American College Of Surgeons Research Articles

Outcomes after ORIF of Bicondylar Schatzker VI (AO type C) Tibial Plateau Fractures in an Elderly Population

BackgroundThe surgical management of bicondylar tibial plateau (BTP) fractures in elderly patients aims to restore knee stability while minimizing soft tissue complications. The purpose of this study was to compare injury characteristics and surgical outcomes after ORIF of BTP fractures (AO/OTA 41-C (Schatzker VI)) in young (< 50 years) versus elderly (> 65 years) patients. MethodsA retrospective cohort study was conducted using data from two American College of Surgeons (ACS) level I trauma centers. Inclusion criteria were: (1) age 18 years or older, (2) bicondylar tibial plateau fracture (AO/OTA 41-C or Schatzker VI), (3) treatment with ORIF, and (4) minimum of 6 months follow-up. Patients between 50 and 65 years of age were excluded. Data collection was performed by reviewing electronic medical records, operative reports, and radiology reports. ResultsWe identified 323 patients (61% male) with 327 BTP fractures and a median follow-up of 685 days. There were 230 young patients (71%) < 50 years and 93 elderly patients (29%) >6 5 years at time of presentation. Elderly patients were significantly more likely to have a low energy mechanism of injury (44.6 vs. 16.2%, p < 0.001), and present with diabetes (19.4 vs. 4.4%, p < 0.001) or coronary artery disease (12.9 vs. 1.3%, p < 0.001). Elderly patients were also significantly less likely to undergo staged management with initial knee-spanning external fixation followed by delayed ORIF (19.2 vs. 33.9%, p = 0.008). Elderly patients had a lower arc of motion at final follow-up (105 vs. 113°, p < 0.001) and reduced PROMIS-10 function scores (43.8 vs. 49.8, p = 0.013). No differences were observed in rates of superficial infection, deep infection, reoperation, or EQ-5D scores between age groups. ConclusionsThis is the largest study to compare injury characteristics and outcomes after ORIF of BTP fractures according to age. Elderly patients (age > 65 years) sustained BTP fractures by lower energy mechanisms than their younger counterparts with similar fracture patterns and were often managed with ORIF. The results of this study suggest that ORIF of BTP fractures in elderly patients is associated with similar complication rates and outcomes as in younger patients despite higher comorbidities and poorer bone quality in the elderly population.

Surgical and Endovascular Management of Extracranial Carotid Artery Aneurysms, Outcomes from the American College of Surgeons - National Surgical Quality Improvement Program

A retrospective review of the American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) between 2013 and 2017. Of 139 patients with extracranial carotid artery aneurysms, there were significantly more postoperative strokes in the 19 patients treated with endovascular intervention (16%) than in the 120 patients treated with open surgery (4%). However, patients treated with endovascular intervention were more likely treated for emergent indications than the open surgical group (26% vs 7%, respectively). Postoperative stroke rates trended higher with endovascular approaches to treat carotid artery aneurysms, perhaps owing to a greater proportion of emergency procedures.

Examination of Racial and Socioeconomic Disparity in Use of Nondirected Kidney Donation in the US.

Nondirected donor (NDD) kidney transplant (NDDKT) continues to improve organ access for waitlisted candidates. Although NDDs are becoming increasingly common, there has been no contemporary evaluation of NDD allograft use, and it is vital to understand sociodemographic, as well as center-level, use across the US. Using national data from the Scientific Registry for Transplant Recipients, this study characterized NDDs, NDDKT recipients, and center-level distribution of NDDKT. Directed donor and NDD characteristics were compared using Fisher's exact and Wilcoxon rank-sum tests for categorical and continuous variables, respectively. Multivariable logistic regression was used to identify characteristics associated with receiving NDDKT, and center distribution of NDDKT was assessed using the Gini coefficient. NDDKT increased from 1.4% (n = 154) of all living donor kidney transplants in 2010 to 6.5% (n = 338) in 2020. Compared with directed living donors, NDDs were older (median [IQR], 44 [33 to 54] vs 43 [33 to 52], p < 0.01), more often male (40.2% vs 36.7%, p < 0.001), and White (91.4% vs 69.5%, p < 0.001). White adult candidates were more likely to receive NDDKT compared with Black (adjusted odds ratio [aOR], 0.300.340.39, p < 0.001), Hispanic/Latino (aOR, 0.360.420.48, p < 0.001), and Other (aOR, 0.410.470.55, p < 0.001) candidates. Black pediatric candidates had lower odds of receiving NDDKT (aOR, 0.090.220.54, p = 0.02). The proportion of centers performing NDDKT has increased from 2010 to 2020 (Gini = 0.77 vs 0.68). Although more centers are performing NDDKT, racial disparities persist among NDDs and NDDKT recipients. Continued effort is needed to recruit living kidney donors and improve access to living donation for minority groups in the US. (J Am Coll Surg 2022;234:000-00. © 2022 by the American College of Surgeons).

