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Ellens NR, Susa S, Hoang R, Love T, Jones J, Santangelo G, Bender MT, Mattingly TK. Comparing Outcomes for Emergent Cranial Neurosurgical Procedures Performed "During Hours" and "After Hours". World Neurosurg 2024; 181:e703-e712. [PMID: 37898280 DOI: 10.1016/j.wneu.2023.10.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 10/21/2023] [Accepted: 10/22/2023] [Indexed: 10/30/2023]
Abstract
OBJECTIVE Surgery performed at night and on weekends is thought to be associated with increased complications. However, the impact of time of day on outcomes has not been studied within cranial neurosurgery. We aim to determine if there are differences in outcomes for cranial neurosurgery performed after hours (AH) compared with during hours (DH). METHODS We performed a single-center retrospective study of cranial neurosurgery patients who underwent emergent surgery from January 2015 through December 2019. Surgery was considered DH if the incision occurred between 8 am and 5 pm Monday through Friday. We assessed outcome measures for differences between operations performed DH or AH. RESULTS Three-hundred and ninety-three patients (114 DH, 279 AH) underwent surgery. There was a lower rate of return to the operating room within 30 days for AH (8.6%) compared with DH (14.0%), P = 0.03, on multivariate analysis. There were no significant differences in length of operation, estimated blood loss, improvement in Glasgow Coma Scale, intensive care unit and total hospital length of stay, 30-day readmission, 30-day mortality, and in-hospital mortality for cases performed DH compared with AH. Further subgroup analyses were performed for patients who underwent immediate surgery for subdural hematomas, with no differences noted in outcomes on multivariate analysis. CONCLUSIONS This study suggests that operating AH does not appear to negatively impact outcomes when compared with operating DH, in cases of cranial neurosurgical emergencies. Further study assessing the impact on elective neurosurgical cases is required.
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Affiliation(s)
- Nathaniel R Ellens
- Department of Neurosurgery, University of Rochester, Rochester, New York, USA.
| | - Stephen Susa
- University of Rochester School of Medicine & Dentistry, Rochester, New York, USA
| | - Ricky Hoang
- Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York, USA
| | - Tanzy Love
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York, USA
| | - Jeremiah Jones
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York, USA
| | | | - Matthew T Bender
- Department of Neurosurgery, University of Rochester, Rochester, New York, USA
| | - Thomas K Mattingly
- Department of Neurosurgery, University of Rochester, Rochester, New York, USA
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Andonov DI, Ulm B, Graessner M, Podtschaske A, Blobner M, Jungwirth B, Kagerbauer SM. Impact of the Covid-19 pandemic on the performance of machine learning algorithms for predicting perioperative mortality. BMC Med Inform Decis Mak 2023; 23:67. [PMID: 37046259 PMCID: PMC10092913 DOI: 10.1186/s12911-023-02151-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 03/15/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Machine-learning models are susceptible to external influences which can result in performance deterioration. The aim of our study was to elucidate the impact of a sudden shift in covariates, like the one caused by the Covid-19 pandemic, on model performance. METHODS After ethical approval and registration in Clinical Trials (NCT04092933, initial release 17/09/2019), we developed different models for the prediction of perioperative mortality based on preoperative data: one for the pre-pandemic data period until March 2020, one including data before the pandemic and from the first wave until May 2020, and one that covers the complete period before and during the pandemic until October 2021. We applied XGBoost as well as a Deep Learning neural network (DL). Performance metrics of each model during the different pandemic phases were determined, and XGBoost models were analysed for changes in feature importance. RESULTS XGBoost and DL provided similar performance on the pre-pandemic data with respect to area under receiver operating characteristic (AUROC, 0.951 vs. 0.942) and area under precision-recall curve (AUPR, 0.144 vs. 0.187). Validation in patient cohorts of the different pandemic waves showed high fluctuations in performance from both AUROC and AUPR for DL, whereas the XGBoost models seemed more stable. Change in variable frequencies with onset of the pandemic were visible in age, ASA score, and the higher proportion of emergency operations, among others. Age consistently showed the highest information gain. Models based on pre-pandemic data performed worse during the first pandemic wave (AUROC 0.914 for XGBoost and DL) whereas models augmented with data from the first wave lacked performance after the first wave (AUROC 0.907 for XGBoost and 0.747 for DL). The deterioration was also visible in AUPR, which worsened by over 50% in both XGBoost and DL in the first phase after re-training. CONCLUSIONS A sudden shift in data impacts model performance. Re-training the model with updated data may cause degradation in predictive accuracy if the changes are only transient. Too early re-training should therefore be avoided, and close model surveillance is necessary.
