photons in Pediatric PatientsDanielle Buswell
Proton radiation therapy may reduce risks of late side effects compared to photon therapy for pediatric patients with medulloblastoma. Proton therapy decreases exit dose which can cause toxicities like heart problems, hearing loss, and neurocognitive deficits. Studies found proton therapy resulted in fewer neurocognitive deficits and lower risks of secondary cancers. While proton therapy may have better outcomes, its higher cost must be considered compared to photon therapy for each patient.
The document provides guidelines for the perioperative management of patients with obstructive sleep apnea (OSA). It defines OSA and discusses its prevalence. The guidelines were developed through a rigorous process including a literature review and input from experts. The guidelines aim to improve perioperative care and reduce risks for patients with OSA undergoing procedures. Recommendations are made regarding preoperative assessment and risk stratification of patients, as well as postoperative monitoring and care.
Duke OHNS Lumbar Drain AN Poster 44x44 vfinalMatthew Crowson
- The study examines whether the pre-operative use of a lumbar drain reduces post-operative cerebrospinal fluid leaks in patients undergoing acoustic neuroma resection.
- 282 patients were included in the study, with 220 receiving a pre-operative lumbar drain and 62 not receiving one. No significant difference was found in CSF leak rates between the two groups.
- While CSF leaks are a common complication, the routine use of pre-operative lumbar drains is not recommended due to the 5.3% complication rate associated with lumbar drain use and no evidence that it decreases CSF leak rates.
Management of pediatric blunt renal trauma a systematic reviewskrentz
This systematic review examines current practices in managing pediatric blunt renal trauma conservatively. 32 studies met the criteria of including cases of high-grade renal injuries in children. The literature supports applying conservative management protocols including observation, percutaneous drainage, stenting, and angioembolization to high-grade pediatric renal trauma, with short and long-term outcomes generally being favorable.
This document summarizes information from various sources on several topics:
1) It provides guidelines from Monroe Carell Jr. Children's Hospital at Vanderbilt for levels of trauma activation, including criteria for level I and level II activations.
2) It discusses the management of pediatric blunt renal trauma, highlighting guidelines that include recommendations for ICU stay, bed rest, imaging and antibiotics based on injury grade.
3) It summarizes literature on non-powder firearm injuries in pediatrics, noting they are underrecognized as dangerous and can cause injuries similar to handguns.
This study evaluated outcomes of 28 patients with intracranial meningiomas treated with hypofractionated radiosurgery. Most tumors were treated with 22.5-30 Gy delivered in 5 fractions. With a mean follow up of 32.6 months, the local tumor control rate was 100% with only one instance of marginal progression. Symptoms improved or resolved in over 66% of patients who originally presented with symptoms. Side effects occurred in 4 patients but the permanent morbidity rate was low at 3.5%. Hypofractionated radiosurgery provided high tumor control with a low risk of side effects, even for large tumors greater than 9 cm3.
Treatment and outcomes_of_fingertip_injuries_at_a.17Zendy Cipriani
This study examined outcomes of 100 fingertip injuries treated at Bellevue Hospital between January and May 2011. 64% healed without surgery, 18% required surgery, and 18% were lost to follow up. Those requiring surgery tended to have larger defects, volar oblique injuries, exposed bone, and distal phalanx fractures. While treatment algorithms exist, the study found that many fingertip injuries can be treated nonoperatively to achieve good function and sensation and allow for earlier return to work.
Step-by-Step Stereotactic Radiotherapy Planning of Vestibular Schwannoma: A G...Kanhu Charan
This document provides a step-by-step guide to stereotactic radiotherapy planning for vestibular schwannoma. It describes the case of a 40-year-old male patient presenting with symptoms of tinnitus, dizziness, and facial twitching. Imaging including CT and MRI confirmed a right-sided vestibular schwannoma. The tumor was graded and treatment options were discussed. The patient was planned for fractionated stereotactic radiotherapy to a dose of 25Gy in 5 fractions based on guidelines. The planning process is then described in detail, including CT simulation, MRI protocol, contouring of targets and organs at risk, plan evaluation criteria, and subsequent treatment.
Adjuvant Radiation Therapy in Early Cervical Cancer - EvidencesDr. Malhar Patel
Radiation therapy is one of the main line of management of carcinoma cervix.
This presentation is regarding evidences of adjuvant radiation therapy (post operative) in case of early carcinoma cervix.
The American Society of General Surgeons (ASGS) supports the use of transoral fundoplication by trained surgeons as a treatment for chronic gastroesophageal reflux disease (GERD) in patients who do not get satisfactory relief from proton pump inhibitors or who wish to avoid lifelong medication dependence. The ASGS believes transoral fundoplication adheres to the same surgical principles as traditional fundoplication techniques by creating a full thickness wrap of the stomach around the esophagus. The ASGS position is supported by peer-reviewed literature demonstrating transoral fundoplication offers comparable results to open and laparoscopic surgery, with high patient satisfaction and relief of GERD symptoms.
The document summarizes three studies related to amputation prevention programs:
1) A retrospective analysis found that a comprehensive amputation prevention program at a community hospital decreased amputation rates from an average of 8.2% before the program to an average of 2.54% after, as more patients received diagnostic testing and interventions.
2) A treatment protocol for diabetic foot ulcers and Charcot deformities achieved successful limb salvage in 92% of patients through staged reconstruction and proper pre-operative vascular evaluation.
3) Implementing skin perfusion pressure (SPP) testing identified 80% of patients as having peripheral artery disease who had normal ankle-brachial indices, allowing for improved treatment and no major amputations
Cancer of Right Breast with Single-Liver MetastasisSimultaneous Treatment of ...Kanhu Charan
Cancer of Right Breast with Single-Liver Metastasis Simultaneous Treatment of Chest Wall with Radiotherapy for Carcinoma Breast and SBRT for Liver Lesion: Procedural
Details of the Complex Procedure
This study analyzed early postoperative complications in 145 adult patients who received total intravenous anesthesia (TIVA) with propofol and remifentanil for elective neurosurgery. The authors found:
1) The overall incidence of shivering was 30.3%, postoperative nausea and vomiting (PONV) was 16.6%, and postoperative hypertension (blood pressure over 25% of preoperative value) was 35.2%.
2) 51% of patients experienced at least one of these complications. Complication rates varied significantly between surgical groups.
3) The intracranial vascular surgery group had the highest rates of shivering (58.8%) and PONV (29.4
This document summarizes Georgia's trauma system and the need to improve it. It notes that Georgia currently has 18 trauma centers but should have 30 to adequately cover the state. The trauma death rate in Georgia is higher than the national average. In 2010, voters rejected an amendment that would have imposed a $10 fee to generate $80 million annually for trauma centers. The document outlines the different levels of trauma centers and the components and goals of Georgia's trauma system and five-year plan to improve emergency care access statewide.
The article discusses the development of a new lung cancer staging system by the International Association for the Study of Lung Cancer (IASLC). The IASLC created an international database of lung cancer patients and conducted extensive statistical analysis. Based on this work, the IASLC is recommending changes to the TNM descriptors and stage groupings for non-small cell lung cancer in the new 7th edition of the cancer staging manual. The recommendations are aimed to create a more robust staging system based on analysis of a large international patient population.
1) The study analyzed outcomes of 728 soft tissue sarcoma patients, 281 of whom underwent unplanned excisions prior to referral to specialty centers.
