Judgment Errors in Surgical Care

BACKGROUND

Human error is impossible to eliminate, particularly in systems as complex as healthcare. The extent to which judgment errors in particular impact surgical patient care or lead to harm is unclear.

STUDY DESIGN

The American College of Surgeons NSQIP (2018) procedures from a single institution with 30-day morbidity or mortality were examined. Medical records were reviewed and evaluated for judgment errors. Preoperative variables associated with judgment errors were examined using logistic regression.

RESULTS

Of the surgical patients who experienced a morbidity or mortality, 18% (31 of 170) experienced an error in judgment during their hospitalization. Patients with hepatobiliary procedure (odds ratio [OR] 5.4 [95% CI 1.23 to 32.75], p = 0.002), insulin-dependent diabetes (OR 4.8 [95% CI 1.2 to 18.8], p = 0.025), severe COPD (OR 6.0 [95% CI 1.6 to 22.1], p = 0.007), or with infected wounds (OR 8.2 [95% CI 2.6 to 25.8], p < 0.001) were at increased risk for judgment errors.

CONCLUSIONS

Specific procedure types and patients with certain preoperative variables had higher risk for judgment errors during their hospitalization. Errors in judgment adversely impacted the outcomes of surgical patients who experienced morbidity or mortality in this cohort. Preventing or mitigating errors and closely monitoring patients after an error in judgment is prudent and may improve surgical safety.

Firearm-Related Violence in the Pediatric Population

Children, particularly adolescents, are dying from firearm-related injuries. Screening for firearms, early recognition of firearm-related concerns, appropriate referrals, and follow-up are crucial to the safety of our patients and their families. Clinicians are strongly encouraged to address firearm-related violence during clinical encounters. Risk reduction, advocacy, and policy implementation are key in mitigating the long-term negative sequelae of firearm violence in youth. The epidemiology of firearm-related death, mass shootings, school firearm violence, adolescent health, prevention, injury patterns, postinjury care, policy, and resources are all discussed in this article. [Pediatr Ann. 2024;53(1):e28-e33.].

Impact of Medicaid Expansion on Abdominal Surgery Morbidity, Mortality, and Hospital Readmission

INTRODUCTION

Medicaid expansion's (ME) impact on postoperative outcomes after abdominal surgery remains poorly defined. We aimed to evaluate ME's effect on surgical morbidity, mortality, and readmissions in a state that expanded Medicaid (Virginia) compared to a state that did not (Tennessee) over the same time period.

METHODS

Virginia Surgical Quality Collaborative (VSQC) American College of Surgeons National Surgical Quality Improvement Program data for Medicaid, uninsured, and private insurance patients undergoing abdominal procedures before Virginia's ME (3/22/18-12/31/18) were compared with post-ME (1/1/19-12/31/19), as were corresponding non-ME state Tennessee Surgical Quality Collaborative (TSQC) data for the same 2018 and 2019 time periods. Postexpansion odds ratios for 30-d morbidity, 30-d mortality, and 30-d unplanned readmission were estimated using propensity score-adjusted logistic regression models.

RESULTS

In Virginia, 4753 abdominal procedures, 2097 pre-ME were compared to 2656 post-ME. In Tennessee, 5956 procedures, 2484 in 2018 were compared to 3472 in 2019. VSQC's proportion of Medicaid population increased following ME (8.9% versus 18.8%, P < 0.001) while uninsured patients decreased (20.4% versus 6.4%, P < 0.001). Post-ME VSQC had fewer 30-d readmissions (12.2% versus 6.0%, P = 0.013). Post-ME VSQC Medicaid patients had significantly lower probability of morbidity (-8.18, 95% confidence interval: -15.52 ∼ -0.84, P = 0.029) and readmission (-6.92, 95% confidence interval: -12.56 ∼ -1.27, P = 0.016) compared to pre-ME. There were no differences in probability of morbidity or readmission in the TSQC Medicaid population between study periods (both P > 0.05); there were no differences in mortality between study periods in VSQC and TSQC patient populations (both P > 0.05).

CONCLUSIONS

ME was associated with decreased 30-d morbidity and unplanned readmissions in the VSQC. Data-driven policies accounting for ME benefits should be considered.

Subcostal lymph nodes: An unusual sentinel lymph node basin in cutaneous melanoma

BACKGROUND AND OBJECTIVES

Lymphatic drainage from subcostal nodes, along the costal groove, have not previously been characterized as sites for melanoma drainage and metastasis. This study reports a series of patients with subcostal nodes draining primary melanomas, with characterization of the sites of primary melanomas that drain to these nodes.

METHODS

Patients who presented to our institution between 2005 and 2020 with documented cutaneous melanoma and sentinel lymph node biopsy of a subcostal node (sentinel = S), or metastases to subcostal nodes later in clinical management (recurrent = R) were included. Patient demographics, melanoma pathology, nodal features, imaging information, surgical approaches, and outcomes data were collected.