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Affiliation(s)
- D I Andonov
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - B Ulm
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, University Hospital Ulm, University of Ulm, Albert-Einstein-Allee 23, Ulm, 89081, Germany
| | - M Graessner
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, University Hospital Ulm, University of Ulm, Albert-Einstein-Allee 23, Ulm, 89081, Germany
| | - A Podtschaske
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - M Blobner
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, University Hospital Ulm, University of Ulm, Albert-Einstein-Allee 23, Ulm, 89081, Germany
| | - B Jungwirth
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, University Hospital Ulm, University of Ulm, Albert-Einstein-Allee 23, Ulm, 89081, Germany
| | - S M Kagerbauer
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany.
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, University Hospital Ulm, University of Ulm, Albert-Einstein-Allee 23, Ulm, 89081, Germany.
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Dawoud BES, Alderson L, Khan U, Safaei H, Murphy C, Milne S, Mannion C, Krishnan O, Parmar J. The effect of lockdown during SARS-CoV-2 pandemic on maxillofacial injuries in a level I trauma centre: a comparative study. Oral Maxillofac Surg 2021; 26:463-467. [PMID: 34618280 PMCID: PMC8495432 DOI: 10.1007/s10006-021-01007-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 09/21/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The SARS-CoV-2 pandemic forced many governments to impose nation-wide lockdowns. Government legislation forced limited travel on the population with restrictions on the normal way of life to limit spread of the SARS-CoV-2 virus. The aim of this study is to explore the effects of lockdown on the presentation of maxillofacial trauma in a level I trauma centre. METHODS Comparative analysis was carried out using prospective and retrospective review of all consecutive patients admitted with any maxillofacial fracture in the lockdown period between 15th March and 15th June 2020 with the same period in 2019 to a Regional Trauma Maxillofacial Surgery Unit. Data included basic demographics and mechanism of injury including alcohol/drug influence, polytrauma, site of injury and treatment modality including escalation of care. RESULTS Across both periods, there were a total of one hundred and five (n = 105) recorded episodes of traumatic fractures with fifty-three (n = 53) in the pre-lockdown cohort and fifty-two (n = 52) in the lockdown. Included patients were significantly (p = 0.024) older during lockdown (mean age 41.44 years SD 20.70, range 5-96) with no differences in gender distribution between cohorts (p = 0.270). Patients in lockdown were more likely to be involved in polytrauma (p < 0.05) and have sustained their injury by cycling/running or any outdoor related activity (p = 0.013). Lockdown saw a significant reduction in alcohol and drug related violence (p < 0.05). Significantly more patients required operative management (p = 0.038). CONCLUSION Local lockdowns form part of the governments public health strategy for managing future outbreaks of SARS-CoV-2. Our study showed no significant reduction in volume of trauma during lockdown. It is vital that hospitals maintain trauma capacity to ensure that patients are treated in a timely manner.
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Affiliation(s)
- Basim E S Dawoud
- Oral & Maxillofacial Surgery, Northwest Deanery, Manchester University NHS Foundation Trust, Manchester, UK.
| | - L Alderson
- Leeds Dental Institute, Leeds Teaching Hospitals NHS Trust, Clarendon Way, Leeds, LS2 9LU, UK
| | - U Khan
- Leeds Dental Institute, Leeds Teaching Hospitals NHS Trust, Clarendon Way, Leeds, LS2 9LU, UK
| | - H Safaei
- Leeds Dental Institute, Leeds Teaching Hospitals NHS Trust, Clarendon Way, Leeds, LS2 9LU, UK
| | - C Murphy
- St James' Hospital, Dublin, James's Street, Dublin 8, Ireland
| | - S Milne
- Leeds Teaching Hospitals NHS Trust, Clarendon Way, Leeds, LS2 9LU, UK
| | - C Mannion
- Leeds Teaching Hospitals NHS Trust, Clarendon Way, Leeds, LS2 9LU, UK
| | - O Krishnan
- Leeds Teaching Hospitals NHS Trust, Clarendon Way, Leeds, LS2 9LU, UK
| | - J Parmar
- Leeds Teaching Hospitals NHS Trust, Clarendon Way, Leeds, LS2 9LU, UK
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Bonitz L, Wruck V, Peretti E, Abel D, Hassfeld S, Bicsák Á. Long-term evaluation of treatment protocols for isolated midfacial fractures in a German nation-wide craniomaxillofacial trauma center 2007-2017. Sci Rep 2021; 11:18291. [PMID: 34521960 PMCID: PMC8440643 DOI: 10.1038/s41598-021-97858-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 08/31/2021] [Indexed: 11/30/2022] Open
Abstract
An update on the trends in maxillofacial traumatology provides additional information on the actual and changing needs. This retrospective study aimed to review all patient records of patients treated for isolated midface fractures in the Department of Cranial- and Maxillofacial Surgery at the Dortmund General Hospital between 2007 and 2017. The patient radiographs and patient files were reviewed. The safety and efficacy of the applied methods were controlled by assessing complications based on the Clavien-Dindo classification system. The statistical analysis included descriptive methods including regression analysis and χ2-test. In eleven years, 3474 isolated midface fracture sites have been identified in 2868 patients. The yearly trend is slightly increasing, in elderly clearly worsening, in children and youth decreasing. The male-to-female ratio was 2.16:1 for the whole study population, in the age group 18-25 y.o. 6.95:1 while in elderly above 80 y.o. 1:2.51, the age group specific incidence reflects this result, too. The most common fractures were nasal bone fractures (1405), zygomatic fractures (832) and orbital floor fractures (700). The average hospital stay was 2.7 days, the most fractures were operated within 24 h. The complication rate was 2.02% (Clavien-Dindo class II-V). The incidence of midfacial fractures is increasing in the total population and especially in elderly, but decreasing in children. Development of injury prevention measures is needed in this population. The diagnostic and therapeutic procedures are appropriate, as there is a low complication rate and short inpatient stay observed.
