Standardizing the Operative Note: A Way to Improve the Quality of Data Collection to Optimize Patient Care
Kurt Bamberger, Leigh Gerson, and James Haran
INTRODUCTION: The standard surgical operative note serves an essential role in documenting the details of an operation; however common key details of the operative note are often omitted. This study investigated the effectiveness of implementing a Laparoscopic Cholecystectomy (LC) specific, intraoperative data collection template directly in the electronic health record to be used as an addition to the standard dictated operative note. We hypothesized that intraoperative data collection would lead to a more complete operative report.
METHODS: In this single center study, we retrospectively analyzed 211 operative notes prior to implementing an intraoperative template and 680 operative notes post template initiation. The data in the operative notes was then compared to the operative note template on seven selected variables. A chi-squared test for independence and a proportions test was used to assess the data and a significance was set to p < 0.005.
RESULTS: Intraoperative recording of the key data points increased documentation of five of the seven selected variables. Significantly more postoperative reports included information on stone spillage, the placement of drains, use of irrigation, intraoperative cholangiogram, and peri-operative antibiotics when completed with the template in comparison to the dictated operative report group without the intraoperative template, with a p < 0.001.
CONCLUSION: Our study demonstrates that “real time” collection of several predefined key data points significantly improves the accuracy and completeness of the standard operative note.
Jessica Barton, Jaclyn Malat, Sergio Perez, and Michael T. Brown
Current trends show that same-day breast reconstruction after oncologic breast surgery is increasing. Data regarding the factors contributing to this increase in oncoplastic surgery is lacking. We examine the timing and type of reconstructive surgery following mastectomy at Reading Hospital between 2011 and 2015. We hypothesized that the majority of women would choose immediate reconstruction rather than delayed reconstruction following mastectomy and that the number of reconstructive surgeries would increase from 2011 to 2015 correlating with the increase in availability and popularity of oncoplastic breast procedures. This retrospective study looked at a total of 579 patients, 129 of which underwent reconstructive surgery following their mastectomy (22%). Of those patients, 98% had immediate reconstruction following mastectomy (same day surgery). Of those that underwent reconstruction, the majority of patients elected for tissue expanders vs. musculocutaneous flaps (98% vs. 2%). While we concluded that the overall rate of breast reconstruction after mastectomy between 2011 and 2015 did not change, the increase in bilateral mastectomies for unilateral disease did. This may reflect the increasing popularity of oncoplastics as well as benefits of immediate reconstruction including time, cost and body image.
Megan M. Finneran, Joseph Georges, Michael Kakareka, Ryan Moncman, Miriam Enriquez, Alan Turtz, Steven S. Yocom, H Warren Goldman, and James Barresse
Background: Epithelioid glioblastoma (eGBM) is a recent addition to the World Health Organization’s classification of central nervous system (CNS) tumors. This rare lesion has a predilection for younger patients, can mimic metastatic disease on preoperative imaging and intraoperative pathology, and portends a poor prognosis due to propensity for leptomeningeal dissemination.
Case Description: We discuss a case of a young woman with a history of ovarian cancer who presented with seizure and a new ring-enhancing left temporal brain lesion. The patient underwent gross-total surgical resection of this lesion, during which frozen section suggested metastasis. However, pathologic interrogation showed pleomorphic epithelioid cells and glial fibrillary acid positivity, suggesting eGBM. The patient has since completed radiotherapy and six-month post-operative imaging has not revealed recurrence or leptomeningeal dissemination.
Conclusion: Our patient's clinical history and pre-operative radiographic evaluation suggested CNS metastatic disease. Ultimately, final pathology revealed eGBM, a newly classified CNS primary tumor. This reinforces the importance of direct tissue sampling and including eGBM on the differential for young patients with histories of systemic cancer presenting with new CNS lesions.
Robert Lynagh, Joseph Georges, Mark Ishak, Brandon Boyer, Steven S. Yocom, and Denah Appelt
Abstract and full text under embargo until 10/30/18
Jillian Ploof, Hamza Shaikh, Jenny Melli, George Jour, and Alan Turtz
Background and Importance: Liposclerosing myxofibrous tumor (LSMFT) are rare benign fibro-osseous tumors most frequently occurring in the proximal femur. We report the first case of this rare tumor occurring within the calvarium.
Clinical Presentation: Our patient presented with a 2-year history of enlarging, painless, fixed mass over the left forehead. She underwent surgical resection and the mass was histologically confirmed to be a liposclerosing myxofibrous tumor.
Conclusion: LSMFT is a rare tumor that should remain on the differential for lesions of the calvarium. When diagnosed, this lesion can be removed with the goal of gross total resection and excellent cosmesis can be achieved.
Endovascular Intervention and Management of Pediatric Mandibular Arteriovenous Malformation: A Case Report
Craig Schreiber and Hamza Shaikh
Arteriovenous malformation of the mandible are a rare and potentially life threatening entity. Exsanguination from these lesions is a well documented event. Management of these lesions is unfortunately unclear and unstandardized due to their rare occurrence. Their presentation is wide and varied ranging from complaints of a loose tooth to acute hemorrhage and shock. Currently a multidisciplinary approach that typically involves input from oral maxillofacial surgeons (OMFS), otolaryngologists, and endovascular neurointerventionalists is required to manage these lesions. Often these lesions require both endovascular intervention and surgical resection. Due to the lesions high rate of recurrence and proximity to vital structures, gross surgical resection of the lesion is required. Gross surgical resection brings its own challenges in the growing pediatric patient including considerable aesthetic deformity and growth disturbances. Therefore definitive treatment with endovascular techniques is a reasonable goal for therapeutic management. Embolization of the lesion nidus is often hard to achieve in these malformations due to their high flow state. Retaining these agents of embolization at the target feeder vessels is difficult for these lesions. The case presented here is an example of a pediatric mandibular arteriovenous malformation that was treated entirely with endovascular management.