RESULTS

Six patients had subcostal sentinel nodes (SNs). Primary sites included the posterior trunk and lateral chest wall. Subcostal nodes were found under ribs 10-12. Subcostal SNs had at least one dimension measuring 3 mm or less. There were no surgical complications related to removing the subcostal SN.

CONCLUSIONS

Melanoma can metastasize to subcostal lymph nodes and be found at the time of SN biopsy or identified at recurrence. These small nodes are fed by lymphatic channels that run in the neurovascular bundle under the ribs. When lymphatic mapping identifies a subcostal SN, it should be excised.

A Novel Fascial Flap Technique After Inguinal Complete Lymph Node Dissection for Melanoma

INTRODUCTION

Inguinal complete lymph node dissection (CLND) for metastatic melanoma exposes the femoral vein and artery. To protect femoral vessels while preserving the sartorius muscle, we developed a novel sartorius and adductor fascial flap (SAFF) technique for coverage.

METHODS

The SAFF technique includes dissection of fascia off sartorius and/or adductor muscles, rotation over femoral vasculature, and suturing into place. Patients who underwent inguinal CLND with SAFF for melanoma at our institution were identified retrospectively from a prospectively-collected database. Patient characteristics and post-operative outcomes were obtained. Multivariate logistic regression assessed associations of palpable and non-palpable disease with wound complications.

RESULTS

From 2008 to 2019, 51 patients underwent CLND with SAFF. Median age was 62 years, and 59% were female. Thirty-one (61%) patients were presented with palpable disease and 20 (39%) had non-palpable disease. Fifty-five percent (95% confidence interval CI: 40%-69%) experienced at least one wound complication: wound infection was most common (45%; 95% CI: 31%-60%), while bleeding was the least (2%; 95% CI: 0.05%-11%). Complications were similar, with and without palpable disease.

CONCLUSIONS

The SAFF procedure covers femoral vessels, minimizes bleeding, preserves the sartorius muscle, and uses standard surgical techniques easily adoptable by surgeons who perform inguinal CLND.

Topical Neck Cooling Without Systemic Hypothermia Attenuates Myocardial Ischemic Injury and Post-ischemic Reperfusion Injury

Background

Following acute myocardial infarction (MI), irreversible damage to the myocardium can only be reduced by shortening the duration between symptom onset and revascularization. While systemic hypothermia has shown promising results in slowing pre-revascularization myocardial damage, it is resource intensive and not conducive to prehospital initiation. We hypothesized that topical neck cooling (NC), an easily implemented therapy for en route transfer to definitive therapy, could similarly attenuate myocardial ischemia-reperfusion injury (IRI).

Methods

Using an in vivo mouse model of myocardial IRI, moderate systemic hypothermia or NC was applied following left coronary artery (LCA) occlusion and subsequent reperfusion, at early, late, and post-reperfusion intervals. Vagotomy was performed after late NC in an additional group. Hearts were harvested to measure infarct size.

Results

Both hypothermia treatments equally attenuated myocardial infarct size by 60% compared to control. The infarct-sparing effect of NC was temperature-dependent and timing-dependent. Vagotomy at the gastroesophageal junction abolished the infarct-sparing effect of late NC. Cardiac perfusate isolated following ischemia had significantly reduced cardiac troponin T, HMGB1, cell-free DNA, and interferon α and β levels after NC.

Conclusions

Topical neck cooling attenuates myocardial IRI in a vagus nerve-dependent manner, with an effect comparable to that of systemic hypothermia. NC attenuated infarct size when applied during ischemia, with earlier initiation resulting in superior infarct sparing. This novel therapy exerts a cardioprotective effect without requiring significant change in core temperature and may be a promising practical strategy to attenuate myocardial damage while patients await definitive revascularization.

How Total Performance Scores of Medicare Value-Based Purchasing Program Hospitals Change Over Time

BACKGROUND AND PURPOSE

The Medicare Value-Based Purchasing (VBP) program established performance-based financial incentives for hospitals. We hypothesized that total performance scores (TPS) would vary by hospital type.

METHODS

Value-Based Purchasing reports were collected from 2015 to 2017 and merged with the Centers for Medicare and Medicaid Services (CMS) Impact File data. A total of 3,005 hospitals were grouped into physician-owned surgical hospitals (POSH), accountable care organizations (ACO), Kaiser, Vizient, and General hospitals. Longitudinal linear mixed-effects models compared temporal differences of TPS and secondary composite outcome, process, patient satisfaction, safety, and cost efficiency measures between hospital types.