Compliance with venous thromboembolism chemoprophylaxis guidelines in non-operative traumatic brain injury

ObjectiveTo determine the level of compliance of The American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) for initiation of venous thromboembolism (VTE) prophylaxis after non-operative traumatic brain injury (TBI) and the explanation for the deviations. MethodsA retrospective review from May 2018 to February 2020 in a Level II trauma center for patients with TBI and length of stay of more than 24 h. We performed an analysis of overall and subgroup compliance with guidelines. The ACS TQIP criteria for low and moderate-risk for hemorrhagic progression were used for subgroup classification. ResultsOf 393 patients, 239 (60.8%) patients received chemoprophylaxis in a mean of 64 (SD: +/−42) hours since admission. “Compliance” was achieved in 52.2% of patients. In subgroup analysis, 51.4% of patients in “low-risk” and 55.1% in “moderate-risk” were “compliant.” The most common rationale for non-compliance in “low-risk” was a stay less than 48 h in 35.9% of patients. However, in “moderate-risk,” the most common non-compliance was starting prophylaxis before the recommended 72 h from admission in 37% of cases. ConclusionsGuidelines streamline clinical practice to optimize outcomes, but there are scenarios in which deviation of the recommendations may be indicated based on clinical judgment. We show that a stay of less than 48 h was the most common rationale for not starting prophylaxis in “low-risk” patients. However, in the “moderate-risk” subgroup, the most common reason was starting chemoprophylaxis before the recommended time frame, which we called a “paradoxical” non-compliance.

Trauma Prevalence and Resource Utilization During 4 COVID-19 "Surges": A National Analysis of Trauma Patients From 92 Trauma Centers.

IntroductionWe aim to assess the trends in trauma patient volume, injury characteristics, and facility resource utilization that occurred during four surges in COVID-19 cases.MethodsA retrospective cohort study of 92 American College of Surgeons (ACS)-verified trauma centers (TCs) in a national hospital system during 4 COVID-19 case surges was performed. Patients who were directly transported to the TC and were an activation or consultation from the emergency department (ED) were included. Trends in injury characteristics, patient demographics & outcomes, and hospital resource utilization were assessed during four COVID-19 case surges and compared to the same dates in 2019.ResultsThe majority of TCs were within a metropolitan or micropolitan division. During the pandemic, trauma admissions decreased overall, but displayed variable trends during Surges 1-4 and across U.S. regions and TC levels. Patients requiring surgery or blood transfusion increased significantly during Surges 1-3, whereas the proportion of patients requiring plasma and/or platelets increased significantly during Surges 1-2. Patients admitted to the hospital had significantly higher Injury Severity Score (ISS) and mortality as compared to pre-pandemic during Surge 1 and 2. Patients with Medicaid or uninsured increased significantly during the pandemic. Hospital length of stay (LOS) decreased significantly during the pandemic and more trauma patients were discharged home.ConclusionsTrauma admissions decreased during Surge 1, but increased during Surge 2, 3 and 4. Penetrating injuries and firearm-related injuries increased significantly during the pandemic, patients requiring surgery or packed red blood cells (PRBCs) transfusion increased significantly during Surges 1-3. The number of patients discharged home increased during the pandemic and was accompanied by a decreased hospital length of stay (LOS).

Precisión de la calculadora de riesgo quirúrgico ACS NSQIP para predecir morbilidad y mortalidad en pacientes mexicanos.