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Affiliation(s)
- Lars Bonitz
- Clinic for Cranial- and Maxillofacial Surgery, Regional Plastic Surgery, Dortmund General Hospital, Chair of the University of Witten-Herdecke, Muensterstrasse 240, 44145, Dortmund, Germany
- Health Faculty, University of Witten/Herdecke, Alfred-Herrhausen-Strasse 45, 58453, Witten, Germany
| | - Vivienne Wruck
- Health Faculty, University of Witten/Herdecke, Alfred-Herrhausen-Strasse 45, 58453, Witten, Germany
| | - Elena Peretti
- Health Faculty, University of Witten/Herdecke, Alfred-Herrhausen-Strasse 45, 58453, Witten, Germany
| | - Dietmar Abel
- Clinic for Cranial- and Maxillofacial Surgery, Regional Plastic Surgery, Dortmund General Hospital, Chair of the University of Witten-Herdecke, Muensterstrasse 240, 44145, Dortmund, Germany
- Health Faculty, University of Witten/Herdecke, Alfred-Herrhausen-Strasse 45, 58453, Witten, Germany
| | - Stefan Hassfeld
- Clinic for Cranial- and Maxillofacial Surgery, Regional Plastic Surgery, Dortmund General Hospital, Chair of the University of Witten-Herdecke, Muensterstrasse 240, 44145, Dortmund, Germany
- Health Faculty, University of Witten/Herdecke, Alfred-Herrhausen-Strasse 45, 58453, Witten, Germany
| | - Ákos Bicsák
- Clinic for Cranial- and Maxillofacial Surgery, Regional Plastic Surgery, Dortmund General Hospital, Chair of the University of Witten-Herdecke, Muensterstrasse 240, 44145, Dortmund, Germany.
- Health Faculty, University of Witten/Herdecke, Alfred-Herrhausen-Strasse 45, 58453, Witten, Germany.
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Okkaoglu MC, Ozdemir FE, Ozdemir E, Karaduman M, Ates A, Altay M. Is there an optimal timing for surgical treatment of pediatric supracondylar humerus fractures in the first 24 hours? J Orthop Surg Res 2021; 16:484. [PMID: 34376234 PMCID: PMC8353804 DOI: 10.1186/s13018-021-02638-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/27/2021] [Indexed: 12/17/2022] Open
Abstract
Background We aimed to determine the ideal surgical timing in the first 24 hours after admission to the hospital of pediatric supracondylar humerus fractures (SHF) that do not require emergent intervention. Materials and Methods Patients who underwent surgery in our institution between January 2011 and January 2019 due to pediatric Gartland type 3 SHFs were evaluated retrospectively. Open fractures, fractures associated with vascular injury and compartment syndrome, flexion type fractures were excluded. A total of 150 Gartland type 3 were included. The effect of early (<12 hours) or late (>12 hours) surgical interventions, daytime or night-time surgeries, working or non-working hour surgeries on operative parameters (operative duration and open reduction rate, reduction quality on postoperative early radiographs) were evaluated in pediatric SHFs. Results Early (<12 hours) or late (>12 hours), daytime or nighttime, working or non-working hour surgeries were found to be similar in Gartland type 3 patients regarding early postoperative reduction quality, duration of surgery, open reduction rate (p>0.05). Mean times passed from first admission to hospital until surgery were longer in working hour, late (>12 hours) and daytime surgery groups than non-working hour, early (<12 hours) and night-time surgery groups (p<0.001). Conclusion Although delaying the operation to the working hours seems to prolong the time until surgery in pediatric Gartland type 3 SHF patients who do not require emergent intervention such as open fractures, neurovascular impairment and compartment syndrome, there may not be a time interval that makes a difference for the patients if surgery is performed within the first 24 hours, thus the surgery could be scheduled according to the surgeons’ preference. Level of Evidence: Level 3, Retrospective cohort study
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Affiliation(s)
- Mustafa Caner Okkaoglu
- Department of Orthopedics and Traumatology, University of Health Sciences, Ankara Kecioren Training and Research Hospital, Pınarbaşı District, Sanatoryum Street, D:25, 06280, Keçiören, Ankara, Turkey.
