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INTRODUCTION AND OBJECTIVE:Clinical practice guidelines recommend antibiotic prophylaxis for transrectal prostate biopsy. However, infectious complications following biopsy have been an emerging co...

OBJECTIVE To develop parsimonious prediction models for postoperative mortality, overall morbidity, and 6 complication clusters applicable to a broad range of surgical operations in adult patients. SUMMARY BACKGROUND DATA Quantitative risk assessment tools are not routinely used for preoperative patient assessment, shared decision making, informed consent, and preoperative patient optimization, likely due in part to the burden of data collection and the complexity of incorporation into routine surgical practice. METHODS Multivariable forward selection stepwise logistic regression analyses were used to develop predictive models for 30-day mortality, overall morbidity, and 6 postoperative complication clusters, using 40 preoperative variables from 2,275,240 surgical cases in the American College of Surgeons National Surgical Quality Improvement Program data set, 2005 to 2012. For the mortality and overall morbidity outcomes, prediction models were compared with and without preoperative laboratory variables, and generic models (based on all of the data from 9 surgical specialties) were compared with specialty-specific models. In each model, the cumulative c-index was used to examine the contribution of each added predictor variable. C-indexes, Hosmer-Lemeshow analyses, and Brier scores were used to compare discrimination and calibration between models. RESULTS For the mortality and overall morbidity outcomes, the prediction models without the preoperative laboratory variables performed as well as the models with the laboratory variables, and the generic models performed as well as the specialty-specific models. The c-indexes were 0.938 for mortality, 0.810 for overall morbidity, and for the 6 complication clusters ranged from 0.757 for infectious to 0.897 for pulmonary complications. Across the 8 prediction models, the first 7 to 11 variables entered accounted for at least 99% of the c-index of the full model (using up to 28 nonlaboratory predictor variables). CONCLUSIONS Our results suggest that it will be possible to develop parsimonious models to predict 8 important postoperative outcomes for a broad surgical population, without the need for surgeon specialty-specific models or inclusion of laboratory variables.

The objective of this study was to determine the effects of using the Surgical Risk Preoperative Assessment System (SURPAS) on patient satisfaction and surgeon efficiency in the surgical informed consent process, as compared to surgeons' "usual" consent process.Patient perception of the consent process was assessed via survey in 2 cohorts: 10 surgeons in different specialties used their "usual" consent process for 10 patients; these surgeons were then taught to use SURPAS, and they used it during the informed consent process of 10 additional patients. The data were compared using Fisher's exact test and the Cochran-Mantel-Haenszel test.One hundred patients underwent the "usual" consent process (USUAL), and 93 underwent SURPAS-guided consent (SURPAS). Eighty-two percent of SURPAS were "very satisfied" and 18% were "satisfied" with risk discussion vs 16% and 72% of USUAL, respectively. Of those who used SURPAS, 75.3% reported the risk discussion made them "more comfortable" with surgery vs 19% of USUAL, and 90.3% of SURPAS users reported "somewhat" or "greatly decreased" anxiety vs 20% of USUAL. All p values were0.0001. Among SURPAS patients, 97.9% reported "enough time spent discussing risks" vs 72.0% of USUAL patients.The SURPAS tool improved the informed consent process for patients compared with the "usual" consent process, in terms of patient satisfaction, ie making patients feel more comfortable and less anxious about their impending operations. Providers should consider integrating the SURPAS tool into their preoperative consent process.

BackgroundAlthough deviations in intraoperative blood pressure are assumed to be associated with postoperative mortality, critical blood pressure thresholds remain undefined. Therefore, the authors estimated the intraoperative thresholds of systolic blood pressure (SBP), mean blood pressure (MAP), and diastolic blood pressure (DBP) associated with increased risk-adjusted 30-day mortality.MethodsThis retrospective cohort study combined intraoperative blood pressure data from six Veterans Affairs medical centers with 30-day outcomes to determine the risk-adjusted associations between intraoperative blood pressure and 30-day mortality. Deviations in blood pressure were assessed using three methods: (1) population thresholds (individual patient sum of area under threshold [AUT] or area over threshold 2 SDs from the mean of the population intraoperative blood pressure values), (2). absolute thresholds, and (3) percent change from baseline blood pressure.ResultsThirty-day mortality was associated with (1) population threshold: systolic AUT (odds ratio, 3.3; 95% CI, 2.2 to 4.8), mean AUT (2.8; 1.9 to 4.3), and diastolic AUT (2.4; 1.6 to 3.8). Approximate conversions of AUT into its separate components of pressure and time were SBP < 67 mmHg for more than 8.2 min, MAP < 49 mmHg for more than 3.9 min, DBP < 33 mmHg for more than 4.4 min. (2) Absolute threshold: SBP < 70 mmHg for more than or equal to 5 min (odds ratio, 2.9; 95% CI, 1.7 to 4.9), MAP < 49 mmHg for more than or equal to 5 min (2.4; 1.3 to 4.6), and DBP < 30 mmHg for more than or equal to 5 min (3.2; 1.8 to 5.5). (3) Percent change: MAP decreases to more than 50% from baseline for more than or equal to 5 min (2.7; 1.5 to 5.0). Intraoperative hypertension was not associated with 30-day mortality with any of these techniques.ConclusionIntraoperative hypotension, but not hypertension, is associated with increased 30-day operative mortality.