American College of Surgeons (ACS) developed the ACS NSQIP surgical risk calculator that predicts the results of elective and emergency surgical procedures. This tool has been useful improving the morbidity and mortality in hospitals in the United States and Canada. To evaluate the usefulness of the ACS NSQIP risk calculator for predicting postoperative complications in Mexican population. Prospective, observational, analytical study. Patients undergoing abdominal surgery were recorded, 21 preoperative variables were captured and entered into the calculator. They were followed up to 30 days postoperatively, identifying 14 types of postoperative complications. 109 patients were registered. A comparison was made between the calculated and observed complications, obtaining a good correlation in the complications of cardiac arrest, surgical site infection, reoperation, sepsis and mortality (p < 0.05). ACS NSQIP risk calculator is useful in the Mexican population, since the score obtained predicts most postoperative complications including mortality. The use of this tool offers an opportunity to improve decision-making in the care of the surgical patient.

Did we do the right thing? The appropriateness of orthopedic operative interventions during the height of the coronavirus disease 2019 pandemic.

Purpose:During the coronavirus disease (COVID) pandemic elective surgeries were cancelled and operative indications curtailed to counteract shortages in resources. We aimed to review each orthopedic operative indication at an urban Level 1 Trauma Center inundated with COVID. We aimed to classify the appropriateness of each operative intervention and determine if exposure to COVID impacted morbidity or mortality.Methods:All orthopedic procedures between March 16, 2020 and May 16, 2020 were reviewed. The most urgent surgical indication for each procedure was classified by 2 fellowship trained orthopedic trauma surgeons and 2 senior residents. The appropriateness of the operative intervention was determined. The American Academy of Orthopedic Surgery (AAOS) and American College of Surgeons (ACS) guidelines for surgery during the pandemic were considered.Results:Seventy-six surgical encounters were performed on 71 inpatients including 99 total procedures. No outpatient procedures were performed. Fifty-four of 71 patients were male. There was a mean age of 51.6 years. Of 71 patients, 41 presented to the emergency department without trauma activation with a mean time to presentation of 2.7 days post injury. The most urgent surgical indications included 18 hip fractures, 18 periarticular fractures, 17 open fractures, 7 severe infections, 5 pelvic fractures, 5 femoral shaft fractures, 3 spinal injuries, 1 tibial fracture, 1 tendon injury, and 1 clavicle fracture. Four procedures could have been delayed for conservative management without causing significant harm. Upon discharge 13/71 patients had tested positive for COVID, 41/71 had remained negative throughout their hospital stay, and 17/71 patients never were tested. Four patients contracted COVID in the hospital. There were 4 in hospital deaths, 2 attributed to hypoxemic respiratory failure secondary to COVID pneumonia.Conclusion:It was determined that 72/76 cases were considered appropriate in following guidelines of the AAOS and ACS. This highlights the value of halting outpatient procedures and limiting patient exposure to COVID. Comprehensive patient/provider discussions addressing the risks, benefits, alternatives to surgery, and the risk of exposure to respiratory illness are vital. It behooves the surgical team to follow established guidelines such as those of the AAOS and ACS when triaging orthopedic patients for a surgical admission.

Comment on "A National Survey of Motor Vehicle Crashes Among General Surgical Residents".

Comment on "A National Survey of Motor Vehicle Crashes Among General Surgical Residents".

356 Patient-and-Hospital-Related Risk Factors for Non-Routine Discharge After Lumbar Decompression and Fusion for Spondylolisthesis