| | - Fırat Emin Ozdemir
- Department of Orthopedics and Traumatology, University of Health Sciences, Ankara Kecioren Training and Research Hospital, Pınarbaşı District, Sanatoryum Street, D:25, 06280, Keçiören, Ankara, Turkey
| | - Erdi Ozdemir
- Department of Orthopedics and Traumatology, University of Health Sciences, Ankara Kecioren Training and Research Hospital, Pınarbaşı District, Sanatoryum Street, D:25, 06280, Keçiören, Ankara, Turkey
| | - Mert Karaduman
- Department of Orthopedics and Traumatology, University of Health Sciences, Ankara Kecioren Training and Research Hospital, Pınarbaşı District, Sanatoryum Street, D:25, 06280, Keçiören, Ankara, Turkey
| | - Ahmet Ates
- Department of Orthopedics and Traumatology, University of Health Sciences, Ankara Kecioren Training and Research Hospital, Pınarbaşı District, Sanatoryum Street, D:25, 06280, Keçiören, Ankara, Turkey
| | - Murat Altay
- Department of Orthopedics and Traumatology, University of Health Sciences, Ankara Kecioren Training and Research Hospital, Pınarbaşı District, Sanatoryum Street, D:25, 06280, Keçiören, Ankara, Turkey
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Hardie JA, Brennan PA. The personal limitations checklist: human factors insights from air accidents to reduce intraoperative harm. Br J Oral Maxillofac Surg 2020; 59:853-857. [PMID: 34274172 DOI: 10.1016/j.bjoms.2020.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/10/2020] [Indexed: 11/27/2022]
Abstract
High Reliability Organisations (HRO), including healthcare and aviation, have a common focus on risk management. The human element is a 'weak link' which may result in accidents or adverse events taking place. Surgeons and other healthcare professionals can learn from aviation's rigorous approach to the role of human factors (HF) in such events, and how we can minimise them. Air Accident Investigation Branch (AAIB) reports show that fatal accidents are frequently caused by pilots flying outside their own personal limits, those of the aircraft or environment. Similarly, patient morbidity or mortality may occur if surgeons work outside personal their capability, with poor procedure selection and patient optimisation, or with a team or theatre environment not suited to the procedure. We introduce the personal limitations checklist - a tool adapted from aviation that allows surgeons to define their limits in advance of any decision to operate, and develop critical self-reflection. It also allows management of patient expectations, shared decision making, and flattening of team hierarchy. The minimum skills, patient characteristics, team and theatre resources for any given procedure to proceed are defined. If the surgeon is 'out of limits', redressing these factors, seeking additional assistance, or thorough patient consenting may be required for the safe conduct of the procedure. We explore external pressures that could cause a surgeon to exceed both personal and organisational limits.
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Affiliation(s)
- J A Hardie
- Trauma & Orthopaedic Department, Frimley Park Hospital, Camberley GU16 7UJ, UK.
| | - P A Brennan
- Maxillofacial Unit, Queen Alexandra Hospital, Portsmouth PO6 3LY, UK.
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Kshirsagar A, Kannur S. Impact of Nighttime Emergency Surgeries on Patients' Outcome: A Prospective Study. Niger J Surg 2020; 26:99-103. [PMID: 33223805 PMCID: PMC7659759 DOI: 10.4103/njs.njs_32_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 09/22/2019] [Accepted: 11/25/2019] [Indexed: 12/02/2022] Open
Abstract
Background and Aim: The aim of this study was to evaluate the relationship between the time of the day the surgery is conducted and its outcome to provide better protection for patients against fatigue-related errors and reduce the incidence of postoperative morbidity/mortality. Methods: All general surgical emergency operations recorded prospectively on the operation theater database of Krishna Hospital and Medical Research Centre, Karad, between April 01, 2018, and March 31, 2019, were included in this study. The operations were categorized according to whether they commenced during the daytime (08:01–20:00 h), or nighttime (20:01–08:00 h). The type of procedure and grade of the participating surgical personnel were also recorded. Results: In total, 1128 emergency operations were performed over the study period. The number of emergency procedures performed during the daytime and nighttime was 652 (57.8%) and 476 (42.2%), respectively. Laparotomies and complex vascular procedures collectively accounted for half of all the cases performed after midnight, whereas they represented only 30% of the combined daytime emergency workload. Thirty-two percent (n = 152) of all nighttime operations were supervised or performed by a consultant surgeon. Conclusion: When considering a surgical procedure, surgeons must bear in mind that cases that start after the routine hours may face an elevated risk of complications that warrants further evaluation and surgical start times are associated with risk-adjusted patient outcomes.