2) Patients who had unplanned excisions were found to have smaller and more superficial tumors on average.
3) After adjusting for factors like tumor grade and size, unplanned excisions were not found to provide any survival benefit compared to planned surgery, and resulted in more complex subsequent procedures.
4) The study concludes that while unplanned excisions do not seem to directly harm prognosis, they should still be avoided due to increased treatment complexity.
This document discusses limiting radiation exposure from diagnostic imaging procedures like CT scans. It provides context about radiation dosage terms and compares the effective radiation dose of different medical imaging exams. While medical imaging only accounts for around 50% of radiation exposure in the US, it may be responsible for about 1% of cancer cases. The document examines balancing radiation risks, which are higher for younger patients and females, with clinical benefits on a case-by-case basis using the ALARA principle to keep radiation as low as reasonably possible. It analyzes the risks and benefits of 4DCT for imaging hyperfunctional parathyroid glands as an example.
HRV in trauma patients during prehospital transportRachel Russo, MD
1) The study found that prehospital heart rate variability (HRV), specifically standard deviation of normal-to-normal R-R intervals (SDNN), predicted patients with a base excess ≤-6, those requiring life-saving procedures, and those classified as seriously injured better than routine trauma criteria or vital signs.
2) When used alone as a triage tool, SDNN had a sensitivity of 80%, specificity of 75%, and accuracy of 76% for predicting life-saving interventions, outperforming other prehospital measures.
3) Incorporating SDNN into trauma triage criteria models improved prediction of outcomes compared to models without SDNN, better discriminating patients who were seriously or minimally injured
Guideline for the Prevention of Surgical Site Infection, 2017RubenMariscal3
This guideline provides evidence-based recommendations for preventing surgical site infections (SSIs). Key recommendations include administering preoperative antimicrobial prophylaxis timed with surgery, maintaining normothermia and glycemic control in patients, and avoiding additional antimicrobial doses after surgery. The guideline is intended to improve patient safety by reducing preventable SSIs and incorporating strategies into surgical quality improvement programs. It is based on a systematic review of the literature evaluating various prevention practices and aims to advance the field by assessing areas deemed important by clinical experts.
Secondary Malignancy after Treatment of Prostate Cancer. Radical Prostatectom...asclepiuspdfs
Background: This study aims to determine whether the treatment of locally confined prostate cancer (PCa) with external radiotherapy (EBRT) increases the risk to develop secondary malignancies (SM) compared to radical prostatectomy (RPE). Materials and Methods: Data from patients who were treated curatively with RPE or EBRT from 2010 to 2018 and who did not have distant metastases, previous malignancy, or previous treatment with radiotherapy or chemotherapy at the time of diagnosis were reviewed to determine the incidence of SM over a median follow-up period of 47 months (range 12–96 months). Regression models were used to correlate the clinicopathological factors with the incidence of SM.
The Influence of Transurethral Resection of Bladder Tumor on Staging of Bladd...asclepiuspdfs
Introduction: Bladder cancer is common, expensive, and the number of cases rising with increased survival in the elderly population. Most centers do computed tomography (CT) scan at the point of investigation, and some will carry this out along with magnetic resonance imaging (MRI) scan to have better local staging once the diagnosis of invasive cancer is made. Any surgical procedure would have a likelihood of influencing local staging, and this is a common belief without any evidence. Methods: We have retrospectively analyzed our data to see where the truth lies. We have compared the final pathology of 236 radical cystectomy patients to the staging reports of 241 CT scans and 65 MRI scans. Results: We have ascertained accuracy, sensitivity, and specificity and whether they were influenced by the timing of the transurethral resection of bladder tumor (TURBT). There was no significant difference between CT and MRI and the timing of the TURBT. Conclusion: This is the first report in the literature outlining the influence of TURBT. We accept the limitation due to the retrospective nature, small sample size, and variability of the biology of bladder cancer.
This document discusses the approach towards re-irradiation of common cancers. It begins by noting that local recurrence after radiation therapy and second primary tumors in irradiated areas are challenges, though re-irradiation can provide durable disease control in some cases. It then discusses key considerations for re-irradiation of head and neck cancers, gliomas, gynecological cancers, bone metastases, and brain metastases. Important factors include the initial radiation dose, interval since prior radiation, intent of re-irradiation, cumulative organ doses, and risk versus benefit. Advanced radiation techniques like IMRT can help minimize toxicity risks from re-irradiation. Careful patient selection and multidisciplinary evaluation are emphasized for meaningful survival benefits from re-
PSD is a leading recruitment firm that specializes in providing permanent and contract technology and business change resources to the asset management sector, including mid to senior level managers, project resources, business technologists, and technology specialists. They have 12 years of experience working with asset management, asset servicing, wealth management, hedge funds, software vendors, and consultancies. They recruit for positions including IT directors, heads of departments, programme managers, business analysts, and specialists with expertise in software products like DST, Charles River, and Simcorp as well as functional areas including client reporting, performance measurement, and trade processing. PSD offers comprehensive recruitment services including executive search, contract/interim placements, and advertised selection through a rigorous project
Management of pediatric blunt renal trauma a systematic reviewskrentz
This systematic review examines current practices in managing pediatric blunt renal trauma conservatively. 32 studies met the criteria of including cases of high-grade renal injuries in children. The literature supports applying conservative management protocols including observation, percutaneous drainage, stenting, and angioembolization to high-grade pediatric renal trauma, with short and long-term outcomes generally being favorable.
This document summarizes information from various sources on several topics:
1) It provides guidelines from Monroe Carell Jr. Children's Hospital at Vanderbilt for levels of trauma activation, including criteria for level I and level II activations.
2) It discusses the management of pediatric blunt renal trauma, highlighting guidelines that include recommendations for ICU stay, bed rest, imaging and antibiotics based on injury grade.
3) It summarizes literature on non-powder firearm injuries in pediatrics, noting they are underrecognized as dangerous and can cause injuries similar to handguns.
This study evaluated outcomes of 28 patients with intracranial meningiomas treated with hypofractionated radiosurgery. Most tumors were treated with 22.5-30 Gy delivered in 5 fractions. With a mean follow up of 32.6 months, the local tumor control rate was 100% with only one instance of marginal progression. Symptoms improved or resolved in over 66% of patients who originally presented with symptoms. Side effects occurred in 4 patients but the permanent morbidity rate was low at 3.5%. Hypofractionated radiosurgery provided high tumor control with a low risk of side effects, even for large tumors greater than 9 cm3.
Treatment and outcomes_of_fingertip_injuries_at_a.17Zendy Cipriani
This study examined outcomes of 100 fingertip injuries treated at Bellevue Hospital between January and May 2011. 64% healed without surgery, 18% required surgery, and 18% were lost to follow up. Those requiring surgery tended to have larger defects, volar oblique injuries, exposed bone, and distal phalanx fractures. While treatment algorithms exist, the study found that many fingertip injuries can be treated nonoperatively to achieve good function and sensation and allow for earlier return to work.
Step-by-Step Stereotactic Radiotherapy Planning of Vestibular Schwannoma: A G...Kanhu Charan
This document provides a step-by-step guide to stereotactic radiotherapy planning for vestibular schwannoma. It describes the case of a 40-year-old male patient presenting with symptoms of tinnitus, dizziness, and facial twitching. Imaging including CT and MRI confirmed a right-sided vestibular schwannoma. The tumor was graded and treatment options were discussed. The patient was planned for fractionated stereotactic radiotherapy to a dose of 25Gy in 5 fractions based on guidelines. The planning process is then described in detail, including CT simulation, MRI protocol, contouring of targets and organs at risk, plan evaluation criteria, and subsequent treatment.