INTRODUCTION: In various spinal surgeries, non-routine discharges have been associated with inferior outcomes. However, there exists a paucity of data regarding the relationship between non-routine discharge and quality of care among patients with spondylolisthesis. METHODS: A retrospective cohort study was performed using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database from 2010 through 2016. Adult patients (=18 years old) who underwent spinal decompression and fusion for lumbar spondylolisthesis were identified using ICD-9-CM diagnosis and CPT procedural coding systems. The study population was divided into two cohorts based on discharge disposition: routine (RD) and non-routine discharge (NRD). A multivariate logistic regression model was used to identify the independent predictors of non-routine discharge and 30-day unplanned readmission. RESULTS: A total of 5,252 patients were identified, of which of which 4,316(82.2%) had a RD and 936 (18.8%) had a NRD. The NRD cohort tended to be older (p&lt;0.001) and have a higher BMI (p&lt;0.001). Patients who experienced a NRD had a longer LOS (NRD: 4.7±3.7 days vs RD: 3.1±2.0 days, p&lt;0.001), a higher proportion of adverse events (p&lt;0.001), higher rates of reoperation (p=0.005) and unplanned 30-day readmission rates (p&lt;0.001). On multivariate regression analysis, age [OR: 1.08, 95% CI (1.06–1.10),p&lt;0.001], female sex [OR: 2.01, 95% (1.51–2.69),p&lt;0.001], non-Hispanic Black race/ethnicity [OR: 2.10, 95% CI (1.36 – 3.24), p=0.001], BMI [OR: 1.03, 95% CI (1.01–1.05), p=0.007), dependent functional status [OR: 3.33, 95% CI (1.59 – 6.99),p=0.001], malnourishment [OR: 2.14, 95% CI (1.27 – 3.62, p=0.005], and LOS [OR: 1.26, 95% CI (1.18 – 1.33),p&lt;0.001] were all independent predictors for NRD. However, NRD did not independently predict an unplanned 30-day readmission on multivariate analysis. CONCLUSION: In our study we found that on univariate analysis NRD was associated with increased adverse events, length of stay and 30-day unplanned readmission. When controlling for patient- and hospital-related factors, we found that female sex, non-Hispanic Black race, BMI, dependent functional status, malnourishment and longer LOS were independently associated with NRD.

A prospective evaluation of the American College of Surgeons Surgical Risk Calculator as a predictor of complications for breast surgery.

The infection rates for operative management of breast cancer are often unpredictable and higher than average for a clean surgical procedure (0.8% and 28%). We aimed to assess the effectiveness of the American College of Surgeons (ACS) Surgical Risk Calculator (SRC), a preoperative scoring system to calculate the risk of surgical site infection (SSI) and serious complications following breast surgery. Prospective risk scoring using the SRC on 213 patients in the preoperative clinic and the incidence of SSI and serious complications within 30 days postoperatively was prospectively collected. The overall SSI rate in our sample was 5% (n=11/210 patients). For a one-unit increase in SRC score, the odds of having SSI increased by a factor of 1.88 (95% CI 1.33 to 2.74). Odds of developing SSI were higher in patients with high Body Mass Index (OR 1.25; 95% 1.13 to 1.40) and American Society of Anesthesiologists score 3 (OR 11.54; 95% CI 2.98 to 43.65). The odds of developing an SSI were ∼19 times higher if a patient had an SRC score >3.0 versus those with an SRC score <3.0. Only 3% (n=4) of patients who had an SRC score of <3.0 experienced SSI, compared with 33% (n=7) for those with a risk score of >3.0. Out of 210 patients, 9 had serious complications (4.2%). ACS SRC Score of more than 3 was associated with a higher likelihood of SSI. SRC was able to predict the risk of SSI and serious complications and can be used preoperatively for identification and risk minimisation.

Characteristics of prostate cancer patients captured by facility-based versus geography-based cancer registries.

237 Background: Cancer registries provide valuable information related to cancer epidemiology, treatment, and outcomes. However, the sampling for inclusion can impact generalizability of findings to other settings. We use a population-based cancer registry to evaluate demographics, cancer factors, and treatment patterns based on eligibility for a facility-based cancer registry. Methods: We used the Surveillance, Epidemiology, and End Results (SEER) database to identify men diagnosed with prostate cancer (site = C61.9) in 2018. Exposure was whether data were reported from a facility accredited by American College of Surgeons’ Commission on Cancer (CoC), providing eligibility for the National Cancer Database (NCDB) (i.e., NCDB-eligible). Outcomes of interest included demographics, tumor factors (e.g., biopsy grade), and treatment. Bivariate testing and multivariable regression analyses tested for significant associations between exposure and outcomes of interest. Results: We identified 57,713 men diagnosed with prostate cancer in 2018, of which 32,384 (61.9%) were eligible for inclusion in NCDB. NCDB-eligible men were younger (66.6 vs 67.8 years, p &lt; 0.001), less likely to be Hispanic/Latino (8.0% vs 14.4%, p &lt; 0.001), and more likely to reside in a county with median income over $75,000 (39.7% vs 33.3%, p &lt; 0.001). NCDB eligibility varied widely by registry, from 96.1% in Connecticut to 44.7% in Utah. The proportion of localized cancer patients with Grade Group 1 cancer on biopsy was higher among men ineligible for NCDB (41.4% vs 26.9%, p &lt; 0.001). The proportion of patients with more advanced disease at presentation was higher among NCDB-eligible patients (metastatic: 9.4% vs 6.8%; regional: 18.7% vs 8.7%; p &lt; 0.001). For patients with localized or regional cancer, treatment was identified more frequently among NCDB-eligible patients for both low-risk (38.5% vs 22.7%, p &lt; 0.001) and high-risk tumors (84.9% vs 64.2%). Among treated patients, use of radical prostatectomy was more common among NCDB-eligible patients (low risk: 58.9% vs 43.1%; high risk: 53.7% vs 43.4%, p &lt; 0.001). Conclusions: Prostate cancer patients eligible for inclusion in the facility based NCDB have important differences in demographics, severity of cancer risk, and treatment patterns compared to those who are not eligible. Generalizations related to epidemiologic trends, practice patterns, and outcomes for prostate cancer patients in the NCDB should be interpreted with caution.