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Affiliation(s)
- Ashok Kshirsagar
- Department of Surgery, Krishna Hospital and Medical Research Centre, Krishna Institute of Medical Sciences "Deemed to be" University, Karad, Maharashtra, India
| | - Shirish Kannur
- Department of Surgery, Krishna Hospital and Medical Research Centre, Krishna Institute of Medical Sciences "Deemed to be" University, Karad, Maharashtra, India
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Martin S, Liebel FX, Fadda A, Lazzerini K, Harcourt-Brown T. Same-day surgery may reduce the risk of losing pain perception in dogs with thoracolumbar disc extrusion. J Small Anim Pract 2020; 61:442-448. [PMID: 32462659 DOI: 10.1111/jsap.13147] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/31/2020] [Accepted: 04/10/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To compare the proportions of dogs with thoracolumbar disc extrusion that lose pelvic limb pain perception if surgery is performed on the day of admission or delayed overnight. To describe the outcome of those dogs that deteriorate to lose pain perception. MATERIALS AND METHODS Retrospective, single centre study on 273 client-owned dogs with thoracolumbar disc extrusion and intact pain perception, but inability to walk unaided on their pelvic limbs. Dogs were subdivided into two groups: early surgery (spinal decompression between their examination at day of admission and the following morning), and delayed surgery (did not undergo surgery between admission and the following morning). The proportion of dogs that lost pelvic limb pain perception overnight was compared between the early and delayed surgery groups. RESULTS Seven of 151 dogs in the early surgery group lost pain perception overnight compared to 15 of 122 in the delayed surgery group (Fisher's exact test, P = 0.025). Number-needed-to-treat analysis suggested that 14 dogs (95% confidence interval: 7-106 dogs) need early surgery to prevent one losing pain perception overnight. Five of the seven dogs that lost pain perception in the early surgery group recovered pain perception by 3 weeks post-operatively, compared to eight of 14 in the delayed group. CLINICAL SIGNIFICANCE This study suggests that an overnight delay before spinal decompression increases the risk of clinically meaningful deterioration in dogs unable to walk following thoracolumbar disc extrusion.
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Affiliation(s)
- S Martin
- Langford Veterinary Services, University of Bristol, Langford, Bristol, BS40 5DU, UK
| | - F X Liebel
- Langford Veterinary Services, University of Bristol, Langford, Bristol, BS40 5DU, UK
| | - A Fadda
- Langford Veterinary Services, University of Bristol, Langford, Bristol, BS40 5DU, UK
| | - K Lazzerini
- Langford Veterinary Services, University of Bristol, Langford, Bristol, BS40 5DU, UK
| | - T Harcourt-Brown
- Langford Veterinary Services, University of Bristol, Langford, Bristol, BS40 5DU, UK
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Rupp M, Schäfer C, Heiss C, Alt V. Pinning of supracondylar fractures in children - Strategies to avoid complications. Injury 2019; 50 Suppl 1:S2-S9. [PMID: 30955872 DOI: 10.1016/j.injury.2019.03.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 03/28/2019] [Indexed: 02/08/2023]
Abstract
In the pediatric population supracondylar humerus fracture (SHF) is one of the most common injuries. Diagnosis is based on inspection and conventional radiography. SHFs should be classified according to the modified Gartland classification, which guides treatment. Non-displaced or minimally displaced fractures (Gartland type-I) should be treated non-operatively, completely displaced type III fractures require closed reduction and K-wire fixation. In type-II fractures, important landmarks, such as the anterior humeral line (Roger´s line), the shaft-physeal angle (Baumann´s angle) and the shaft condylar angle should be considered to guide treatment. Special attention has to be paid for potential rotational dislocation, which is indicated by a ventral spur. In such cases surgery is necessary. The degree of acceptable extension malpositioning depends on patient´s age. In 10-year-old children fractures with a shaft condylar angle of more than 15° are still suitable for non-operative therapy. Timing for surgery is controversially discussed. Postponing surgery to the next day seems reasonable if absence of pain, intact soft tissue and normal neurovascular status are present. Neurovascular complications are not uncommon, especially in Gartland type-III fractures and in cases with additional forearm injuries. A white hand without palpable pulse needs emergency surgery, the management of the pulseless pink hand is still controversially discussed. Different operative techniques exist for surgical treatment. The golden standard is closed reduction and percutaneous K-wire pinning. Crossed pinning seems to achieve best biomechanical stability. Since ulnar nerve injuries are reported to occur in 6% after medially inserting K-wires, lateral divergent insertion of two K-wires has been compared to crossed pinning fixation in several randomized controlled trials. Meta-analyses demonstrated a higher risk for ulnar nerve injury for the crossed pinning technique while risk for loss of fixation was higher in lateral only pinning. In both cases, K-wires should be removed 3-6 weeks after surgery with consolidation of the fracture. Clinical and radiological follow-up should be carried out at 3 weeks post fracture fixation to rule out loss of reduction. If this should occur, early revision surgery has been demonstrated beneficial.