Adjuvant Radiation Therapy in Early Cervical Cancer - EvidencesDr. Malhar Patel
Radiation therapy is one of the main line of management of carcinoma cervix.
This presentation is regarding evidences of adjuvant radiation therapy (post operative) in case of early carcinoma cervix.
The American Society of General Surgeons (ASGS) supports the use of transoral fundoplication by trained surgeons as a treatment for chronic gastroesophageal reflux disease (GERD) in patients who do not get satisfactory relief from proton pump inhibitors or who wish to avoid lifelong medication dependence. The ASGS believes transoral fundoplication adheres to the same surgical principles as traditional fundoplication techniques by creating a full thickness wrap of the stomach around the esophagus. The ASGS position is supported by peer-reviewed literature demonstrating transoral fundoplication offers comparable results to open and laparoscopic surgery, with high patient satisfaction and relief of GERD symptoms.
The document summarizes three studies related to amputation prevention programs:
1) A retrospective analysis found that a comprehensive amputation prevention program at a community hospital decreased amputation rates from an average of 8.2% before the program to an average of 2.54% after, as more patients received diagnostic testing and interventions.
2) A treatment protocol for diabetic foot ulcers and Charcot deformities achieved successful limb salvage in 92% of patients through staged reconstruction and proper pre-operative vascular evaluation.
3) Implementing skin perfusion pressure (SPP) testing identified 80% of patients as having peripheral artery disease who had normal ankle-brachial indices, allowing for improved treatment and no major amputations
Cancer of Right Breast with Single-Liver MetastasisSimultaneous Treatment of ...Kanhu Charan
Cancer of Right Breast with Single-Liver Metastasis Simultaneous Treatment of Chest Wall with Radiotherapy for Carcinoma Breast and SBRT for Liver Lesion: Procedural
Details of the Complex Procedure
This study analyzed early postoperative complications in 145 adult patients who received total intravenous anesthesia (TIVA) with propofol and remifentanil for elective neurosurgery. The authors found:
1) The overall incidence of shivering was 30.3%, postoperative nausea and vomiting (PONV) was 16.6%, and postoperative hypertension (blood pressure over 25% of preoperative value) was 35.2%.
2) 51% of patients experienced at least one of these complications. Complication rates varied significantly between surgical groups.
3) The intracranial vascular surgery group had the highest rates of shivering (58.8%) and PONV (29.4
This document summarizes Georgia's trauma system and the need to improve it. It notes that Georgia currently has 18 trauma centers but should have 30 to adequately cover the state. The trauma death rate in Georgia is higher than the national average. In 2010, voters rejected an amendment that would have imposed a $10 fee to generate $80 million annually for trauma centers. The document outlines the different levels of trauma centers and the components and goals of Georgia's trauma system and five-year plan to improve emergency care access statewide.
The article discusses the development of a new lung cancer staging system by the International Association for the Study of Lung Cancer (IASLC). The IASLC created an international database of lung cancer patients and conducted extensive statistical analysis. Based on this work, the IASLC is recommending changes to the TNM descriptors and stage groupings for non-small cell lung cancer in the new 7th edition of the cancer staging manual. The recommendations are aimed to create a more robust staging system based on analysis of a large international patient population.
1) The study analyzed outcomes of 728 soft tissue sarcoma patients, 281 of whom underwent unplanned excisions prior to referral to specialty centers.
2) Patients who had unplanned excisions were found to have smaller and more superficial tumors on average.
3) After adjusting for factors like tumor grade and size, unplanned excisions were not found to provide any survival benefit compared to planned surgery, and resulted in more complex subsequent procedures.
4) The study concludes that while unplanned excisions do not seem to directly harm prognosis, they should still be avoided due to increased treatment complexity.
This document discusses limiting radiation exposure from diagnostic imaging procedures like CT scans. It provides context about radiation dosage terms and compares the effective radiation dose of different medical imaging exams. While medical imaging only accounts for around 50% of radiation exposure in the US, it may be responsible for about 1% of cancer cases. The document examines balancing radiation risks, which are higher for younger patients and females, with clinical benefits on a case-by-case basis using the ALARA principle to keep radiation as low as reasonably possible. It analyzes the risks and benefits of 4DCT for imaging hyperfunctional parathyroid glands as an example.
HRV in trauma patients during prehospital transportRachel Russo, MD
1) The study found that prehospital heart rate variability (HRV), specifically standard deviation of normal-to-normal R-R intervals (SDNN), predicted patients with a base excess ≤-6, those requiring life-saving procedures, and those classified as seriously injured better than routine trauma criteria or vital signs.
2) When used alone as a triage tool, SDNN had a sensitivity of 80%, specificity of 75%, and accuracy of 76% for predicting life-saving interventions, outperforming other prehospital measures.
3) Incorporating SDNN into trauma triage criteria models improved prediction of outcomes compared to models without SDNN, better discriminating patients who were seriously or minimally injured
Guideline for the Prevention of Surgical Site Infection, 2017RubenMariscal3
This guideline provides evidence-based recommendations for preventing surgical site infections (SSIs). Key recommendations include administering preoperative antimicrobial prophylaxis timed with surgery, maintaining normothermia and glycemic control in patients, and avoiding additional antimicrobial doses after surgery. The guideline is intended to improve patient safety by reducing preventable SSIs and incorporating strategies into surgical quality improvement programs. It is based on a systematic review of the literature evaluating various prevention practices and aims to advance the field by assessing areas deemed important by clinical experts.
Secondary Malignancy after Treatment of Prostate Cancer. Radical Prostatectom...asclepiuspdfs
Background: This study aims to determine whether the treatment of locally confined prostate cancer (PCa) with external radiotherapy (EBRT) increases the risk to develop secondary malignancies (SM) compared to radical prostatectomy (RPE). Materials and Methods: Data from patients who were treated curatively with RPE or EBRT from 2010 to 2018 and who did not have distant metastases, previous malignancy, or previous treatment with radiotherapy or chemotherapy at the time of diagnosis were reviewed to determine the incidence of SM over a median follow-up period of 47 months (range 12–96 months). Regression models were used to correlate the clinicopathological factors with the incidence of SM.
The Influence of Transurethral Resection of Bladder Tumor on Staging of Bladd...asclepiuspdfs
Introduction: Bladder cancer is common, expensive, and the number of cases rising with increased survival in the elderly population. Most centers do computed tomography (CT) scan at the point of investigation, and some will carry this out along with magnetic resonance imaging (MRI) scan to have better local staging once the diagnosis of invasive cancer is made. Any surgical procedure would have a likelihood of influencing local staging, and this is a common belief without any evidence. Methods: We have retrospectively analyzed our data to see where the truth lies. We have compared the final pathology of 236 radical cystectomy patients to the staging reports of 241 CT scans and 65 MRI scans. Results: We have ascertained accuracy, sensitivity, and specificity and whether they were influenced by the timing of the transurethral resection of bladder tumor (TURBT). There was no significant difference between CT and MRI and the timing of the TURBT. Conclusion: This is the first report in the literature outlining the influence of TURBT. We accept the limitation due to the retrospective nature, small sample size, and variability of the biology of bladder cancer.