Technical Standards for Cancer Surgery: Commission on Cancer Standards 5.3-5.8.

Clinical practice guidelines in oncology have typically focused on workup, disease staging, and medical management. Although recommendations for surgical care have been included in these guidelines, those recommendations have primarily addressed issues such as the role of surgery or the incorporation of surgery into multidisciplinary treatment strategies, not the technical performance of the operative procedures themselves. Therefore, the quality of surgery, the only component of multidisciplinary cancer care proven to be potentially curative, has been poorly controlled. During the past decade, the American College of Surgeons (ACS) cancer programs have attempted to fill this gap by developing "operative standards" for cancer surgery. This report discusses the history of the operative standards, highlights evidence to demonstrate their efficacy, and describes the activities of the ACS Commission on Cancer and Cancer Surgery Standards Program toward disseminating and implementing them.

Big data insights into predictors of acute compartment syndrome

BackgroundThere remain gaps in knowledge regarding the pathophysiology, initial diagnosis, treatment, and outcome of acute compartment syndrome (ACS). Most reported clinical outcomes are from smaller studies of heterogeneous patients. For a disease associated with a financial burden to society that represents billions of dollars worldwide the literature does not currently establish baseline diagnostic parameters and risk factors that may serve to predict treatment and outcomes. MethodsThis study looks at a very large cohort of trauma patients obtained from four recent years of the Trauma Quality Programs data from the American College of Surgeons. From 3,924,127 trauma cases - 203,500 patients with tibial fractures were identified and their records examined for demographic information, potential risk factors for compartment syndrome, an associated coded diagnosis of muscle necrosis, and presence of other outcomes associated with compartment syndrome. A recurrent multiple logistic regression model was used to identify factors predictive of fasciotomy. The results were compared to the reported results from the literature to validate the findings. ResultsThe rate of fasciotomy treatment for ACS was 4.3% in the cohort of identified patients. The analysis identified several clinical predictors of fasciotomy. Proximal and midshaft tibial fractures (P <0.0001) showed highest increases in the likelihood of ACS. Open fractures were twice (O.R [2.20–2.42]) as likely to have ACS. Having a complex fracture (P<0.0001), substance abuse disorder (P<0.0002), cirrhosis (P = 0.002) or smoking (P<0.0051) all increased the likelihood of ACS. Age decreased the likelihood by 1% per year (OR= [0.99–0.993]). Crush and penetrating injuries showed an important increase in the likelihood of ACS (O.R of 1.83 and 1.37 respectively). Additionally, sex, BMI, cirrhosis, tobacco smoking and fracture pattern as defined by OTA group and OTA subgroup had predictive value on actual myonecrosis. Fasciotomies for open tibial fractures were more likely to uncover significant muscle necrosis compared to closed fractures. Amputation resulted after 5.4% of fasciotomies. ConclusionThis big data approach shows us that ACS is primarily linked to the extent of soft tissue damage. However, newfound effect of some comorbidities like cirrhosis and hypertension on the risk of ACS imply other mechanisms.