BACKGROUND Blood transfusion has been associated with worse outcomes in adult trauma patients with traumatic brain injury (TBI). However, the effects in injured children have not been evaluated. We hypothesize that blood transfusion is also associated with worse outcomes in children with TBI. METHODS A retrospective review of the trauma database at two Level I pediatric trauma centers was performed. We reviewed all patients 18 years and younger with TBI, who survived at least 24 hours, from 2002 to 2011. Exclusion criteria include those who underwent craniotomy, thoracotomy, exploratory laparotomy, and any orthopedic procedure. RESULTS A total of 1,607 children with TBI were included in the study population (mean age, 6.4 [5.7] years; 65% male), 178 of whom received a blood transfusion. Mean Injury Severity Score (ISS) was 16.5 (9.1). Patients who received a transfusion had a higher ISS than those who did not (26.7 vs. 15.3). After controlling for age, sex, ISS, Glasgow Coma Scale (GCS) score on presentation, and mechanism of injury, patients who received a blood transfusion were more likely to be admitted to the intensive care unit (p < 0.0001), less likely to survive to hospital discharge (p = 0.02), more likely to be discharged to a rehabilitation facility (p = 0.01) and be dependent on caretakers at follow-up (p < 0.0001), as well as more likely to develop urinary tract infection (p = 0.02) and bacteremia (p = 0.02) during their hospital stay. These differences in outcomes among those who did and did not receive a blood transfusion began to disappear in patients with a nadir hemoglobin of less than 8.0 g/dL. CONCLUSION Pediatric patients sustaining TBI who receive blood transfusion and do not require operative intervention have worse outcomes compared with patients who do not receive transfusion. This includes an increased risk of death. These data suggest that a transfusion trigger of hemoglobin level at 8.0 g/dL in injured children with TBI may be beneficial. LEVEL OF EVIDENCE Epidemiologic study, level III. Therapeutic study, level IV.

Background: Physician bias is a likely contributor to gender disparities in the use of cardiac procedures. The Implicit Association Test (IAT) is a validated tool to measure implicit (unconscious) attitudes but has not been used to study gender disparities in health care. We measured attitudes around patient gender among cardiology physicians using the IAT. Methods: We developed two web-based IATs focused on gender attitudes applicable to cardiology procedures. The IAT measures implicit biases by comparing the speed with which concepts can be sorted, when paired in different combinations (i.e. women=strength and men=weakness vs. men=strength and women=weakness). The Strong-IAT measured gender associations with “strength versus weakness” and the Risk-IAT measured gender associations with “risk-taker versus risk-averse”. The IAT is scored from –2.0 to +2.0 with negative scores suggesting a pro-female bias (e.g. women are stronger than men), a positive score suggesting a pro-male bias (e.g. men are stronger than women) and “0” meaning no bias. We emailed a web-based survey including the IATs to all physician members of a state cardiology association. Potential participants received three weekly reminders and, for validation purposes, a subset re-took the survey after 30-days. Results: Of the 317 cardiology physicians with valid email addresses, 52 (16.4%) completed the survey. Participants’ mean age was 48.2 (+/- 12.1), 81% were male, and 77% were white. Most (63%) were non-invasive cardiologists (22% interventional cardiologists and 16% electrophysiologists) and 67% practiced in an academic setting. The mean Strong-IAT score was 0.60 (SD = 0 .42) and Risk-IAT score was 0.45 (SD = 0.54) revealing a significant pro-male bias. Over 38% had a high degree of pro-male bias for both IATs (Figure). Among the 11 participants who retook the survey, test-retest reliability was high (Strong-IAT r=0.68; Risk-IAT r=0.79). Conclusions: On average, cardiology physicians exhibited implicit gender bias suggesting they are more likely to view men as being stronger and more likely to take risks than women. These attitudes appeared to be relatively stable over time. Future work is needed to understand whether these attitudes influence treatment decisions and contribute to gender disparities in cardiology care.

Background: Gender differences in evaluation of coronary artery disease (CAD) have been suggested in observational cohorts. Whether gender differences in care exist under standardized conditions is not well known. Methods: We developed a web-based survey that randomly varied a case vignette by patient gender alone. The first part described a patient presenting with symptoms suggestive of CAD and the second described the results of an abnormal ETT (exercise treadmill test) in that patient. For both parts, the scenario was designed to represent an intermediate likelihood of obstructive CAD regardless of patient gender. Providers were asked to rate the likelihood of obstructive CAD and to choose the best treatment option. The survey was emailed to all physician members of a state cardiology association. A total of 3 reminder emails were sent. Results: Of the 317 cardiologists with valid addresses, 71 (22.4%) completed the survey. Participants were mostly men (82.4%) and non-invasive cardiologists (63%). For both parts of the vignette, cardiologists tended to estimate the likelihood of obstructive CAD as “high” more often when the patient was a man (Table). Respondents were equally likely to recommend cardiac testing based on symptoms suggestive of CAD regardless of patient gender; however, after an abnormal ETT, cardiologists were more likely to recommend angiography for male patients and more likely to recommend a second stress test with imaging for female patients (Table). Conclusions: Using a standardized case patient at intermediate risk for CAD, cardiologists tended to estimate the likelihood of CAD as higher and were more likely to recommend cardiac angiography after an abnormal ETT in male patients and more likely to recommend stress testing with imaging for women. Our findings suggest differences in how cardiologists evaluate symptoms and manage abnormal stress test results according to patient gender.