This document discusses the approach towards re-irradiation of common cancers. It begins by noting that local recurrence after radiation therapy and second primary tumors in irradiated areas are challenges, though re-irradiation can provide durable disease control in some cases. It then discusses key considerations for re-irradiation of head and neck cancers, gliomas, gynecological cancers, bone metastases, and brain metastases. Important factors include the initial radiation dose, interval since prior radiation, intent of re-irradiation, cumulative organ doses, and risk versus benefit. Advanced radiation techniques like IMRT can help minimize toxicity risks from re-irradiation. Careful patient selection and multidisciplinary evaluation are emphasized for meaningful survival benefits from re-
PSD is a leading recruitment firm that specializes in providing permanent and contract technology and business change resources to the asset management sector, including mid to senior level managers, project resources, business technologists, and technology specialists. They have 12 years of experience working with asset management, asset servicing, wealth management, hedge funds, software vendors, and consultancies. They recruit for positions including IT directors, heads of departments, programme managers, business analysts, and specialists with expertise in software products like DST, Charles River, and Simcorp as well as functional areas including client reporting, performance measurement, and trade processing. PSD offers comprehensive recruitment services including executive search, contract/interim placements, and advertised selection through a rigorous project
This document discusses injuries to the chest, including initial evaluation and management of thoracic injuries during the primary survey, indications for tube thoracostomy, tension pneumothorax, retained hemothorax and empyema, and emergency department thoracotomy. It provides guidance on prioritizing airway, breathing, and circulation during the primary survey. Tube thoracostomy is recommended for tension pneumothorax, massive hemothorax, or uncontrolled air leaks. Retained blood increases risk of infection and empyema, so aggressive removal is warranted. Emergency department thoracotomy has a low survival rate for blunt trauma but higher for penetrating injuries or cardiac wounds.
Famciclovir (Virovir Tablets) is used for treatment of recurrent episodes of Herpes labialis (cold sores) and treatment of recurrent episodes or suppressive therapy of recurrent episodes of Genital herpes.
Ramakrishnan Krishnan has over 13 years of experience in banking, with 10 years in IT business analysis focused on the banking sector. He currently works as a senior business analyst for Citibank at Wipro Technologies, and has previously worked for Standard Chartered and American Express in roles analyzing payments, foreign exchange, and wholesale banking. He is knowledgeable in various banking processes and has experience defining requirements, testing solutions, and managing projects.
Diagnostic and therapeutic endoscopy of the gastrointestinal tract has become the dominant modality for diagnosis and treatment of GI diseases since the 1970s. Esophagogastroduodenoscopy (EGD) allows examination of the esophagus, stomach, and duodenum. During EGD, the endoscope is advanced through the mouth and throat to inspect the GI tract. Abnormal findings can be biopsied. Therapeutic endoscopy is used to control variceal hemorrhage using band ligation or sclerotherapy and to control nonvariceal bleeding using injection, coagulation, or laser therapy. Strictures can be dilated using balloons under fluoroscopy. Endoscopy is a generally safe procedure but
The Hero's Journey Amsterdam. Making Money Doing What You Love. Peter de Kuster
The Creative Hero
This chapter discusses creative heroes and how they have found tremendous success and creative freedom, not just financially but also in their work. It emphasizes focusing on your strengths and embracing what makes you unique rather than trying to fit a mold. True success comes from finding your gifts and using your creativity in your career. While society often rewards more conventional left-brain approaches, being creative requires using both sides of your brain and finding a whole-brain approach that works for you. The key is taking time to understand yourself so you can work with your natural abilities and find fulfilling work that fits you like a glove.
Moestuinier Wim Lybaert kan ook winst oogstenThierry Debels
De Brugse onderneming van Wim Lybaert heeft de eerste jaarrekening neergelegd.
In het eerste verlengde boekjaar (van 10 december 2013 tot 30 september 2015) werd een brutomarge van 78.000 euro behaald. Het leverde de Bruggeling uiteindelijk een mooie nettowinst van 42.000 euro op.
This document discusses various sources of data for benchmarking surgical outcomes. It describes public reporting programs that release hospital or surgeon-specific outcomes data online. However, these programs often rely on administrative data, which has limitations. The document also discusses public use administrative databases that surgeons can access themselves, such as Medicare and Nationwide Inpatient Sample data. Finally, it covers clinical outcomes registries like the National Surgical Quality Improvement Program (NSQIP), which prospectively collect detailed clinical data but have high costs of participation. Overall, the document evaluates the strengths and weaknesses of different data sources for benchmarking surgical performance.
Hand-assisted laparoscopic surgery (HALS) is a hybrid technique that provides many of the advantages of traditional open surgery and laparoscopic colectomy. HALS employs a special access device that allows the surgeon to place a hand in the abdomen to assist with retraction, dissection, and visualization while maintaining pneumoperitoneum and laparoscopic instrumentation through trocars. Studies have shown HALS results in shorter operative times and lower conversion rates to open surgery compared to traditional laparoscopic colectomy while preserving similar short-term clinical outcomes. HALS may help expand the use of minimally invasive approaches for complex colectomies by providing an easier transition from open surgery than traditional laparoscopic techniques.
Accountable care organizations (ACOs) are new healthcare delivery models mandated by the Affordable Care Act that focus on primary care but also affect oncologists. Oncologists cannot lead ACOs but can join them. Few quality measures outlined for ACOs relate specifically to cancer care. The potential savings in oncology through ACOs will depend on how incentive structures are designed and how much oncologists are allowed to provide cost-effective care while still prioritizing patients. However, ACOs may put pressure on oncologists to choose between cost savings for the ACO or high-quality cancer care for patients.
Order & Unity: UT Southwestern Case Study on Imaging AppropriatenessMick Brown
On a sunny Saturday in May 2017, nearly 400 primary care physicians, specialists, nurse practitioners, physician assistants, technologists, and nurses crowded into the Gaylord Texan Convention Center in Grapevine, Tex. Despite the beautiful spring weather, participants eagerly gathered indoors to attend the second “The Right Scan from Head to Toe” radiology utilization conference, where they would learn about and discuss best practices for enhancing performance- based metrics when ordering radiology exams.
Journal of applied clinical medical physics Vol 14, No 5 (2013)oncoportal.net
The document discusses the importance of CT protocol management and review for ensuring patient safety and image quality. It outlines responsibilities and qualifications for members of the protocol review team, which should include at least a lead radiologist, technologist, and medical physicist. The medical physicist's role involves meeting with the team, performing measurements, and reviewing images and protocols. An effective protocol review process evaluates all exam parameters, pays attention to scanner capabilities, consolidates outdated protocols, and stays up to date with current literature. Regular protocol review is crucial for quality patient care and making full use of CT system capabilities.
1) Regulatory reforms are expected to promote accountable care organizations and increased usage of healthcare IT. This is driving merger and acquisition activity as providers consolidate to form ACOs.
2) Accountable care organizations are networks of providers that share responsibility for patient care costs and quality. The Medicare Shared Savings Program aims to incentivize ACOs beginning in 2012.
3) Increased adoption of electronic health records is also being driven by incentives from the HITECH Act. EHRs are expected to improve care coordination and reduce costs over the long run. However, providers face significant upfront costs to develop EHR systems.
