The latest medical research on General Surgery
The research magnet gathers the latest research from around the web, based on your specialty area. Below you will find a sample of some of the most recent articles from reputable medical journals about general surgery gathered by our medical AI research bot.
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In-house versus on-call trauma surgeon coverage: A systematic review and meta-analysis.J Trauma Acute Care
A rapid trauma response is essential to provide optimal care for severely injured patients. However, it is currently unclear if the presence of an in-house trauma surgeon affects this response during call and influences outcomes. This study compares in-hospital mortality and process-related outcomes of trauma patients treated by a 24/7 in-house versus an on-call trauma surgeon.
PubMed/Medline, Embase and CENTRAL databases were searched on the first of November 2020. All studies comparing patients treated by a 24/7 in-house versus an on-call trauma surgeon were considered eligible for inclusion. A meta-analysis of mortality rates including all severely injured patients (i.e., ISS ≥ 16) was performed. Random effect models were used to pool mortality rates, reported as risk ratios. The main outcome measure was in-hospital mortality. Process-related outcomes were chosen as secondary outcome measures.
In total, 16 observational studies, combining 64,337 trauma patients, were included. The meta-analysis included 8 studies, comprising 7,490 severely injured patients. A significant reduction in mortality rate was found in patients treated in the 24/7 in-house trauma surgeon group compared with patients treated in the on-call trauma surgeon group (risk ratio 0.86, 95% confidence interval 0.78 to 0.95; P=0.002; I2=0%). In 10 out of 16 studies, at least one process-related outcome improved after the in-house trauma surgeon policy was implemented.
A 24/7 in-house trauma surgeon policy is associated with reduced mortality rates for severely injured patients treated at level I trauma centers. Additionally, presence of an in-house trauma surgeon during call may improve process-related outcomes. This review recommends implementation of a 24/7 in-house attending trauma surgeon at level I trauma centers. However, the final decision on attendance policy might depend on center and region-specific conditions.
Level III, therapeutic study type.
Can Social Vulnerability Indices Predict County Trauma Fatality Rates?J Trauma Acute Care
Social vulnerability indices were created to measure resiliency to environmental disasters based on socioeconomic and population characteristics of discrete geographic regions. They are comprised of multiple validated constructs that can also potentially identify geographically vulnerable populations after injury. Our objective was to determine if these indices correlate with injury fatality rates in the US.
3,137 US counties were included. Only 24.6% of counties fell into the same vulnerability quartile for all three indices. Despite this, all indices were associated with increasing fatality rates for overall, firearm, and MVC fatality. The DCI performed best by model fit, explanation of variance, and diagnostic performance on overall injury fatality. There is significant geographic variation in SoVI, DCI, and injury fatality rates at the county-level across the US, with moderate spatial autocorrelation of SoVI (Moran's I 0.35, p<0.01) and high autocorrelation of injury fatality rates (Moran's I 0.77, p<0.01) and DCI (Moran's I 0.53, p<0.01).
While the indices contribute unique information, higher social vulnerability is associated with higher injury fatality across all indices. These indices may be useful in the epidemiologic and geographic assessment of injury-related fatality rates. Further study is warranted to determine if these indices outperform traditional measures of socioeconomic status and related constructs used in trauma research.
Optimizing a decision support system for damage control resuscitation using mixed methods human factors analysis.J Trauma Acute Care
Damage control resuscitation (DCR) improves trauma survival; however, consistent adherence to DCR principles through multiple phases of care has proven challenging. Clinical decision support may improve adherence to DCR principles. In this study we designed and evaluated a DCR decision support system using an iterative development and human factors testing approach.
Therapeutic/Care Management, Level V.
In Phase 0, 14 of 16 participants (87.5%) noted they would use the decisions support system in a clinical setting. Twenty-four trauma team members then participated in simulated resuscitations with decision support where 178 of 228 (78.1%) of tasks were passed and 27 (11.8%) were passed with difficulty. Twenty-three (95.8%) completed a post-simulation survey. Following iterative improvements in system design, Phase 2 evaluation included 21 trauma team members during multiple real-world trauma resuscitations. Of these, 15 (71.4%) completed a formal postresuscitation survey. Device-level feedback on a Likert scale (range 0-4) confirmed overall ease of use (median score 4, interquartile range [IQR] 4-4) and indicated the system integrated well into their workflow (median score 3, IQR 2-4). Final refinements were then completed in preparation for a pilot clinical study using the decision support system.
An iterative development and human factors testing approach resulted in a clinically useable DCR decision support system. Further analysis will determine its applicability in military and civilian trauma care.