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Affiliation(s)
- Markus Rupp
- Department of Trauma Surgery, University Hospital Giessen-Marburg GmbH, Campus Giessen, 35385, Giessen, Germany
| | - Christoph Schäfer
- Department of Trauma Surgery, University Hospital Giessen-Marburg GmbH, Campus Giessen, 35385, Giessen, Germany
| | - Christian Heiss
- Department of Trauma Surgery, University Hospital Giessen-Marburg GmbH, Campus Giessen, 35385, Giessen, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Medical Centre Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany.
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‘After-hours’ non-elective spine surgery is associated with increased perioperative adverse events in a quaternary center. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 28:817-828. [DOI: 10.1007/s00586-018-5848-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 11/30/2018] [Indexed: 10/27/2022]
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Subramaniam S, Febbo A, Clohessy J, Bobinskas A. Retrospective analysis of postoperative interventions in mandibular fractures: a shift towards outpatient day surgery care. Br J Oral Maxillofac Surg 2018; 56:486-489. [PMID: 29754748 DOI: 10.1016/j.bjoms.2018.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 02/08/2018] [Indexed: 11/16/2022]
Abstract
The management of fractured mandibles typically involves admission and operation at the time of presentation. While this should involve only a short stay in hospital these patients are surgically stable, and so priority is often given to more urgent cases. We retrospectively evaluated the postoperative medical requirements of patients who were operated on at Fiona Stanley Hospital, Perth, Western Australia between 1 January 2015 and 31 December 2016. Patients were excluded if they had had multiple facial fractures, multiple injuries, had fractures that were comminuted or in edentulous mandibles, and those who had been in hospital for preoperative medical investigations and care. We also excluded fractures in children aged 16 years and under. The results showed that of a total of 173 patients, 12 had had medical consultations during their hospital stay, and only four had required intervention. The mean (range) preoperative time was 37 (1 - 46) hours and that from operation to discharge 21.5 (2 - 93) hours. While traditional management involves emergency admission and open reduction and internal fixation as soon as possible, delays of up to five days were not associated with appreciably worse outcomes. This, together with the negligible requirements for medical management perioperatively, provides a strong argument for a selected group to be treated as outpatients.
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Affiliation(s)
- Shiva Subramaniam
- Consultant, Department of Oral and Maxillofacial Surgery, Fiona Stanley Hospital, Murdoch, WA, 6150.
| | - Anthony Febbo
- Registrar, Department of Oral and Maxillofacial Surgery, Royal Perth Hospital, Perth, WA, 6000.
| | - James Clohessy
- Medical Intern and Associate Lecturer, Faculty of Medicine, University of New South Wales, Sydney, NSW, 2052.
| | - Alexander Bobinskas
- Consultant, Department of Oral and Maxillofacial Surgery, Fiona Stanley Hospital, Murdoch, WA, 6150.
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12
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Wynell-Mayow W, Guevel B, Quansah B, O'Leary R, Carrothers AD. Cambridge Polytrauma Pathway: Are we making appropriately guided decisions? Injury 2016; 47:2117-2121. [PMID: 27496722 DOI: 10.1016/j.injury.2016.05.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 05/29/2016] [Indexed: 02/02/2023]
Abstract
Addenbrooke's Hospital, the Major Trauma Centre for the East of England Trauma Network, received 1070 major trauma patients between 1st January and 31st December 2014. In order to improve care, an audit was performed of 59 patients meeting our own selection criteria for orthopaedic polytrauma between 1st January 2013 and 31st December 2013. The Cambridge Polytrauma Pathway was devised through NCEPOD guidelines, literature review, internal and external discussion. It facilitates provision of best practice Early Appropriate Care, encompassing - multidisciplinary consultant decisions around the patient in our Neurological and Trauma Critical Care Unit, early full body trauma CT scans, serial measurements of lactate and fibrinogen levels, and out-of-hours orthopaedic theatre reserved for life-and-limb threatening injuries. Re-audit was conducted of 15 patients meeting selection criteria, admitted between 1st October 2014 and 31st March 2015. Significant improvements in recording of lactate and fibrinogen were demonstrated, both on admission (lactate - p<0.000, fibrinogen - p=0.015), and preoperatively (lactate - p=0.003, fibrinogen - p=0.030). Time to trauma CT was unchanged (p=0.536) with a median time to CT of 0.53h at re-audit (IQR 0.48-0.75). The number of patients receiving definitive orthopaedic intervention out-of-hours reduced from 8 to zero (p=0.195). The approach of facilitating management decisions to be made at early daytime MDT meetings has been adopted. It is anticipated that this pathway will improve outcomes in orthopaedic polytrauma patients and it is recommended that either the GOS-E, or the EQ-5D scoring systems be introduced to assess this.