Universal access to virtual colonoscopy may be on the horizonYael Waknine
Virtual colonoscopy (CT colonography) has been endorsed by several medical organizations since 2008 as a screening method for colorectal cancer. However, it is not covered by Medicare for reimbursement due to political opposition from organizations supporting traditional colonoscopy and concerns about risks. Radiologists argue that many of the original concerns about virtual colonoscopy have been addressed by peer-reviewed research showing it is a safe and cost-effective screening option. They call for public advocacy to change the test's rating by the US Preventive Services Task Force in order to gain Medicare coverage, which would significantly boost low colorectal cancer screening rates in the US.
The document discusses a study that found aviation-based crew resource management training improved patient safety behaviors like checklist use and incident reporting in hospital staff over several years. The training led to increased empowerment scores and a sustained culture of safety. While errors still occur, physician-led programs may be more effective than penalties at improving safety.
PACS (Picture Archive and Communication Systems) are digital systems used to store, view, and manage diagnostic imaging studies. They allow for faster access to images compared to traditional film, which can improve patient care. While initial implementation of PACS is costly, studies have shown cost savings from reduced lost images, repeated exams, and shorter hospital stays. PACS integrate with other hospital information systems and allow multiple providers to view images simultaneously from different locations. This improves care coordination and patient discussions. Overall, PACS aim to make healthcare delivery more effective and efficient through electronic access and sharing of diagnostic images.
A publication dedicated to bringing articles and advice, specific to the anesthesia and pain management community, that are practical and tangible.
This edition covers the following topics:
• Using Big Data for Big Research: MPOG, NACOR and other Anesthesia Registries
• Another Year of Changes Lies Ahead for Anesthesiologists
• Disruptive Change, Anesthesiologists, and ASCs
• Performing High Acuity Cases in ASCs: The Anesthesiologist’s Role
• Endoscopy: Revisited
• Reporting Postoperative Pain Management in 2014
• 2014 CPT Coding and Key Reimbursement Changes
Clinical Decision Support Systems - Sunil Nair Health Informatics Dalhousie U...Sunil Nair
Clinical decision support systems (CDSS) aim to enhance patient care by intelligently presenting clinical knowledge and patient information to clinicians. Early CDSS focused on diagnosis but now emphasize a variety of applications. Effective CDSS integrate easily into clinical workflows, are user-friendly, and adapt based on monitoring impact. While CDSS can improve outcomes, their success depends on overcoming integration challenges and ensuring the technology supports rather than replaces clinicians.
The document provides an overview of clinical information systems (CIS) and their key components. It discusses that a CIS is a technology-based system used at the point of care to support information acquisition, storage, and processing. The eight basic components of an electronic health record are also outlined. The document then examines the clinical decision support system within a CIS and its structure. It also discusses the key players involved in choosing, implementing, and revising a CIS. Finally, it covers important aspects of CIS security and safety.
Digital Picture Archiving and Communication Systems (PACS) have led to significant efficiencies and cost savings for Canadian hospitals by eliminating film-based radiology systems. PACS have reduced costs by over $1 billion annually through eliminating expenses associated with film and film processing. PACS have also improved productivity equivalent to adding 500 radiologists by allowing fast access to medical images anywhere, reducing duplicate exams, and speeding diagnosis and treatment. However, rising demand for medical imaging poses ongoing challenges for cost containment despite these savings. Efforts are underway to connect local and regional PACS to create a pan-Canadian diagnostic imaging system and establish common standards.
ACC Expert Consensus Document On Ethical Coding And Billing Practices For Car...Jessica Henderson
This document provides guidance to cardiovascular specialists on ethical coding and billing practices. It addresses the complexity of coding, financial pressures physicians face, and the differences between coding, pricing, and billing. The document emphasizes obtaining expert advice, avoiding upcoding and unbundling, seeking advice for codeless procedures and code ambiguities, using modifiers appropriately, and documenting medical necessity. Physicians are responsible for accurate coding but face challenges from frequent code changes and ambiguity; following these guidelines helps ensure ethical practices and fair compensation.
Technology and data-driven approaches are helping advance our understanding of science and medicine. Deep learning algorithms can analyze large amounts of medical data to identify patterns and make diagnoses. One study found that a deep learning system correctly identified the diagnosis of skin lesions 72% of the time, outperforming board-certified dermatologists who were correct 66% of the time. Initiatives like the Cancer Moonshot aim to apply these types of data-driven approaches and machine learning to make breakthroughs in cancer research, with a goal of accelerating progress by 10 years. These new technologies have potential to transform how doctors learn, practice medicine, and improve patient outcomes.
A clinical information system (CIS) is a technology-based system used at the point of care to support information acquisition, processing, storage and retrieval. It provides a complete electronic health record. Key benefits include easy access to patient data, ability to search and analyze data. Key players who use the CIS include administrators, physicians, nurses and other clinical staff. It is important for all stakeholders to be involved in selection and use. Components of an electronic health record include health information, order management, decision support and administrative functions. Clinical decision support systems can be knowledge-based, providing accurate clinical data, or non-knowledge based, using machine learning from past data. Safety, security, costs and staff education must all be considered for successful
This document discusses how machine learning can be applied to help plastic surgeons better analyze and interpret the large amounts of patient data that are now routinely collected. It begins by explaining that traditional data analysis techniques struggle with "big data," which contains complex patterns. Machine learning, a subfield of artificial intelligence, can generate algorithms capable of acquiring knowledge from historical examples to help address this challenge. The document then provides examples of how machine learning has already been successfully applied in other fields and in cancer treatment. It proposes that plastic surgeons should also look to machine learning approaches to more efficiently deliver healthcare and improve surgical outcomes by extracting meaningful insights from their extensive patient data collections. Specific potential applications discussed include burn surgery, microsurgery, and various types of reconstruct
From testing to spread: Sharing the knowledge and learning from organisations...NHS Improvement
From testing to spread:Sharing the knowledge and learning from organisations spreading the Winning Principles - case studies
The spread case studies illustrate many of these factors and provide an opportunity for sharing ‘working’ knowledge and learning experiences with the intention to promote further spread, adoption and action of good practice across the country and benefit more patients (Published July 2010).
The radiology department at
Baton Rouge General Medical
Center takes pride in using
advanced technologies to offer
top-notch care to patients and
unparalleled service to referring
physicians.
Acs0522 procedures for benign and malignant biliary tract disease-2005medbookonline
This document discusses procedures for benign and malignant biliary tract diseases. It provides guidance on preoperative evaluation and management of biliary obstruction. Specific considerations are given to infection, renal dysfunction, impaired immunity, malnutrition, and coagulation issues. The document outlines operative planning details such as patient positioning, exposure techniques, and guidelines for biliary anastomoses including suture placement and techniques for difficult access situations.
This document discusses the anatomy and surgical procedure of splenectomy. It describes:
- The spleen's highly variable arterial blood supply, which can take bundled or distributed patterns. This variability impacts the difficulty of surgery.
- The splenic artery typically branches off the celiac axis but can originate from other nearby arteries in rare cases.
- Additional branches of the splenic artery before it enters the spleen, including short gastric and pancreatic arteries.
- A history of splenectomy beginning in the 16th century and its increasing use through the 20th century for trauma and hematologic disorders.