Readmission Following Surgical Stabilization of Rib Fractures: Analysis of Incidence, Cost, and Risk Factors Utilizing the Nationwide Readmissions Database.J Trauma Acute Care
Surgical stabilization of rib fractures (SSRF) has become increasingly common for the treatment of traumatic rib fractures; however, little is known about related postoperative readmissions. The aims of this study were to determine the rate, and cost of readmissions as well as to identify patient, hospital, and injury characteristics that are associated with risk of readmission in patients who underwent SSRF. The null hypotheses were that readmissions following rib fixation were rare and unrelated to the SSRF complications.
Epidemiological study, level III.
2,522 patients who underwent SSRF were included, of whom 276 (10.9%) were readmitted within 30 days. In 36.2% of patients the reasons for readmissions were related to complications of rib fractures or SSRF. The rest of the patients (63.8%) were readmitted due to mostly non-trauma reasons (32.2%) and new traumatic injuries (21.1%) among other reasons. Multivariate analysis demonstrated that ventilator use, discharge other than home, hospital size, and medical comorbidities were significantly associated with risk of readmission. Nationally, an estimated 2,498 patients undergo SSRF each year, with costs of $176 million for initial admissions and $5.9 million for readmissions.
Readmissions after SSRF are rare and mostly attributed to the reasons not directly related to sequelae of rib fractures or SSRF complications. Interventions aimed at optimizing patients' pre-existing medical conditions prior to discharge should be further investigated as a potential way to decrease rates of readmission after SSRF.
Physician-Staffed Ambulance and Increased In-Hospital Mortality of Hypotensive Trauma Patients Following Prolonged Prehospital Stay: A Nationwide Study.J Trauma Acute Care
The benefits of physician-staffed emergency medical services (EMS) for trauma patients remain unclear due to conflicting results on survival. Some studies suggested potential delays in definitive hemostasis due to prolonged prehospital stay when physicians are dispatched to the scene. We examined hypotensive trauma patients who were transported by ambulance, with the hypothesis that physician-staffed ambulances would be associated with increased inhospital mortality, compared with EMS-personnel-staffed ambulances.
level III, therapeutic.
Among 14,652 patients eligible for the study, 738 were transported by a physicianstaffed ambulance. In-hospital mortality was higher in the physician-staffed ambulance than in the EMS-personnel-staffed ambulance (291/738 [28.8%] vs 2287/13,090 [17.5%]; odds ratio [OR] 1.90 [1.61-2.26]; adjusted OR 1.18 [1.10-1.26]; p < 0.01), and the physician-staffed ambulance showed longer prehospital time (50 [36-66] vs 37 [29-48] min, difference = 12 [11-12] min, p < 0.01). Such potential harm of the physician-staffed ambulance was only observed among patients who arrived at the hospital with persistent hypotension (sBP < 90 mmHg on hospital arrival) in subgroup analyses.
Physician-staffed ambulances were associated with prolonged prehospital stay and increased in-hospital mortality among hypotensive trauma patients compared with EMSpersonnel-staffed ambulance.
EAST Oriens Award: Why I Want a Career in Trauma and Acute Care Surgery.J Trauma Acute Care
The opportunity to compose this essay for the Eastern Association for the Surgery Trauma's Oriens Award has been the most terrific privilege of my ...
Effects of the first lockdown of the COVID-19 pandemic on the trauma surgery clinic of a German Level I Trauma Center.Eur J Trauma Emerg Surg
The effects of the first pandemic wave on a German Level I Trauma Center should be evaluated to find ways to redistribute structural, personnel, and financial resources in a targeted manner in preparation for the assumed second pandemic wave.
We examined the repercussions of the first wave of the pandemic on the trauma surgery clinic of a Level I Trauma Center and compared the data with data from 58 other trauma clinics. The results could aid in orientating the distribution of structural, financial, and human resources (HR) during the second wave. The period between March 16 and April 30, 2020 was compared with the data over the same period during 2019. Information was collected from the HR department, central revenue management, and internal documentation.
The proportion of trauma surgical patients in the emergency room decreased by 22%. The number of polytrauma cases increased by 53%. Hospital days of trauma surgery patients in the intensive and intermediate care wards increased by 90%. The number of operations decreased by 15%, although the operating time outside of normal working hours increased by 44%. Clinics with more than 600 beds recorded a decrease in cases and emergencies by 8 and 9%, respectively, while the Trauma Center showed an increase of 19 and 12%. The results reflect the importance of level I trauma centers in the lockdown phase.
To reduce the risk of an increased burden on the healthcare infrastructure, it suggests the care of trauma and COVID-19 patients should be separated locally, when possible.
