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In This Issue of JAMA Surgery
October 2013


JAMA Surg. 2013;148(10):901-903. doi:10.1001/jamasurg.2013.2204

Surgical site infections (SSIs) may increase health care costs, but few studies have conducted an analysis from the perspective of hospital administrators. At 5 hospitals in the Johns Hopkins Health System, Shepard and colleagues identified 25 849 surgical procedures. Using the Centers for Disease Control and Prevention definitions, trained infection control practitioners conducted a medical record review and identified 618 SSIs. The data suggests that the total change in profit if all the SSIs were eliminated would be $2 268 589; it would be $12 164 457 if it is assumed 30-day readmissions would not be reimbursed.

Continuing Medical Education

Surgeons’ perioperative instruction can be objectively measured and results used to motivate faculty to promote deliberate teaching of residents. Trained preclinical students observed operative teaching done by surgeons blinded to the study, and educationally oriented preoperative briefings and postoperative debriefings were established to enhance instruction. Process improvement initiatives were applied to facilitate change during 2 academic years to demonstrate sustainability. Anderson and colleagues demonstrated a 239% improvement over baseline in deliberate perioperative teaching.

Related Invited Commentary

Severe renal injuries after blunt trauma cause diagnostic and therapeutic challenges for treating clinicians. In a retrospective, multicenter study of 206 adult patients admitted between January 2000 and December 2011, van der Wilden and colleagues determined the rate, causes, predictors, and consequences of failure of nonoperative management in grade IV and grade V blunt renal injuries. They found that patients with the most severe kidney injuries can be confidently managed with nonoperative management.

Continuing Medical Education

Nonfunctioning pancreatic neuroendocrine tumors are often indolent neoplasms without lymph node metastasis at diagnosis. To preoperatively predict the risk for pN+ for nonfunctioning pancreatic neuroendocrine tumors (NF-PanNETs), Partelli and colleagues retrospectively reviewed clinical and pathological data using multiple logistic regression analysis. They found that patients with NF-PanNET-G1 have a very low risk of pN+ in the absence of radiological signs of node involvement. When preoperative grading assessment is not achieved, the radiological size of the lesion is a powerful alternative predictor of pN+.

Unnecessary trauma imaging leads to greater costs, emergency department time, and patient exposure to ionizing radiation. At 9 US trauma centers, Rodriguez and colleagues prospectively evaluated the NEXUS Chest decision instrument for the detection of thoracic injury seen on chest imaging (TICI) in 9905 adult blunt trauma patients. NEXUS Chest had high sensitivity and negative predictive value for TICI and TICI with major injury, and it may safely reduce the need for chest imaging in blunt trauma evaluation.

The risk factors for enteroatmospheric fistula and intra-abdominal sepsis after damage control laparotomy have not been well elucidated. Using multivariate logistic regression analysis of the American Association for the Surgery of Trauma registry of 517 patients who underwent damage control laparotomy after trauma, Bradley and colleagues found that large bowel resection, total fluid intake greater than 5 L during the initial 48 hours, and the number of reexplorations required were independent predictors of these complications.

Related Invited Commentary

Reduction in length of hospital stay is a veritable target in reducing the overall costs of health case. Using data from a trauma registry, supplemented by information from electronic medical records and hospital billing databases, Hwabejire and colleagues uncovered the true causes of excessively prolonged hospitalization in trauma patients. Patients stay for prolonged periods in the hospital because of unresolved insurance issues, difficult-to-find rehabilitation beds, and in-hospital operational breakdowns.

With low recurrence rates, chronic pain after inguinal hernia repair has become the most important clinical outcome. Chen and colleagues prospectively studied 20 patients who underwent laparoscopic triple neurectomy of the ilioinguinal, iliohypogastric, and genitofemoral nerve trunks in the retroperitoneal lumbar plexus for the treatment of refractory inguinodynia. Numeric pain scores and narcotic dependence decreased, while activity level increased. This treatment was found to be effective for inguinodynia, allowing access proximal to all potential sites of peripheral neuropathy and overcoming many of the limitations of open triple neurectomy.

To combat the dwindling number of medical students matching into general, trauma, and acute care surgery, Stroh and colleagues evaluated an educational model designed to inspire interest early in the medical school curriculum. They found that a student-run trauma shadowing program designed for preclinical medical students, while not mandatory, received high levels of participation and significantly improved interest in the surgical specialties from students not initially planning to match into the field.