- The development of laparoscopic splenectomy in the early 1990s and ongoing refinement of minim
Gastrostomy is commonly used as a temporary procedure to avoid discomfort from prolonged nasogastric suction after major abdominal surgery. It can also be used permanently when the esophagus is obstructed to nonresectable cancer. The Stamm gastrostomy is most common temporary procedure where a catheter is placed through the stomach wall and anchored to the skin. The Janeway gastrostomy is a permanent alternative where a flap of stomach is brought through the abdominal wall and attached to form a mucosal lined tube to prevent regurgitation. Postoperative care involves gradual advancement to oral intake as the stomach heals and functions return to normal.
This document describes the Billroth I gastric resection procedure, which involves removing part of the stomach and reattaching it to the duodenum. Key steps include transecting the stomach, attaching it to the duodenum using a circular stapler, and closing the gastrotomy site. The procedure aims to control peptic ulcers by combining hemigastrectomy with vagotomy while restoring normal gastrointestinal continuity. Postoperative care focuses on gradual advancement of oral intake and monitoring for complications.
This document describes the Billroth I procedure for gastroduodenostomy. It involves extensive mobilization of the stomach and duodenum to allow for an end-to-end anastomosis between the stomach and duodenum, restoring normal continuity of the gastrointestinal tract. The stomach is divided and sutured closed, then sutured to the duodenum in layers to create the gastroduodenal connection. Postoperative care focuses on gradual advancement of diet and monitoring for gastric retention to support healing and prevent complications.
Gastrostomy is commonly used as a temporary procedure to avoid discomfort from prolonged nasogastric suction after major abdominal surgery. It can also be used permanently when the esophagus is obstructed to nonresectable cancer. The Stamm gastrostomy is most common temporary procedure where a catheter is placed through the stomach wall and anchored to prevent leakage. The Janeway gastrostomy is a permanent alternative where a flap of stomach is brought through the abdominal wall and lined with mucosa to form a permanent opening, preventing regurgitation. Postoperative care involves gradual advancement to oral intake as the stomach and bowel recover function.
Gastrojejunostomy is a surgical procedure that connects the stomach directly to the jejunum. It is indicated for patients with duodenal ulcers complicated by pyloric obstruction or nonresectable stomach or pancreatic cancers causing obstruction. The procedure involves opening the stomach and jejunum, suturing them together to form a stoma, then closing in multiple layers. Postoperatively, gastric emptying is monitored and diet advanced gradually to ensure proper healing.
This document provides guidance on treating a perforated ulcer or subphrenic abscess. It describes:
1) Preparing patients preoperatively by administering IV fluids/antibiotics and gastric suction.
2) Closing perforations by suturing the ulcer and reinforcing it with omentum, or sealing it if too indurated.
3) Draining subphrenic abscesses extraperitoneally by making incisions below the costal margin or through the 12th rib bed and inserting drains into the abscess cavity.
A C S0103 Perioperative Considerations For Anesthesiamedbookonline
This document discusses perioperative considerations for anesthesia. It notes advancements in modern surgical care and alterations in anesthetic management to maximize patient benefit. A preoperative evaluation is important to assess medical history and current medications. Certain medications may need to be adjusted or discontinued before surgery, such as MAOIs, oral anticoagulants, and some herbal supplements, to reduce risks of adverse reactions or bleeding complications during the procedure. The risks and options for anesthesia should be discussed with the patient.
Postoperative pain is a complex experience involving sensory, emotional, and mental components. Effective pain management is important for patient comfort and recovery. Guidelines for postoperative pain treatment have been developed for specific procedures. Multimodal analgesic regimens targeting multiple pathways are recommended over reliance on opioids alone to prevent tolerance and hyperalgesia. Nonpharmacological complementary therapies can be combined with drug treatments to enhance pain control.
The document discusses the approach to a patient experiencing ongoing bleeding. It outlines the following key steps:
1. First consider the possibility of a technical cause like an unligated vessel and examine for injuries.
2. If no technical cause is found, check the patient's temperature and perform laboratory tests. Hypothermia can cause coagulopathy.
3. Evaluate test results along with the patient's history for clues to underlying causes like platelet dysfunction, coagulation factor deficiencies, or inherited bleeding disorders. Treat the specific condition while continuing evaluation.
A C S0812 Brain Failure And Brain Deathmedbookonline
This document discusses brain failure and brain death. It defines different levels of impaired consciousness from cloudy consciousness to coma. It describes how brain failure results from cardiac arrest and the challenges of restarting the brain after lack of oxygen. It outlines the criteria for diagnosing brain death, including absence of brain stem reflexes and apnea testing. It also discusses the evolution of determining death as technology has allowed life support to prolong vital signs indefinitely.
This document provides information on parotidectomy surgery and the Fundamentals of Laparoscopic Surgery (FLS) program.
It describes the technique for parotidectomy surgery, including identifying and dissecting around the facial nerve. It notes that most parotid tumors are benign and complications are usually temporary facial nerve paralysis.
It then discusses the development of the FLS program to standardize laparoscopic surgery training. The program includes cognitive training and manual skills assessment. Many residency programs and hospitals now require surgeons to complete the FLS. A large grant will help make the program more accessible to residency programs.
This document discusses organ procurement from cadaveric donors. It describes the coordination between donor and recipient activities, including matching organs to recipients based on factors like blood type, medical urgency, and waiting time. The evaluation of donor organs is outlined for different organs. Careful donor management aims to optimize organs while respecting donor dignity.
The document summarizes the evolution of trauma surgery training and practice in the United States. It discusses how trauma surgery originated in large city hospitals but has since expanded to regional trauma centers. It also notes changes in surgical training away from generalist models towards increased specialization. Trauma surgery is increasingly encompassing broader emergency general surgery duties due to workforce shortages, while training programs emphasize specialized rather than broad skills.
This document provides reference values for many common clinical chemistry analytes measured in various specimens like plasma, serum, urine, and whole blood. The analytes include metabolic panels, lipids, proteins, electrolytes, vitamins, and more. Reference ranges are given in conventional and SI units for each analyte. The purpose is to provide clinicians with the normal expected ranges to interpret laboratory results at the Massachusetts General Hospital.
Acs0905 Gynecologic Considerations For The General Surgeonmedbookonline
This document discusses several gynecologic conditions and considerations for general surgeons:
- Gynecologic emergencies like bleeding from ovarian cysts, adnexal torsion, pelvic inflammatory disease, and ectopic pregnancy. Diagnosis and treatment approaches are outlined.
- Outpatient gynecologic problems including evaluating pelvic masses and abnormal uterine bleeding.
- Gynecologic malignancies like ovarian and cervical cancer that some general surgeons may encounter.
- Most conditions can be initially managed conservatively but may require surgery depending on patient stability or response to treatment. Diagnostic tools like ultrasound, CT, and laparoscopy are discussed.
Acs0904 Urologic Considerations For The General Surgeonmedbookonline
This document discusses urologic considerations for general surgeons. It begins with an overview of genitourinary anatomy, including the kidneys, ureters, bladder, prostate, seminal vesicles, penis, and urethra. It then discusses common urologic injuries general surgeons may encounter, such as those resulting from multiple trauma or iatrogenic injuries during other operations. Urologic malignancies and benign prostatic hyperplasia are also briefly mentioned.
This document discusses considerations for pediatric surgical patients. Some key points:
- Pediatric physiology differs significantly from adults, with higher fluid needs and electrolyte requirements. Careful fluid and electrolyte management is important.
- Nutritional needs are also higher in pediatric patients, especially infants, due to rapid growth. Enteral nutrition is preferred when possible, otherwise total parenteral nutrition may be needed. Close monitoring of nutrition and growth parameters is important.