Management of scaphoid fractures with CT scanning and virtual fracture clinic pathway reduces need for face-to-face clinic appointments.Annals of the Rheumatic Diseases
Early diagnosis is key to managing scaphoid fractures effectively. Computed tomography (CT) imaging can be effective if plain radiographs are negative. With increasing pressure on face-to-face clinics, consultant-led virtual fracture clinics (VFCs) are becoming increasingly popular. This study evaluates the management of patients with suspected scaphoid fractures using a standardised treatment protocol involving CT imaging and VFC evaluation.
The study was conducted at a busy district general hospital. The pathway began in February 2018. Patients presenting to the emergency department with a clinically suspected scaphoid fracture but an indeterminate radiograph had a CT scan, which was then reviewed in the VFC. Patients with a confirmed fracture were seen in a face-to-face clinic; patients without a confirmed fracture were discharged. Patient pathway outcome measures were analysed pre- and post-pathway, and a cost analysis was performed.
A total of 164 pre-pathway patients (93%) were given a face-to-face fracture clinic appointment; 76 were discharged after their first visit. Nine patients seen in clinic had a CT scan and were discharged with no fracture. If these patients had been referred to the VFC, had CT scans and been directly discharged, it would have saved £1,629. A total of 41 patients from the post-pathway group (37%) had a CT scan and were discharged from the VFC. Avoiding face-to-face clinic appointments saved £7,421. Extrapolating, the annual savings would be £29,687.
This study shows that a VFC/CT pathway to manage patients with a suspected scaphoid fracture is cost-effective. It limits face-to-face appointments by increasing use of CT to exclude fractures.
The safety and efficacy of day-case total joint arthroplasty.Annals of the Rheumatic Diseases
The popularity of day-case arthroplasty has been fuelled by focus on its cost effectiveness for the healthcare system. Safety concerns still remain. The aim of this review was to compare readmission rates after total joint arthroplasty for patients undergoing day-case surgery and for inpatients.
A comprehensive online search of databases was performed for all published articles in the English language evaluating readmission rates after total hip arthroplasty (THA) and total knee arthroplasty (TKA). Seventeen studies were deemed eligible and included in the meta-analysis.
All studies included in the meta-analysis described readmission rates following THA/TKA. The readmission rate for day-case patients was 1.9% (n=124) whereas for inpatients, it was 2.0% (n=12,399). Compared with inpatient arthroplasty, day-case arthroplasty was associated with lower total readmission rates (odds ratio [OR]: 0.77, 95% confidence interval [CI]: 0.63-0.94, p=0.01). Furthermore, day-case surgery conferred a decrease in readmission rates for both THA (1.3% vs 7.0%) and TKA (2.7% vs 4.3%). Moreover, day-case THA and TKA were both associated with a decreased chance of readmission (OR: 0.27, 95% CI: 0.17-0.42, p<0.00001; and OR: 0.55, 95% CI: 0.42-0.72, p<0.00001 respectively).
This review emphasises that with a thoughtful, designated protocol and with careful patient selection, day-case arthroplasty is a safe and effective option.
A huge ureteric stone in a functionally, metabolically and anatomically normal kidney: an alliance of rarity.Annals of the Rheumatic Diseases
Urinary stones are a common health problem, necessitating frequent outpatient visits and hospital admissions. Ureteric stones demand special attent...
Primer malignant giant cell tumour of kidney: a case report.Annals of the Rheumatic Diseases
Osteoclast-like giant cell tumours of the kidney are extremely rare and usually accompanied by a conventional urothelial neoplasm such as papillary...
Routine group and save screening prior to emergency laparoscopic surgery.Annals of the Rheumatic Diseases
Two group and save (G&S) samples are routinely collected from patients undergoing diagnostic laparoscopy and/or emergency appendicectomy. We aimed to identify the necessity of this practice by looking at the perioperative transfusion rates.
Data were obtained from our electronic theatre system for all patients who underwent emergency laparoscopic surgery (specifically diagnostic laparoscopy and/or laparoscopic appendicectomy) between January 2017 and December 2018. Records were reviewed for the number of G&S samples sent and perioperative transfusion rates.
A total of 451 patients were included in the study. The numbers of procedures performed in 2017 and 2018 were 202 (44.8%) and 249 (55.2%), respectively. The total number of samples sent was 930. Only 786 (84.5%) samples were processed and the rest were rejected for various reasons. Of the 451 patients included in the study, 308 (68.3%) had two G&S samples sent, whereas 41 patients (9.1%) had only one G&S sample sent. Fifty-six (12.4%) and 20 (4.4%) patients had three and four G&S samples sent, respectively. Only two patients required transfusion perioperatively (0.4%), and the indication in both was irrelevant to the primary operation.
These results demonstrate a near-zero transfusion rate in this patient cohort. Omitting G&S is safe and potentially saves time and resources.