RESULTS

Total performance scores decreased across all hospital types (p < .001). Physician-owned surgical hospitals had the highest TPS (59.9), followed by Kaiser (49.2), ACO (36.7), General (34.8), and Vizient (30.7) (p < .001). Hospital types differed significantly in size, geography, mean case-mix index, Medicare patient discharges, percent Medicare days to inpatient days, Disproportionate Share Hospital payments, and uncompensated care per claim. Scores improved in 84% of POSH and 14.6% of Kaiser hospitals using score reallocations.

CONCLUSION

In comparison with General hospitals, the TPS was higher for POSH and Kaiser and lower for Vizient in part due to weighting reallocation and individual domain scores.

IMPLICATIONS

Centers for Medicare and Medicaid Services scoring system changes have not addressed the methodological biases favoring certain hospital types.

Hydroxychloroquine Attenuates Myocardial Ischemic and Post-Ischemic Reperfusion Injury by Inhibiting the Toll-Like Receptor 9 – Type I Interferon Pathway

Background:

We hypothesized that hydroxychloroquine (HCQ) attenuates myocardial ischemia/reperfusion injury (IRI) via TLR9 – type I interferon (IFN-I) pathway inhibition.

Methods:

The left coronary artery of wild-type (WT) C57BL/6 and congenic TLR9^−/− mice was occluded for 40 minutes, with or without 60 minutes of reperfusion (40’/0’ or 40’/60’). Either ODN-2088 or HCQ (TLR9 inhibitors), or ODN-1826 (TLR9 agonist) was administered to determine effect on infarct size (IS). After 40’/0’, cardiac perfusate (CP) was collected from harvested hearts and administered to either intact WT mice after 20 minutes of ischemia or isolated splenocytes. Type-I interferon (IFNα and IFNβ) levels were measured in plasma and splenocyte culture supernatant, and levels of damage associated molecular patterns HMGB1 and cell-free DNA (cfDNA) were measured in CP.

Results:

After 40’/60’, WT mice treated with HCQ or ODN-2088 had significantly reduced IS. TLR9^−/− mice and HCQ-treated WT mice undergoing 40’/0’ and 40’/60’ similarly attenuated IS, with significantly lower IFN-Is in CP after 40’/0’ and in plasma after 40’/60’. IS was significantly increased in 40’/0’ CP-treated and ODN-1826-treated 20’/60’ WT mice. CP-treated WT splenocytes produced significantly higher IFN-I in culture supernatant, which was significantly reduced with HCQ.

Conclusions:

The TLR9–IFN-I-mediated inflammatory response contributes significantly to both ischemic and post-ischemic myocardial ischemia-reperfusion injury. HMGB1 and cfDNA released from ischemic myocardium activated the intra-myocardial TLR9 – IFN-I inflammatory pathway during ischemia and the extra-myocardial TLR9 – IFN-I inflammatory pathway during reperfusion. Hydroxychloroquine reduces production of IFN-I and attenuates myocardial IRI, likely by inhibiting the TLR9–IFN-I pathway.

Acellular porcine heart matrices: whole organ decellularization with 3D-bioscaffold & vascular preservation

Regenerative medicine, particularly decellularization-recellularization methods via whole-organ tissue engineering, has been increasingly studied due to the growing donor organ shortage. Though numerous decellularization protocols exist, the ideal decellularization protocol for optimal recellularization is unclear. This study was performed to optimize existing heart decellularization protocols and compare current methods using the detergents SDS (sodium dodecyl sulfate), Triton X-100, OGP (octyl β-D-glucopyranoside), and CHAPS (3-[(3-cholamidopropyl) dimethylammonio]-1-propanesulfonate) through retrograde aortic perfusion via aortic cannulation of a whole porcine heart. The goal of decellularization is to preserve extracellular matrix integrity and architecture, which was analyzed in this study through histology, microscopy, DNA analysis, hydroxyproline content analysis, materials analysis and angiography. Effective decellularization was determined by analyzing the tissue organization, geometry, and biological properties of the resultant extracellular matrix scaffold. Using these parameters, optimal decellularization was achieved between 90 and 120 mmHg pressure with 3% SDS as a detergent. Relevance for patients: This study provides important information about whole heart decellularization, which will ultimately contribute to heart bioengineering.

Novel vs clinical organ preservation solutions: improved cardiac mitochondrial protection

Background

Heart transplantation remains the gold standard for end-stage heart failure, with current ex vivo organ storage times limited to 4 to 6 h before critical tissue damage occurs. Many preservation solutions exist in an attempt to limit both ischemic and reperfusion damage. In order to compare the effects of various storage solutions, mitochondrial function can be used to provide a sensitive analysis of cellular metabolic function.

Methods

Experimental plates were seeded with cardiac myoblasts and kept in suspended animation for either 4 or 8 h at either 4^o or 21 °C, in Celsior®, Perfadex®, or Somah storage solutions. Cells were then reanimated for 1 h at 37 °C to simulate a reperfusion or clinical transplant scenario. Cellular bioenergetics were measured immediately thereafter to examine biochemical differences between preservation solutions and their effectiveness on preserving metabolic function.