- Vital signs and fluid intake/output norms differ for pediatric patients compared to adults. Recognizing what is normal for different pediatric age groups is essential for surgical care.
The document discusses considerations for elderly surgical patients. Older patients represent a growing demographic undergoing more procedures. While age alone is a poor indicator of health, the aging process involves physiological changes that reduce cardiac, pulmonary, renal and other organ reserves. Careful preoperative evaluation of functional status is important to assess risks. Perioperative strategies aim to support compromised systems and avoid stressors that can precipitate complications in elderly patients.
1. www.acssurgery.com
WILEY W. SOUBA, MD, ScD, FACS, Editorial Chair DOUGLAS W. WILMORE, MD, FACS, Founding Editor June 2008
THE BEST THIS MONTH’S UPDATES
SURGICAL Elements of Contemporary Public reporting programs related
to other surgical procedures gener-
THINKING Practice
3 Benchmarking Surgical
ally rely on administrative data. The
most widely available source of
surgical outcomes data comes from
A New Publisher for ACS Outcomes proprietary rating firms.
Surgery Emily V. A. Finlayson, MD, MS,
Wiley W. Souba, MD, ScD, FACS and John D. Birkmeyer, MD, Public Use Administrative
FACS
Ohio State University College of Databases
University of Michigan Health ather than relying on outside
Medicine
DOI 10.2310/7800.2008.NCjun
System R analysis, surgeons can obtain
administrative data and do it
DOI 10.2310/7800.SECPC03
he American College of Surgeons
T recently entered into a long-term
agreement with BC Decker Inc as the
Public reporting programs, public
use administrative databases, and
themselves. For example, surgeons
can obtain data from the Nation-
wide Inpatient Sample, a database
new publisher of ACS Surgery. Brian clinical registries all offer surgical
containing information from
Decker and the editors are very outcomes data to benchmark
hospital and even surgeon-specific approximately 8 million hospital
interested in continuing to elevate the
performance. admissions annually.
high quality of ACS Surgery and
Administrative data have many
making this a win-win relationship nterest about surgical outcomes is
through the sharing of ideas and
materials and joint promotion of the
I growing. Patients want to make
informed decisions about where and
limitations for benchmarking
outcomes, but the most important
College and ACS Surgery. We want to limitations relate to problems with
from whom to receive surgical care, accuracy, completeness, and clinical
see ACS Surgery serve as a resource to
and public and private payers want precision of coding.
enhance the quality of surgical
information about surgical perfor-
practice and to increase membership
mance for their value-based pur-
in the American College of Surgeons.
The ongoing evolution of ACS chasing initiatives.
Surgery offers many advantages and
continued on page 2
opportunities for its readers. As a Public Reporting Programs
current subscriber, you should know he most readily available source
that ACS Surgery was designed to be
innovative and cutting edge. Our
T of surgical outcomes data is
Internet-based public reporting
In This Issue
commitment to you is to continue this
programs. Currently, those based on The Best Surgical Thinking
tradition. We will expand and A New Publisher for ACS Surgery 1
strengthen our efforts to integrate and clinical data are limited to cardiac
surgery. Some states administer Elements of Contemporary Practice
communicate principles and guidelines 3 Benchmarking Surgical Outcomes 1
for effective surgical practice in longitudinal clinical registries and
1 Basic Surgical and Perioperative
cooperation with the College to assure regularly release information on Considerations
subscribers that important new risk-adjusted mortality rates for 1 Prevention of Postoperative
studies, therapies, and procedures are coronary artery bypass surgery. All Infection 3
systematically incorporated into ACS states release hospital-specific 6 Vascular System
Surgery as rapidly as possible. performance data, but only some 12 Aortoiliac Reconstruction 4
continued on page 2 report surgeon-specific information.
3. www.acssurgery.com What’s New in ACS Surgery 3
Risk-adjusted morbidity and their own performance against these
mortality results for each hospital
are calculated semiannually and are
benchmarks are not, particularly at
the level of individual procedures. This Month’s CME
reported as observed versus expect-
ed ratios. Nonetheless, the NSQIP is
When sample sizes are too small, it
may be difficult to determine Chapters
expensive to administer, and risk whether complication rates higher ACS Surgery offers CME in
adjustment is not based on risk than the benchmark reflect genuine convenient online format. As
factors specific to individual problems or simply chance. many as 60 AMA PRA Category
procedures. Generalizability is another 1 credits can be earned at
The Society of Thoracic Surgeons limitation. Owing to the individual any time during the year. The
national database is the best source characteristics of each database, following chapters are available
for benchmarking outcomes with different data sets yield different for CME credit this month:
cardiac surgery. Its database
mortality estimates. Although none 1 Basic Surgical and Perioperative
includes clinical data on more than
of these mortality estimates are Considerations
70% of all adult cardiothoracic
“wrong,” surgeons must recognize 1 Prevention of Postoperative Infection
operations performed annually in
that risk estimates depend on the 6 Vascular System
the United States. A major weakness
is the lack of external auditing to composition of each database and 12 Aortoiliac Reconstruction
ensure the accuracy and complete- may not be generalizable to their Elements of Contemporary Practice
ness of outcomes data submitted by own practice. 3 Benchmarking Surgical Outcomes
hospitals.
The National Cancer Data Base
(NCDB) tracks information related Basic Surgical and Perioperative only skin and subcutaneous tissue),
to the treatment and outcome of
cancer patients. About 1,400
Considerations deep incisional (involving deep
soft tissue), and organ or space
hospitals nationwide submit data to 1 Prevention of (involving anatomic areas that are
the NCDB, which currently captures
approximately 75% of incident
Postoperative Infection opened or manipulated in the course
of the procedure).
cancer cases in the United States. Jonathan L. Meakins, MD, DSc,
FACS Current risk assessments integrate
Individuals at approved cancer
the three determinants of infection:
centers can access benchmark University of Oxford bacteria, local environment (including
reports that summarize data from
DOI 10.2310/7800.S01C01 surgeon factors), and systemic host
the user’s own center and compari-
defenses (patient factors).
sons with state, regional, or national Surgical site infections have no
data. However, data are not single cause, but can be systemati-
externally audited to ensure cally reduced by stricter attention Role of Bacteria, Surgeon
accuracy and completeness. to the bacteria that cause SSIs and Factors, and Patient Factors
Currently, approximately 556 various environmental and host
hospitals submit data to the Nation- in SSIs
factors.
al Trauma Data Bank, including ithout an infecting agent, no
70% of Level I– and 53% of Level
II–designated trauma centers. Data H istorically, wound infection
control depended on antiseptic
W infection will result. Accord-
ingly, most of what is known about
submission is voluntary and not and aseptic techniques directed at bacteria is put to use in major
externally audited. coping with the infecting organism. efforts directed at reducing their
Two programs track outcomes In the 19th century and the early numbers by means of asepsis and
with bariatric surgery. Clinical part of the 20th century, wound antisepsis. Endogenous bacteria are
registries of the ACS Bariatric infections had devastating conse- a more important cause of SSI than
Surgery Center Network Program quences and a measurable mortality. exogenous bacteria. In clean-
and the Surgical Review Corpora- Even in the 1960s, before the correct contaminated, contaminated, and
tion support hospital accreditation use of antibiotics and the advent of dirty-infected operations, the source
and “centers of excellence” modern preoperative and postopera- and the amount of bacteria are
designations in bariatric surgery. tive care, as many as one quarter of functions of the patient’s disease and
the surgical ward patients might the specific organs being operated
Limitations of Surgical have had wound complications. on.