Associations between First Year Medical Students’ Lifestyles, Resting Blood Pressure, and Resting ECGs
Christina Spino-Oleck, Bram Sakdiponephong, Karen Davis, Kaela Frizzell, Charlotte H. Greene PhD, and Bruce Kornberg
Introduction: There is considerable evidence that psychological stressors can impact cardiovascular
health. Medical students experience a high degree of stress based upon their responses to survey questionnaires, although there are few physiological studies that support this association that are targeted specifically to medical students. Medical students in general represent an underrepresented age group in the context of cardiovascular treatment guidelines. Therefore, medical students are a pertinent cohort for study based upon these findings.
Objective:The purpose of this study was to analyze whether medical student lifestyles impact normal baseline cardiovascular measurements of blood pressures and electrocardiograms in this population.
Methods: Twenty five Medical students in the Philadelphia College of Osteopathic Medicine graduating class of 2017 were recruited and met inclusion criteria. Blood pressure and lifestyle factor surveys were obtained on a weekly basis and ECGs were recorded biweekly. All ECGs were read by a cardiologist. Participation by the cardiologist and the subjects was voluntary and without compensation. BP and Heart Rate data were statistically analyzed using ANOVA and the ECG analyses using Fisher Exact Test. Data obtained throughout the study was compared to the subjects’ initial data gathered at the beginning of the academic year. Data was organized into the male gender category, the female gender category, and a category that combined the data for both genders.
Results: There were statistically significant differences in the amount of caffeine consumption and systolic BP abnormalities (p=0.05), and also a statistically significant difference in the amount of strength training exercise and diastolic BP abnormalities (p=0.04) for the male gender category.
There were statistically significant differences in the amount of strength training exercise and prevalence of early repolarization (p=0.01), and the amount of study hours and bradycardia (p= 0.04) for the female gender category.There were statistically significant differences between the amount of aerobic exercise and T wave inversions (p=0.03), anxiety level and voltage criteria for left ventricular hypertrophy (p=0.05), the amount of strength exercise and systolic BP abnormalities (p=0.02), the amount of strength exercise and diastolic abnormalities (p=0.004), the amount of study hours and bradycardia (p=0.034), and the amount of study hours and inverted T waves (p=0.008) for the combined gender category.
Conclusion: Changes in both blood pressure and ECGs in association with both behavioral and curriculum lifestyle factors were demonstrated. Whether the behavioral habits that differed significantly from baseline were due to the curriculum cannot be determined from these preliminary analyses. However, these findings in this population are concerning with respect to younger adults as a discrete and unique population, and may warrant closer scrutiny in conjunction with the American Heart Association Guidelines to determine whether a new category of recommendations for younger adults may be warranted with respect to blood pressure and heart rate parameters.
A Case Series: Pre-Operative Internal Maxillary Artery Embolization Before Temporomandibular Joint Reconstruction
Amber Valeri, Joseph Georges, Carl Bifano, Hayan Dayoub, and Hamza Shaikh
Introduction: Temporomandibular joint (TMJ) ankylosis is an often-disfiguring pathology causing significant reduction in mandibular mobility leading to disability in mastication, digestion, speech, and oral hygiene. Caused by trauma, radiation, infection, and iatrogenic injury, TMJ ankylosis requires complete excision of the ankylosing mass following by arthroplasty. Substantial hemorrhage during this procedure, up to 3.7L, resulting from injury to the internal maxillary artery (IMA) as it courses around the ankylosing mass may occur. There are few data to recommend pre-operative IMA embolization, though a case series describing two patients who underwent the procedure describes significant decrease in intra-operative blood loss. Our aim is to interrogate the efficacy and safety of pre-operative bilateral IMAX embolization in TMJ replacement.
Methods: Two patients from October 2016 to April 2017 underwent cerebral angiogram with pre-operative selective embolization of bilateral internal maxillary arteries immediately deep to the ankylosing mass with platinum micro-coils. After embolization, both patients were taken for bilateral temporomandibular joint replacements with arthroplasty of the temporomandibular joints, glenoid fossa and zygomatic arches. Blood loss during each procedure was documented and compared to blood loss from the same surgeon’s previous similar procedures. Patients 1 and 2 were followed up for 6 months and 1 year, respectively and outcomes compared to similar patients who did not undergo embolization.
Results: Bilateral selective internal maxillary artery embolization was successful in decreasing intraoperative blood loss in both patients. Each patient sustained 200cc of estimated blood loss during subsequent temporomandibular joint reconstruction compared to patients not undergoing embolization. At 6 months and 1 year, patients had significant improvement in their maximal incisural opening and functional status with no evidence of necrosis or wound break down.
Conclusions: In our cases, after embolization, both patients had successful TMJ reconstruction with 200cc blood loss, compared to the reported possibility of hemorrhage resulting in up to 3.7L of estimated blood loss. Upon follow up at 6 months and 1 year, neither patient had evidence of tissue necrosis or wound break down. Based on these observations, pre-operative embolization has shown to be a safe and effective procedure for minimizing hemorrhage during TMJ reconstruction.
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