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Background We sought to prospectively identify risk factors for biliary complications and 30-day readmission after cholecystectomy for choledocholithiasis and gallstone pancreatitis across multiple US hospitals. Methods We performed a prospective, observational study of patients who underwent same admission cholecystectomy for choledocholithiasis and gallstone pancreatitis between 2016 and 2019 at 12 US centers. Patients with prior history of endoscopic retrograde cholangiopancreatography or diagnosis of cholangitis were excluded. We used logistic regression to determine associations between preoperative demographics, labs, and imaging on primary outcomes: postoperative biliary complications and 30-day readmission. Results There were 989 patients in the cohort. There were 16 (1.6%) patients with postoperative biliary complications, including intra-abdominal abscesses, endoscopic retrograde cholangiopancreatography-induced pancreatitis, and biliary leaks. Increasing operative time (odds ratio 1.01, 95% confidence interval 1.00–1.01, P = .02), worsening leukocytosis (odds ratio 1.16, 95% confidence interval 1.07–1.25, P = .0002), and jaundice (odds ratio 3.25, 95% confidence interval 1.01–10.42, P = .04) were associated with postoperative biliary complications. There were 36 (3.6%) patients readmitted within 30 days owing to a surgical complication. A prior postoperative biliary complication (odds ratio 7.8, 95% confidence interval 1.63–37.27, P = .01), male sex (odds ratio 2.42, 95% confidence interval 1.2–4.87, P = .01), and index operative duration (odds ratio 1.01, 95% confidence interval 1.00–1.01, P = .03) were associated with 30-day readmission. Conclusion Among patients undergoing cholecystectomy for common bile duct stones, jaundice, worsening leukocytosis, and longer operations are associated with postoperative biliary complications. A prior biliary complication is also predictive of a 30-day readmission. Surgeons should recognize these factors and avoid prematurely discharging at-risk patients given their propensity to develop complications and require readmission.

During the first and second wave of Covid-19 pandemics, Balkan countries were among the least affected areas of Europe, especially those having islands as naturally protected quarantine environment (Greece, Croatia, Cyprus, Malta), as well as countries with less tourism in Spring such as Montenegro, Albania, and Bulgaria Therefore, the health care system was not overwhelmed by Covid-19 infected patients and was able to continue on normal outpatient and inpatient bases This pilot population-based study in rural Albania shows only a low and temporary break of health and social services for just 1 month during the first wave, in April 2020

Background: Surgical task-sharing is a strategy allowing trained mid-level providers to perform essential surgery in low-resource areas. Despite case volumes second only to obstetric surgery, no large-scale comparative study has been previously performed examining task-sharing for acute abdominal surgery. Both general surgeons and mid-level emergency surgical officers (ESOs) perform laparotomies in the same facilities in Ethiopia, presenting an opportunity for comparative analysis of outcomes. Methods: A three-year retrospective study collected surgical case data at 4 general hospitals (n = 1540) with ESOs and MD surgeons, and 2 comparison samples from a primary (n = 100) and a tertiary (n = 142) hospital. Bivariate analysis compared mortality and morbidity stratified by provider type, sub-stratified by facility and twelve categories of emergency abdominal surgery. Multivariable logistic regression modeled the impact of provider training level on odds of perioperative mortality, complication and SSI rates, adjusting for patient age, gender, hospital facility, distance score and preoperative health score. Results: Both overall and within each general hospital across 12 diagnosis categories of emergency abdominal surgery, no significant additional risk was found for ESO mortality, complication and SSI rates. Logistic regression modeling found no additional odds of mortality, complication or surgical site infection for ESOs, controlling for patient age, gender, treatment site, distance travelled, and preoperative health. Conclusion: Emergency surgical officers at general hospitals performed a wide range of abdominal surgery with similar risks of in-hospital mortality, perioperative morbidity and surgical site infection versus similar procedures performed by physician surgeons. Cases performed by ESOs included appendectomy, bowel decompression, bowel resection, perforated peptic ulcer repair, colostomy creation, hemicolectomy, salpingectomy and oophorectomy, and abdominal trauma management with no additional detectable risk. Referral to surgical specialists remains essential in abdominal cases involving liver, spleen, gallbladder, pancreas, and complex vascular or oncological complications. Funding Statement: The funding source for this study was a grant provided by Dr. Mark Hardy, MD, Columbia University Department of Surgery, partially supported by the Il-song Education Foundation and Hallym University Global Medicine Program. Declaration of Interests: The authors have no financial conflicts of interest to disclose. Ethics Approval Statement: Ethical approval was granted by the Columbia University Medical Center Institutional Review Board with a designation of Exempt Research (IRB-AAAR9424) and by the Ethiopian Federal Ministry of Health (Ref. MT(1)/45/300).

