Surgery
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Urinary tract infections, a risk factor for readmission, have been deemed a potentially preventable problem and, therefore, not reimbursable by the Centers for Medicare and Medicaid Services since 2008. Defining the risk factors for development of urinary tract infection in the postoperative period will provide risk stratification for development of urinary tract infection in these challenging patients. ⋯ Although postoperative rates of urinary tract infection decreased after the Centers for Medicare and Medicaid Services decree, the lack of reimbursement is not justified, as few modifiable risk factors to further improve postoperative urinary tract infection rates in elderly emergency surgical patients were identified. Although targeted interventions may be developed, this complication is not easily preventable and will continue to plague acute care surgeons taking care of this challenging patient population.
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Severe injury initiates an inflammatory response that can perpetuate immunological dysfunction, uncontrolled inflammation, and subsequent multisystem organ failure. MicroRNAs (miRNAs) have recently been identified as regulators of this inflammatory response. Our study sought to identify the differential expression of unique miRNAs and their correlations with genes of the Toll-like receptor (TLR) pathways, and clinical parameters in the severely injured. ⋯ Differential expression and correlations between miRNAs, genes of the TLR pathways, and clinical parameters are unique findings in the severely injured and may lead to a greater understanding of the regulation of sterile inflammation after severe injury.
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Hepatic resection is associated with substantial morbidity and resource use. To contain costs and improve outcomes, recent health care regulations focus on reducing hospital readmissions while using readmission rates as a quality measure. The goal of this investigation was to characterize the incidence, patterns, and risk factors for readmission after resection for hepatocellular carcinoma. ⋯ Early readmission after hepatectomy remains relatively common. Postoperative complications and patient comorbidities are the dominant factors in readmission, and we must be mindful of those patients at increased risk for readmission.
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Readmission after complex gastrointestinal surgery is a frequent occurrence that burdens the health care system and leads to increased cost. Recent studies have demonstrated 30- and 90-day readmission rates of 15% and 19%, respectively, following pancreaticoduodenectomy. Given the psychosocial issues often associated with chronic pancreatitis, we hypothesized that readmission rates following surgery for chronic pancreatitis would be higher than previously reported for pancreaticoduodenectomy. ⋯ To our knowledge, our data represent the first report demonstrating very high readmission rates after surgery for chronic pancreatitis, more than double the previous rates reported for pancreaticoduodenectomy. This cohort of patients requires extensive discharge planning focused on pain control, nutritional optimization, and close postoperative monitoring.
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Hemorrhagic shock leads to a complex cascade of metabolic and hormonal processes that may result in hypoperfusion, end organ damage, and death even when blood pressure is restored. Studies have shown that morbidity and mortality could be attributable to a diminished availability of endothelial-derived nitric oxide (eNO). It is unclear whether adequate levels of citrulline (CIT) and arginine (ARG)--the precursors of eNO synthesis--are available to sustain the eNO needed to maintain adequate perfusion in severe shock. An indirect measure of eNO is the ratio between the levels of ARG and its inhibitor asymmetric dimethylarginine (ARG/ADMA). The purpose of the study was to identify the temporal impact of the ARG/ADMA ratio, ARG, CIT, and ADMA in response to hemorrhage and crystalloid fluid resuscitation by the use of a porcine model of severe hemorrhagic shock. ⋯ Our results suggest that a sufficient decrease in MAP during hemorrhagic shock is associated with a subsequent increase in IL-6, persisting impairment of end organ perfusion, and evidence of ongoing eNO deficit and an increase in ADMA despite resuscitation. The ARG/ADMA ratio reflects both of these parameters and corresponds to the increase in IL-6 and persistent ischemia after resuscitation. We propose that the mechanism of IL-6 increase in trauma derives from eNO deficiency, and the ARG/ADMA ratio more accurately depicts the pathologic mechanism responsible for increased morbidity and mortality in trauma.