Simplified risk-prediction for benchmarking and quality improvement in emergency general surgery. Prospective, multicenter, observational cohort study

BACKGROUND AND AIMS

Emergency General Surgery (EGS) conditions account for millions of deaths worldwide, yet it is practiced without benchmarking-based quality improvement programs. The aim of this observational, prospective, multicenter, nationwide study was to determine the best benchmark cutoff points in EGS, as a reference to guide improvement measures.

METHODS

Over a 6-month period, 38 centers (5% of all public hospitals) attending EGS patients on a 24-h, 7-days a week basis, enrolled consecutive patients requiring an emergent/urgent surgical procedure. Patients were stratified into cohorts of low (i.e., expected morbidity risk <33%), middle and high risk using the novel m-LUCENTUM calculator.

RESULTS

A total of 7258 patients were included; age (mean ± SD) was 51.1 ± 21.5 years, 43.2% were female. Benchmark cutoffs in the low-risk cohort (5639 patients, 77.7% of total) were: use of laparoscopy ≥40.9%, length of hospital stays ≤3 days, any complication within 30 days ≤ 17.7%, and 30-day mortality ≤1.1%. The variables with the greatest impact were septicemia on length of hospital stay (21 days; adjusted beta coefficient 16.8; 95% CI: 15.3 to 18.3; P < .001), and respiratory failure on mortality (risk-adjusted population attributable fraction 44.6%, 95% CI 29.6 to 59.6, P < .001). Use of laparoscopy (odds ratio 0.764, 95% CI 0.678 to 0.861; P < .001), and intraoperative blood loss (101-500 mL: odds ratio 2.699, 95% CI 2.152 to 3.380; P < .001; and 500-1000 mL: odds ratio 2.875, 95% CI 1.403 to 5.858; P = .013) were associated with increased morbidity.

CONCLUSIONS

This study offers, for the first time, clinically-based benchmark values in EGS and identifies measures for improvement.

The use of helical computed tomography in pregnancy for the diagnosis of acute appendicitis

OBJECTIVE

Accurate diagnosis of acute appendicitis in pregnancy by clinical evaluation is difficult. A safe, reliable test was sought to decrease a delay in diagnosis and to avoid unnecessary invasive procedures. A helical or spiral computed tomographic technique has proven to be a very accurate test in the nonobstetric population for the identification of acute appendicitis. We report its use in pregnant patients with suspected acute appendicitis.

STUDY DESIGN

All pregnant patients who were undergoing helical computed tomography at our institution from April 1997 to February 1998 for the suspected clinical diagnosis of acute appendicitis were retrospectively reviewed. Helical computed tomography was performed by standard departmental protocol. A positive study was reported if an enlarged appendix, which did not fill with contrast material, was present with periappendiceal inflammatory changes. Outcomes were determined by the results of surgery and pathologic examination or clinical follow-up.

RESULTS

Seven patients were identified in the study period. Two patients had positive findings on helical computed tomography, and acute appendicitis was confirmed at laparotomy and by pathologic inspection. There were no further prenatal complications and both patients delivered at term. Five patients had a normal-appearing appendix on helical computed tomography, and all of these patients had resolution of their pain and symptoms.

CONCLUSION

Helical computed tomography appears to be a useful, noninvasive test to accurately diagnose acute appendicitis in pregnancy.

The 2H4 (CD45R) antigen is selectively decreased in multiple sclerosis lesions

To analyze expression of the 2H4 (CD45R) Ag on inflammatory cells in the central nervous system immune response, immunohistochemical staining with a panel of anti-T cell mAb was performed on central nervous system tissues from 12 patients with multiple sclerosis (MS) and 8 patients with viral encephalitis. Only rare cells were stained with anti-2H4 in MS plaques, plaque edges, and adjacent white matter, whereas 2H4+ cells were more numerous in viral encephalitis (p less than 0.001). By contrast, no quantitative differences were found between MS plaque edges and viral encephalitis with anti-4B4 (helper-inducer function associated), anti-CD4, anti-CD3, and anti-IL-2R mAb, although there were fewer CD8+ cells in MS (p less than 0.01). These data indicate that the 2H4 Ag is selectively decreased and, because it is associated with suppressor-inducer function of CD4+ cells, that there may be a defect in the down-regulation of the in situ immune response in MS.

The 2H4 (CD45R) antigen is selectively decreased in multiple sclerosis lesions

To analyze expression of the 2H4 (CD45R) Ag on inflammatory cells in the central nervous system immune response, immunohistochemical staining with a panel of anti-T cell mAb was performed on central nervous system tissues from 12 patients with multiple sclerosis (MS) and 8 patients with viral encephalitis. Only rare cells were stained with anti-2H4 in MS plaques, plaque edges, and adjacent white matter, whereas 2H4+ cells were more numerous in viral encephalitis (p less than 0.001). By contrast, no quantitative differences were found between MS plaque edges and viral encephalitis with anti-4B4 (helper-inducer function associated), anti-CD4, anti-CD3, and anti-IL-2R mAb, although there were fewer CD8+ cells in MS (p less than 0.01). These data indicate that the 2H4 Ag is selectively decreased and, because it is associated with suppressor-inducer function of CD4+ cells, that there may be a defect in the down-regulation of the in situ immune response in MS.