These infections have been reduced, The most obvious pathogenic
Benchmarking but continue to have huge clinical bacteria in surgical patients are
ll surgical benchmarks have
A common limitations. The first
relates to sample size. Although the
and financial implications.
The Centers for Disease Control
gram-positive cocci (e.g., Staphylo-
coccus aureus and streptococci).
and Prevention uses the term S. aureus—in particular, MRSA—is
benchmarks are usually based on surgical site infection (SSI) to take a major cause of SSI. The preopera-
large numbers and are thus statisti- into consideration the operative site tive hospital stay also contributes to
cally robust, the outcomes of as a whole. SSIs can be classified as wound infection rates. The usual
hospitals and surgeons assessing superficial incisional (involving explanation is that either more
4. 4 What’s New in ACS Surgery • June 2008 www.acssurgery.com
endogenous bacteria are present or understanding of the steps necessary extent of testing is tailored to the
commensal flora is replaced by to reduce SSIs overall: level of cardiac risk.
hospital flora. • Keeping the bacterial
Most of the local factors that contamination as low as Operative Techniques for
make a surgical site favorable to possible via asepsis and
bacteria are under the surgeon’s Aortoiliac Reconstruction
antisepsis, preoperative prepara-
lthough localized aortoiliac
control, and the reach extends
beyond good hand-washing
tion of patient and surgeon, and
antibiotic prophylaxis. A endarterectomy is less commonly
performed today than it once was, it
practices. For example, the use of • Maintaining local factors in
drains that a surgeon chooses varies such a way that they can remains useful for a subgroup of
widely and is very subjective. Using prevent the lodgment of bacteria patients with focal aortic bifurcation
a closed suction drain reduces the and thereby provide a locally disease. The classic candidate has
potential for contamination and unreceptive environment. minimal disease of the infrarenal
infection. Also, in most studies, abdominal aorta and the external
• Maintaining systemic responses
contamination increases with the iliac arteries, but a severely diseased
at such a level that they can con-
and narrowed aortic bifurcation.
duration of the operation. Nonethe- trol the bacteria that become
Iliofemoral bypass, already an
less, it is only expeditious operation established.
uncommon procedure, has now
that is appropriate, not speed.
largely been supplanted by advances
Finally, the use of electrocautery in percutaneous endoluminal
devices has been associated with an 6 Vascular System techniques. Nevertheless, it is still
increase in the incidence of superfi- used and is worth knowing. One
cial SSIs unless used properly. 12 Aortoiliac Reconstruction limitation is that aortoiliac occlusive
The human systemic response is Mark K. Eskandari, MD, FACS disease typically causes diffuse aortic
designed to control and eradicate and bilateral iliac artery narrowing.
infection, but can be overwhelmed Northwestern University Feinberg
School of Medicine Iliofemoral bypass is most suitable
by certain factors. Patients at risk for those rare patients who have
for wound infection are those DOI 10.2310/7800.S06C12 isolated unilateral external iliac
with three or more concomitant artery disease.
diagnoses, those undergoing a Surgeons can choose a revascu- Before the application of percuta-
clean-contaminated or contaminated larization approach to ameliorate neous balloon angioplasty and
abdominal procedure, and those aortoiliac occlusive disease. stenting, aortofemoral bypass
undergoing any procedure expected ymptomatic aortoiliac occlusive grafting was the revascularization
to last longer than 2 hours. Also
increasing the risk of SSI are shock,
S disease is the consequence of a
diffuse atherosclerotic process
operation of choice for patients with
diffuse aortoiliac occlusive disease.
advanced age, transfusion, and the exacerbated by smoking, hyperten- This operation is still favored by
use of steroids and other immuno- sion, hypercholesterolemia, and many, and it yields excellent long-
suppressive drugs, including term patency.
diabetes. The resultant narrowing of
chemotherapeutic agents. A thoracofemoral bypass is ideal
the aorta and the iliac vessels
for a small subgroup of patients,
impairs circulation into the pelvis
comprising (1) those with an
Steps Necessary to Reduce and the lower extremities, causing occluded old aortofemoral bypass
complaints such as impotence and
SSIs claudication and even ulceration or
graft, (2) those with a so-called lead-
ntibiotics have not always pipe calcified infrarenal aorta that is
A prevented SSI successfully.
Although surgeons were quick to
gangrene. Choosing a surgical
revascularization approach is based
unusable as an inflow source, and
(3) those with a so-called hostile
on anatomic constraints and abdomen. Candidates must have
appreciate the possibilities of
comorbid conditions. adequate pulmonary reserve and be
antibiotics, the efficacy of antibiotic
Preoperatively, the physician able to tolerate a thoracotomy.
prophylaxis was not accepted until
should determine the extent of There is risk of paralysis.
the following was unequivocally
occlusive disease by measuring
proved:
lower extremity blood flow with
• They are most effective when arterial waveforms and ankle-
given before inoculation of brachial indices. An imaging study is
bacteria.
• They are ineffective if given 3
hours after inoculation.
also required to guide revasculariza-
tion. If an extra-anatomic bypass is Coming in July
anticipated, ancillary tests, including 2 Head and Neck
• They are of intermediate bilateral arm blood pressure 6 Parotidectomy
effectiveness when given measurements and computed 9 Thyroid and Parathyroid Procedures
between these times. tomography scans of the chest, 4 Thorax
Significant advances in the control abdomen, or pelvis may be neces- 8 Minimally Invasive Esophageal
of wound infection during the past sary. A standard cardiac risk Procedures
several decades are linked to a better assessment is mandatory, and the
5. www.acssurgery.com What’s New in ACS Surgery 5
Axillofemoral bypass is ideally disease has grown exponentially Overall Long-term
suited to elderly patients who since its introduction in the 1990s.
cannot tolerate an aortic operation. With regard to short-term results,
Survival in Patients with
The hemodynamic changes occur- patients experience less pain, recover Symptomatic Aortoiliac
ring during the operation are more quickly, and regain function Disease
minimal, and recovery from the earlier. egardless of which operation is
three small incisions is generally
quick. R performed, the subsequent
outcome should be immediate relief
A femorofemoral crossover bypass Complications of Aortoiliac
is well suited to patients who have of presenting symptoms. Unfortu-
Revascularization nately, overall long-term survival in
unilateral complete occlusion or a
leeding, distal embolization, graft
diffusely diseased iliac system but
have a relatively normal contralat- B thrombosis, and graft infection
are associated with all revasculariza-
patients with symptomatic aortoiliac
occlusive disease is not improved by
eral iliac system. It is performed operative management and is
similarly to an axillofemoral bypass, tion procedures. Late graft infection, typically 10 to 15 years less than
but without the axillary anastomo- recurrent disease, and pseudoaneu- that in a normal age-matched group.
sis. rysm formation are known long- The most significant long-term cause
In terms of endovascular therapy, term complications. Some complica- of death is atherosclerotic cardiac
the use of percutaneous balloon tions are unique to one or more of disease, underscoring the impor-
angioplasty and stenting for the the procedures but do not arise with tance of a thorough preoperative
treatment of peripheral vascular the others. cardiac evaluation.