Development and Validation of a Multivariable Prediction Model for Postoperative Intensive Care Unit Stay in a Broad Surgical Population

Despite limited capacity and expensive cost, there are minimal objective data to guide postoperative allocation of intensive care unit (ICU) beds. The Surgical Risk Preoperative Assessment System (SURPAS) uses 8 preoperative variables to predict many common postoperative complications, but it has not yet been evaluated in predicting postoperative ICU admission. To determine if the SURPAS model could accurately predict postoperative ICU admission in a broad surgical population. This decision analytical model was a retrospective, observational analysis of prospectively collected patient data from the 2012 to 2018 American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database, which were merged with individual patients' electronic health record data to capture postoperative ICU use. Multivariable logistic regression modeling was used to determine how the 8 preoperative variables of the SURPAS model predicted ICU use compared with a model inputting all 28 preoperatively available NSQIP variables. Data included in the analysis were collected for the ACS NSQIP at 5 hospitals (1 tertiary academic center, 4 academic affiliated hospitals) within the University of Colorado Health System between January 1, 2012, and December 31, 2018. Included patients were those undergoing surgery in 9 surgical specialties during the 2012 to 2018 period. Data were analyzed from May 29 to July 30, 2021. Surgery in 9 surgical specialties, including general, gynecology, orthopedic, otolaryngology, plastic, thoracic, urology, vascular, and neurosurgery. Use of ICU care up to 30 days after surgery. A total of 34 568 patients were included in the analytical data set: 32 032 (92.7%) in the cohort without postoperative ICU use and 2545 (7.4%) in the cohort with postoperative ICU use (no ICU use: mean [SD] age, 54.9 [16.6] years; 18 188 women [56.8%]; ICU use: mean [SD] age, 60.3 [15.3] years; 1333 men [52.4%]). For the internal chronologic validation of the 7-variable SURPAS model, data from 2012 to 2016 were used as the training data set (n = 24 250, 70.2% of the total sample size of 34 568) and data from 2017 to 2018 were used as the test data set (n = 10 318, 29.8% of the total sample size of 34 568). The C statistic improved in the test data set compared with the training data set (0.933; 95% CI, 0.924-0.941 vs 0.922; 95% CI, 0.917-0.928), whereas the Brier score was slightly worse in the test data set compared with the training data set (0.045; 95% CI, 0.042-0.048 vs 0.045; 95% CI, 0.043-0.047). The SURPAS model compared favorably with the model inputting all 28 NSQIP variables, with both having good calibration between observed and expected outcomes in the Hosmer-Lemeshow graphs and similar Brier scores (model inputting all variables, 0.044; 95% CI, 0.043-0.048; SURPAS model, 0.045; 95% CI, 0.042-0.046) and C statistics (model inputting all variables, 0.929; 95% CI, 0.925-0.934; SURPAS model, 0.925; 95% CI, 0.921-0.930). Results of this decision analytical model study revealed that the SURPAS prediction model accurately predicted postoperative ICU use across a diverse surgical population. These results suggest that the SURPAS prediction model can be used to help with preoperative planning and resource allocation of limited ICU beds.

National Outcomes of Prophylactic Lymphovenous Bypass during Axillary Lymph Node Dissection.

Breast cancer treatment, including axillary lymph node excision, radiation, and chemotherapy, can cause upper extremity lymphedema, increasing morbidity and health care costs. Institutions increasingly perform prophylactic lymphovenous bypass (LVB) at the time of axillary lymph node dissection (ALND) to reduce the risk of lymphedema but reports of complications are lacking. We examine records from the American College of Surgeons (ACS) National Surgery Quality Improvement Program (NSQIP) database to examine the safety of these procedures. Procedures involving ALND from 2013 to 2019 were extracted from the NSQIP database. Patients who simultaneously underwent procedures with the Current Procedural Terminology (CPT) codes 38999 (other procedures of the lymphatic system), 35201 (repair of blood vessel), or 38308 (lymphangiotomy) formed the prophylactic LVB group. Patients in the LVB and non-LVB groups were compared for differences in demographics and 30-day postoperative complications including unplanned reoperation, deep vein thrombosis (DVT), wound dehiscence, and surgical site infection. Subgroup analysis was performed, controlling for extent of breast surgery and reconstruction. Multivariate logistic regression was performed to identify predictors of reoperation. The ALND without LVB group contained 45,057 patients, and the ALND with LVB group contained 255 (0.6%). Overall, the LVB group was associated with increased operative time (288 vs. 147 minutes, p < 0.001) and length of stay (1.7 vs. 1.3 days, p < 0.001). In patients with concurrent mastectomy without immediate reconstruction, the LVB group had a higher rate of DVTs (3.0 vs. 0.2%, p = 0.009). Reoperation, wound infection, and dehiscence rates did not differ across subgroups. Multivariate logistic regression showed that LVB was not a predictor of reoperations. Prophylactic LVB at time of ALND is a generally safe and well-tolerated procedure and is not associated with increased reoperations or wound complications. Although only four patients in the LVB group had DVTs, this was a significantly higher rate than in the non-LVB group and warrants further investigation.