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Affiliation(s)
- William Wynell-Mayow
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge CB2 0QQ, UK
| | - Borna Guevel
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge CB2 0QQ, UK
| | - Benjamin Quansah
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge CB2 0QQ, UK
| | - Ronan O'Leary
- Neurosciences and Trauma Critical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge CB2 0QQ, UK
| | - Andrew D Carrothers
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge CB2 0QQ, UK.
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13
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Fernandes S, Carvalho AF, Rodrigues AJ, Costa P, Sanz M, Goulart A, Rios H, Leão P. Day and night surgery: is there any influence in the patient postoperative period of urgent colorectal intervention? Int J Colorectal Dis 2016; 31:525-33. [PMID: 26744066 DOI: 10.1007/s00384-015-2494-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND Medical activity performed outside regular work hours may increase risk for patients and professionals. There is few data with respect to urgent colorectal surgery. The aim of this work was to evaluate the impact of daytime versus nighttime surgery on postoperative period of patients with acute colorectal disease. METHODS A retrospective study was conducted in a sample of patients with acute colorectal disease who underwent urgent surgery at the General Surgery Unit of Braga Hospital, between January 2005 and March 2013. Patients were stratified by operative time of day into a daytime group (surgery between 8:00 and 20:59) and the nighttime group (21:00-7:59) and compared for clinical and surgical parameters. A questionnaire was distributed to surgeons, covering aspects related to the practice of urgent colorectal surgery and fatigue. RESULTS A total of 330 patients were included, with 214 (64.8%) in the daytime group and 116 (35.2%) in the nighttime group. Colorectal cancer was the most frequent pathology. Waiting time (p < 0.001) and total length of hospital stay (p = 0.008) were significantly longer in the daytime group. There were no significant differences with respect to early or late complications. However, 100% of surgeons reported that they are less proficient during nighttime. CONCLUSIONS Among patients with acute colorectal disease subjected to urgent surgery, there was no significant association between nighttime surgery and the presence of postoperative medical and surgical morbidities. Patients who were subjected to daytime surgery had longer length of stay at the hospital.
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Affiliation(s)
- Sofia Fernandes
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal.,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Ana F Carvalho
- General Surgery, Hospital of Braga, Braga, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal.,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Ana J Rodrigues
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal.,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Patrício Costa
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal.,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Moreno Sanz
- General Surgery, Complejo Hospitalario La Mancha-Centro, Cdad. Real, Spain
| | | | - Hugo Rios
- General Surgery, Hospital of Braga, Braga, Portugal
| | - Pedro Leão
- General Surgery, Hospital of Braga, Braga, Portugal. .,Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal. .,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal.
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14
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Isgren CM, Salem SE, Archer DC, Worsman FCF, Townsend NB. Risk factors for surgical site infection following laparotomy: Effect of season and perioperative variables and reporting of bacterial isolates in 287 horses. Equine Vet J 2016; 49:39-44. [PMID: 26713622 DOI: 10.1111/evj.12564] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 12/17/2015] [Indexed: 12/14/2022]
Abstract
REASONS FOR PERFORMING STUDY Surgical site infection (SSI) is an important cause of post operative morbidity following laparotomy. OBJECTIVES To investigate risk factors for SSI, including effect of season and surgery performed outside normal working hours, and to report bacterial isolates and antimicrobial resistance patterns. STUDY DESIGN Retrospective cohort study. METHODS Data were obtained from horses that had undergone exploratory laparotomy over a 3-year period (2010-2013) in a UK hospital population. SSI was defined as any purulent or serous discharge from the laparotomy incision of >24 h duration that developed during hospitalisation. Multivariable logistic regression was used to identify associations between pre-, intra- and post operative variables and altered likelihood of SSI. RESULTS Surgical site infection developed in 73/287 (25.4%) horses during hospitalisation. Horses of greater bodyweight (odds ratio [OR] 1.002, 95% confidence interval [CI] 1.0002-1.005, P = 0.03), increased packed cell volume (≥48%) on admission (OR 3.03, 95% CI 1.32-6.94, P = 0.01), small intestinal resection (OR 2.27, 95% CI 1.15-4.46, P = 0.02) and post operative colic (OR 2.86, 95% CI 1.41-5.79, P = 0.003) were significantly associated with increased likelihood of SSI in a multivariable model. SSI was also significantly more likely to occur during winter (OR 3.84, 95% CI 1.38-10.70, P = 0.01) and summer (OR 5.63, 95% CI 2.07-15.3, P = 0.001) months in the model. Three-layer closure of the incision was protective (OR 0.31, 95% CI 0.16-0.58, P<0.001) compared to 2-layer closure. There was no effect of surgery being performed outside normal working hours (P = 0.5). The most common bacterial isolates were Escherichia coli (59.5%), Enterococcus spp. (42.4%) and Staphylococcus spp. (25.4%). Penicillin resistant isolates accounted for 92% (96/104) of isolates while 18% (21/119) of isolates were gentamicin resistant. CONCLUSIONS Laparotomy during winter and summer months was associated with increased likelihood of SSI but there was no effect of surgery performed outside normal working hours. This information assists in identifying horses at high risk of SSI and informing development of preventive strategies.