Results

The oxygen consumption rates of Somah solution were significantly higher than Celsior® and Perfadex® at 4 °C, with the exception of Perfadex® at 4^o for 4 h. This effect was sustained up to 8 h. At 21 °C, oxygen consumption rates of Somah solution are significantly higher than Celsior® and Perfadex® at basal conditions after 4 h, but this effect is not sustained after 8 h.

Conclusions

The purpose of this experiment was to study the efficacy of various preservation solutions on a mitochondrial level. The significantly higher oxygen consumption rates of Somah at 4 °C suggests that Somah solution may have the ability to protect cellular mitochondrial integrity, improve transplanted organ function by reducing ischemic-reperfusion injury, and thereby improve transplant outcomes. Given that Somah offers benefits over Celsior® and Perfadex® at 4 °C, it should be a target in future organ preservation solution research.

Electronic supplementary material

The online version of this article (doi:10.1186/s13019-017-0564-x) contains supplementary material, which is available to authorized users.

Anti-inflammatory properties of amniotic membrane patch following pericardiectomy for constrictive pericarditis

BACKGROUND

Since constrictive pericarditis is most often idiopathic and the pathophysiology remains largely unknown, both the diagnosis and the treatment can be challenging. However, by definition, inflammatory processes are central to this disease process. Amniotic membrane patches have been shown to possess anti-inflammatory properties and are believed to be immune privileged. Due to these properties, amniotic membrane patches were applied intraoperatively in a complicated patient presenting with constrictive pericarditis.

CASE PRESENTATION

A patient with a history of multiple cardiac surgeries presented with marked fatigue, worsening dyspnea and sinus tachycardia. He was found to have constrictive physiology during cardiac catheterization, with cardiac MRI demonstrating hepatic vein dilatation, atrial enlargement and ventricular narrowing. After amniotic membrane patch treatment and pericardiectomy, post-operative cardiac MRI failed to demonstrate any appreciable pericardial effusion or inflammation, with no increased T2 signal that would suggest edema.

CONCLUSIONS

Given the positive results seen in this complex patient, we suggest continued research into the beneficial properties of amniotic membrane patches in cardiac surgery.

Interactions of microorganisms with polymer nanocomposite surfaces containing oxidized carbon nanotubes

In many environmental scenarios, the fate and impact of polymer nanocomposites (PNCs) that contain carbon nanotubes (CNT/PNCs) will be influenced by their interactions with microorganisms, with implications for antimicrobial properties and the long-term persistence of PNCs. Using oxidized single-wall (O-SWCNTs) and multi-wall CNTs (O-MWCNTs), we explored the influence that CNT loading (mass fraction≤0.1%-10%) and type have on the initial interactions of Pseudomonas aeruginosa with O-CNT/poly(vinyl alcohol) (PVOH) nanocomposites containing well-dispersed O-CNTs. LIVE/DEAD staining revealed that, despite oxidation, the inclusion of O-SWCNTs or O-MWCNTs caused PNC surfaces to exhibit antimicrobial properties. The fraction of living cells deposited on both O-SWCNT and O-MWCNT/PNC surfaces decreased exponentially with increasing CNT loading, with O-SWCNTs being approximately three times more cytotoxic on a % w/w basis. Although not every contact event between attached microorganisms and CNTs led to cell death, the cytotoxicity of the CNT/PNC surfaces scaled with the total contact area that existed between the microorganisms and CNTs. However, because the antimicrobial properties of CNT/PNC surfaces require direct CNT-microbe contact, dead cells were able to shield living cells from the cytotoxic effects of CNTs, allowing biofilm formation to occur on CNT/PNCs exposed to Pseudomonas aeruginosa for longer time periods.

Maxillary sinus manifestations of methamphetamine abuse

Methamphetamines are the second most commonly used illicit drug worldwide and cost the United States health-care system ∼$23.4 billion annually. Use of this drug affects multiple organ systems and causes a variety of clinical manifestations. Although there are commonly known sequelae of methamphetamine abuse such as "meth mouth," there is limited evidence regarding maxillary sinus manifestations. The following cases highlight the initial evaluation and management of two methamphetamine abusers with loculated purulent collections within the maxillary sinus as a result of methamphetamine abuse. Our aim was to delineate the otolaryngologic symptoms associated with the patients' methamphetamine abuse. Computed tomography and magnetic resonance imaging studies revealed loculated purulent collections within the maxillary sinus of probable odontogenic origin in both patients. Methamphetamine abuse leading to rampant caries and poor oral hygiene may predispose individuals for craniofacial infections and fluid collections. These cases illustrate the development of maxillary sinusitis and maxilla mucoceles that have been associated with methamphetamine use.