Editorial introductions.

Editorial introductions.

"Don't Ask Me How I Know This…".

"Don't Ask Me How I Know This…".

ASA Promotes Patient Safety at 2021 NCSL Legislative Summit

State Beat| February 2022 ASA Promotes Patient Safety at 2021 NCSL Legislative Summit Jason Hansen, MS, JD Jason Hansen, MS, JD Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor February 2022, Vol. 86, 29. https://doi.org/10.1097/01.ASM.0000820420.71787.6b Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share MailTo Twitter LinkedIn Cite Icon Cite Get Permissions Search Site Citation Jason Hansen; ASA Promotes Patient Safety at 2021 NCSL Legislative Summit. ASA Monitor 2022; 86:29 doi: https://doi.org/10.1097/01.ASM.0000820420.71787.6b Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search In early November 2021, ASA State Affairs represented the society at the National Conference of State Legislatures (NCSL) 46th annual Legislative Summit in Tampa, Florida. For more than 15 years, ASA has participated as an exhibitor at this important gathering of state lawmakers. Jay Epstein, MD, FASA, Chair of the ASA Task Force on State Advocacy, joined State Affairs staff in interacting with state legislators and legislative staff at the exhibit booth. ASA represented physician anesthesiologists as part of a larger joint physician booth called “Physicians Advocating for Patients.” This booth included representatives of the American Academy of Anesthesiologist Assistants, American Society for Dermatologic Surgery, American Academy of Dermatology, American College of Surgeons, and the Federation of State Medical Boards. NCSL has become one of the largest bipartisan organizations of state lawmakers in the country. It serves state lawmakers and legislative staff throughout the U.S. with policy research and... You do not currently have access to this content.

The National Blood Shortage-An Impetus for Change.

The National Blood Shortage-An Impetus for Change.

Machine Learning Refinement of the NSQIP Risk Calculator: Who Survives the "Hail Mary" Case?

The American College of Surgeons (ACS) NSQIP risk calculator helps guide operative decision making. In patients with significant surgical risk, it may be unclear whether to proceed with "Hail Mary"-type interventions. To refine predictions, a local interpretable model-agnostic explanations machine (LIME) learning algorithm was explored to determine weighted patient-specific factors' contribution to mortality. The ACS-NSQIP database was queried for all surgical patients with mortality probability greater than 50% between 2012 and 2019. Preoperative factors (n = 38) were evaluated using stepwise logistic regression; 26 significant factors were used in gradient boosted machine (GBM) modeling. Data were divided into training and testing sets, and model performance was substantiated with 10-fold cross validation. LIME provided individual subject mortality. The GBM-trained model was interpolated to LIME, and predictions were made using the test dataset. There were 6,483 deaths (53%) among 12,248 admissions. GBM modeling displayed good performance (area under the curve = 0.65, 95% CI 0.636-0.671). The top 5 factors (% contribution) to mortality included: septic shock (27%), elevated International Normalized Ratio (22%), ventilator-dependence (14%), thrombocytopenia (14%), and elevated serum creatinine (5%). LIME modeling subset personalized patients by factors and weights on survival. In the entire cohort, mortality positive predictive value with 2 factor combinations was 53.5% (specificity 0.713), 3 combinations 64.2% (specificity 0.835), 4 combinations 72.1% (specificity 0.943), and all 5 combinations 77.9% (specificity 0.993). Conversely, mortality positive predictive value fell to 34% in the absence of 4 factors. Through the application of machine learning algorithms (GBM and LIME), our model individualized predicted mortality and contributing factors with substantial ACS-NSQIP predicted mortality. USE of machine learning techniques may better inform operative decisions and family conversations in cases of significant surgical risk.