Early Ambulation is Associated with Improved Outcomes Following Colorectal Surgery

BACKGROUND

The Enhanced Recovery After Surgery (ERAS) society lists early mobilization as one of their recommendations for improving patient outcomes following colorectal surgery. The level of supporting evidence, however, is relatively weak, and furthermore, the ERAS guidelines do not clearly define "early" mobilization. In this study, we define mobilization in terms of time to first ambulation after surgery and develop an outcome-based cutoff for early mobilization.

METHODS

This is a retrospective cohort study comprised of 291 patients who underwent colorectal operations at a large, academic medical center from June to December 2019. Three cutoffs (12 hours, 24 hours, and 48 hours) were used to divide patients into early and late ambulation groups for each cutoff, and statistical analysis was performed to determine differences in postoperative outcomes between the corresponding groups.

RESULTS

Multivariate analysis showed no difference between the early and late ambulation groups for the 12-hour and 48-hour cutoffs; however, ambulation before 24 hours was associated with a decreased rate of severe complications as well as fewer adverse events overall. Patients who ambulated within 24 hours had a 4.1% rate of severe complications and a 22.1% rate of experiencing some adverse event (complication, return to the emergency department, and/or readmission). In comparison, 11.8% of patients who ambulated later experienced a severe complication (P = 0.026), while 36.1% of patients experienced some adverse event (P = 0.011).

CONCLUSIONS

Ambulation within 24 hours after colorectal surgery is associated with improved postoperative outcomes, particularly a decreased rate of severe complications.

FDA-approved machine learning algorithms in neuroradiology: A systematic review of the current evidence for approval

Over the past decade, machine learning (ML) and artificial intelligence (AI) have become increasingly prevalent in the medical field. In the United States, the Food and Drug Administration (FDA) is responsible for regulating AI algorithms as "medical devices" to ensure patient safety. However, recent work has shown that the FDA approval process may be deficient. In this study, we evaluate the evidence supporting FDA-approved neuroalgorithms, the subset of machine learning algorithms with applications in the central nervous system (CNS), through a systematic review of the primary literature. Articles covering the 53 FDA-approved algorithms with applications in the CNS published in PubMed, EMBASE, Google Scholar and Scopus between database inception and January 25, 2022 were queried. Initial searches identified 1505 studies, of which 92 articles met the criteria for extraction and inclusion. Studies were identified for 26 of the 53 neuroalgorithms, of which 10 algorithms had only a single peer-reviewed publication. Performance metrics were available for 15 algorithms, external validation studies were available for 24 algorithms, and studies exploring the use of algorithms in clinical practice were available for 7 algorithms. Papers studying the clinical utility of these algorithms focused on three domains: workflow efficiency, cost savings, and clinical outcomes. Our analysis suggests that there is a meaningful gap between the FDA approval of machine learning algorithms and their clinical utilization. There appears to be room for process improvement by implementation of the following recommendations: the provision of compelling evidence that algorithms perform as intended, mandating minimum sample sizes, reporting of a predefined set of performance metrics for all algorithms and clinical application of algorithms prior to widespread use. This work will serve as a baseline for future research into the ideal regulatory framework for AI applications worldwide.

Diabetes as a Risk Factor for Perforated Appendicitis: A National Analysis

BACKGROUND

A few important risk factors play into rates of perforation following acute appendicitis. Diabetes may be an additional risk factor due to various systemic complications that may contribute to perforation and additional adverse outcomes following acute appendicitis, all of which currently remains unknown in the United States.

METHODS

Adult patients with acute appendicitis under 65 years of age were identified from the National Inpatient Sample between 2012 and 2014 and the distribution of baseline variables was examined across diabetic status using Rao-Scott chi square and student's t-test. A propensity score match was implemented for a conditional logistic regression that assessed differences in rates of perforation, outcomes, as well as postoperative complications.

RESULTS

Among all patients with acute appendicitis, approximately 7% had diabetes. Diabetics were more likely to experience perforated appendicitis (odds ratio 95% confidence interval 1.093 (1.029, 1.160); P = .0036), experience a longer length of stay (1.540 (1.434, 1.654); P < .0001), receive an open appendectomy (1.139 (1.05, 1.236); P = .0018), and experience postoperative cardiovascular complications (2.103 (1.325, 3.340)); P = .0016).

DISCUSSION

Diabetic adult patients under 65 years of age with acute appendicitis experience higher rates in perforation, a longer length of stay, more open surgical approach, and cardiovascular postoperative complications. Diabetes should be one of many risk factors considered in the evaluation and management of perforation following acute appendicitis.