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Affiliation(s)
- C M Isgren
- Philip Leverhulme Equine Hospital, School of Veterinary Science/Institute of Infection and Global Health, Leahurst Campus, University of Liverpool, Neston, Wirral, UK
| | - S E Salem
- Philip Leverhulme Equine Hospital, School of Veterinary Science/Institute of Infection and Global Health, Leahurst Campus, University of Liverpool, Neston, Wirral, UK.,Department of Surgery, Faculty of Veterinary Medicine, Zagazig University, Zakazik, Egypt
| | - D C Archer
- Philip Leverhulme Equine Hospital, School of Veterinary Science/Institute of Infection and Global Health, Leahurst Campus, University of Liverpool, Neston, Wirral, UK
| | - F C F Worsman
- Philip Leverhulme Equine Hospital, School of Veterinary Science/Institute of Infection and Global Health, Leahurst Campus, University of Liverpool, Neston, Wirral, UK
| | - N B Townsend
- Philip Leverhulme Equine Hospital, School of Veterinary Science/Institute of Infection and Global Health, Leahurst Campus, University of Liverpool, Neston, Wirral, UK
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Isedale G, Harris I, Rider M. Improving hand surgery access and care through service redesign. ANZ J Surg 2015; 86:581-3. [PMID: 26631355 DOI: 10.1111/ans.13395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND The hand surgery service in our major trauma centre comprised predominantly emergency surgery with poor theatre access, resulting in many cases being postponed and performed after hours and with low rates of supervision. METHOD We report the results of a before-and-after study describing the change in processes and outcomes associated with a change in the model of care to a sequestered, area-wide hand surgery service. The study uses data from 12 months prior to and 12 months after the change in practice. RESULTS The hand service experienced a 24.7% increase in demand for surgery in the first 12 months after the relocation. However, demand for overnight beds fell by 303%, the rate of specialist supervision increased from 23.5% to 81.3% (P < 0.0001), the time between admission and surgery fell from 5.1 to 2.7 h (P < 0.0001), the rate of cancellations fell from 21.8% to 7.7% (P < 0.0001), the proportion of emergency surgery conducted in normal hours increased from 65.8% to 93.6% (P < 0.0001), the 28-day unplanned reoperation rate fell from 1.2% to 0.5% (P = 0.02) and surgical time decreased to an equivalent of 41 half day operating sessions per year. CONCLUSION These outcomes are in line with international experiences of service centralization. The project may be used as a template for practice change in other surgical fields.
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Affiliation(s)
- Grant Isedale
- Critical Care & Surgical Specialties Clinical Stream, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
| | - Ian Harris
- South Western Sydney Clinical School, University of New South Wales, Ingham Institute for Applied Medical Research, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
| | - Mark Rider
- South Western Sydney Hand Centre, Fairfield Hospital, Prairiewood, New South Wales, Australia
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Recent advances in the management of oral and maxillofacial trauma. Br J Oral Maxillofac Surg 2015; 53:913-21. [DOI: 10.1016/j.bjoms.2015.08.261] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 08/20/2015] [Indexed: 11/17/2022]
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Perioperative outcomes of primary renal tumour resections: comparison of in-hours to out-of-hours surgery. Pediatr Surg Int 2014; 30:1003-7. [PMID: 25070689 DOI: 10.1007/s00383-014-3560-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Primary resection is typically performed for children with localised suspected Wilms tumours. Resource limitation may necessitate performing these operations nights and weekends. We hypothesise that outcomes will be worse in patients having nephrectomies out-of-hours (OOH) compared to those in-hours (IH). METHODS With IRB ethics approval, primary renal tumour resections performed on oncology patients from 1989-2011 were reviewed retrospectively. IH operations were defined as Monday-Friday 0745-1530 hours. Outcomes included major intraoperative complications, capsule rupture, and blood loss. Data were analysed using Fischer Exact and Mann-Whitney U tests. RESULTS There were 64 patients with renal tumours who underwent primary resection. Forty-five procedures were performed IH, and 19 OOH. Groups were similar in age, ASA status, tumour size and grade. In a comparison of major intraoperative complications, capsule rupture, and mean blood loss, differences were 2 vs. 26% (p = 0.007), 27 vs. 42% (p = 0.12), 178 vs. 244 ml (p = 0.15) for IH and OOH respectively. There was one perioperative mortality (OOH). CONCLUSIONS Primary renal tumour resections performed OOH were associated with an increase in major complications compared to those performed in standard hours. Avoidance of OOH operating where possible may reduce morbidity for children undergoing primary renal tumour resections.
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