Trends in utilization of laparoscopic colectomy according to race: an analysis of the NIS database

BACKGROUND

Laparoscopic colectomy has been associated with improved recovery and decreased complications when compared to an open approach. Consequently, the rates of laparoscopic colectomy have increased. Race has been identified as a factor that influences a patient's likelihood of undergoing laparoscopic colectomy. Therefore, the purpose of this study is to analyze the rates of laparoscopic colectomy stratified by race over time.

METHODS

Patients were selected using procedure codes for colectomy within the National Inpatient Sample (NIS) database from 2009 to 2018. The primary independent variable was race (Black, BL; Hispanic, HI; White, WH), and the primary outcome was surgical approach (laparoscopic vs open). Covariates included age, sex, case complexity, insurance status, income, year of surgery, urbanicity, region, bedsize, and teaching status. We examined the univariable association of race with laparoscopic vs open colectomy with chi-square. We used multivariable logistic regression to examine the association of race with procedure type adjusting for covariates. All analyses were done using SAS (version 9.4, Cary, NC) with p < .05 considered significant.

RESULTS

267,865 patients (25,000 BL, 19,685 HI, and 223,180 WH) were identified. Laparoscopy was used in 47% of cases, and this varied significantly by race (BL 44%, HI 49%, WH 47%, p < .0001). After adjusting for covariates, Black patients had significantly lower adjusted odds of undergoing laparoscopic colectomy vs White patients (aOR 0.92, p < 0.0001). Utilization of laparoscopy was similar in Hispanic compared to White patients (aOR 1.00, p = 0.9667). Racial disparity in the adjusted odds of undergoing laparoscopic colectomy was persistent over time.

CONCLUSION

Race was independently associated with the rate of laparoscopic colectomy, with Black patients less likely to receive laparoscopic surgery than White patients. This disparity persisted over a decade. Attention should be paid to increasing the rates of laparoscopic colectomy in under-represented populations in order to optimize surgical care and address racial disparities.

Age Does Not Predict Failure to Rescue Following Resuscitative Thoracotomy in Penetrating Trauma

BACKGROUND

The limitations of resuscitative thoracotomy (RT) after penetrating trauma have been well documented, but there is a paucity of data on the effect age has on mortality. This begs the question as to the utility of RT in an aging patient population. We investigate the significance of age as a predictor for failure to rescue after RT in penetrating trauma.

OBJECTIVE

We sought to identify whether chronologic age has a measurable effect on rates of failure to rescue after RT.

METHODS

We performed a retrospective cohort analysis using the Trauma Quality Improvement Program from 2011 to 2015 including all pulseless patients undergoing RT after penetrating injury. Our primary outcome was failure to rescue defined as death in the emergency department after RT. Multivariate analyses were performed to identify the relationship between age and morality controlling for injury severity.

RESULTS

One thousand one hundred twelve RTs were performed during the study period with an overall failure to rescue rate of 61.8% (n = 687) within the emergency department and an in-hospital mortality rate of 96.9%, which is in line with national data. On univariate analysis, there was no significant association between age and mortality (p = 0.44). On multivariate analysis examining the interaction between age and mortality adjusting for injury severity, we found that chronologic age was not an independent predictor of death after RT.

CONCLUSIONS

Age does not appear to be an independent predictor of failure to rescue after RT in penetrating trauma and should not be a sole determinant in procedural decision making.

Comparison of Thessaly Test with Joint Line Tenderness and McMurray Test in the Diagnosis of Meniscal Tears

Introduction:

Meniscus injuries are the most frequent problem of the knee. The aim of this study was to investigate the accuracy of the Thessaly test and comparing it with those of McMurray and Joint-line tenderness tests for diagnosing meniscal tears.

Materials and methods: This study was designed as a prospective observational one done in an outpatient clinic at a university hospital. 106 patients with knee pain and 82 age-matched control were included during study period (from February 2014 to January 2015). Each patient was clinically examined with McMurray, Thessaly, and joint line tenderness tests. Then, the findings were matched by MRI and arthroscopic findings. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy were calculated as main outcomes.

Results:

Based on MRI, Thessaly was the most sensitive for medial meniscus tears (56.2%), while McMurray and joint-line tenderness were more specific (89.1% and 88.0%, respectively). For lateral meniscus tears, McMurray was the most sensitive (56.2%) and all were specific (McMurray 89.6%, Thessaly 88.4%, joint-line tenderness 90.2%). With arthroscopy, Thessaly was the most sensitive for medial meniscus (76.6%), while McMurray and joint-line tenderness were more specific (81.0%, and 81.0%). Agreement with arthroscopy was the highest with McMurray (for medial meniscus kappa=0.40, p<0.001, and for lateral meniscus kappa=0.38, p=0.002).

Conclusion:

The Thessaly can be used to screen for medial meniscus tears. McMurray and joint-line tenderness should be used for suspected medial meniscus tears. For lateral meniscus, McMurray is appropriate for screening and all the tests are useful in clinic.