To analyze in-room video recordings of operating room (OR) to intensive care unit (ICU) handoffs to determine tempo and quality of team interactions on nights and weekends compared with weekdays, and to demonstrate how existing telemedicine technology can be used to evaluate handoffs.This prospective observational study of OR-to-ICU bedside handoffs was conducted in the surgical ICU of the Hospital of the University of Pennsylvania in July 2014-January 2015. Handoff video recordings were obtained for quality improvement purposes using existing telemedicine cameras. Evaluators used adapted validated in-person assessment measures to analyze basic characteristics and quality measures (timing, report types, report duration, presence of physical exam, teamwork skills, engagement, report delivery skills, listening skills, interruptions, unprofessional comments or actions).Sixteen weekday and 16 night and weekend handoffs were compared. There were no significant differences in basic characteristics. Most quality measures were similar on weekdays compared with nights and weekends. Surgeons demonstrated better report delivery skills and engagement on nights and weekends (P = .002 and P = .04, respectively), whereas OR anesthesiologists' scores were similar during both time frames.This study presents a novel approach of assessing handoff quality in OR-to-ICU handoffs using an existing telemedicine infrastructure. Using this approach, quality measures of night and weekend handoffs were found to be no worse-and sometimes better-than those during weekdays. Video analysis may emerge as an ideal unobtrusive quality improvement methodology to monitor handoffs and improve education and compliance with institutional handoff policies.

Operating room (OR) to intensive care unit (ICU) handoffs are complex and known to be associated with adverse events and patient harm. The authors hypothesized that handoff quality diminishes during nights/weekends and that bedside handoff practices are similar between ICUs of the same health system. Bedside OR-to-ICU handoffs were directly observed in 2 surgical ICUs with different patient volumes. Handoff quality measures were compared within the ICUs on weekdays versus nights/weekends as well as between the high- and moderate-volume ICUs. In the high-volume ICU, transmitter delivery scores were significantly better during off hours, while other measures were not different. High-volume ICU scores were consistently better than those in the moderate-volume ICU. Bedside handoff practices are not worse during off hours and may be better in ICUs used to a higher patient volume. Specific handoff protocols merit evaluation and training to ensure consistent practices in different ICU models and at different times.

Long Hartmann or rectal stump blowout is a dreaded complication of an often already complicated patient scenario. In this chapter, we discuss strategies for stump blowout prevention, diagnosis, and management.

Heparin-induced thrombocytopenia (HIT) is a common drug induced autoimmune condition. The thrombocytopenia is caused in most cases by an antibody directed against the complex PF4/heparin. Recently, we have induced an experimental model of HIT by idiotypic manipulation. To confirm further the idiotypic involvement of HIT, we have treated successfully three patients with HIT with high-dose intravenous γ-globulin (IVIG). Our three patients join other two cases previously reported who were treated with IVIG and point to the efficacy of this type of therapy with minimal side effects. IVIG suppression of the anti-PF4/heparin autoantibody may support the idiotypic etiology of HIT.

RESULTS: A total of 315,400 records were analyzed (Table). Average age was 51.4 ( 19.9) years; 65.1% were female. Conversion to open surgery occurred in 0.3% (n1⁄41,023) of cases. Riskadjusted odds of conversion increased by 14% (95% CI 1.131.15) for each day that surgery was delayed. Risk-adjusted costs per patient were 122% higher (absolute difference $47,800) for patients who underwent conversion (relative 101% increase [absolute difference $41,100] when restricted to acute cholecystitis cases).

The genetic algorithm is applied to developing optimal or near optimal backpropagation neural networks for fault-prone/not-fault-prone classification of software modules. The algorithm considers each network in a population of neural networks as a potential solution to the optimal classification problem. Variables governing the learning and other parameters and network architecture are represented as substrings (genes) in a machine-level bit string (chromosome). When the population undergoes simulated evolution using genetic operators-selection based on a fitness function, crossover, and mutation-the average performance increases in successive generations. We found that, on the same data, compared with the best manually developed networks, evolved networks produced improved classifications in considerably less time, with no human effort, and with greater confidence in their optimality or near optimality. Strategies for devising a fitness function specific to the problem are explored and discussed.

In this empirical study, from a large data set of software metrics for program modules, thirty distinct partitions into training and validation sets are automatically generated with approximately equal distributions of fault prone and not fault prone modules. Thirty classification models are built for each of the two approaches considered-discriminant analysis and the evolutionary neural network (ENN) approach-and their performances on corresponding data sets are compared. The lower error proportions for ENNs on fault prone, not fault prone, and overall classification were found to be statistically significant. The robustness of ENNs follows from their superior performance on the range of data configurations used. It is suggested that ENNs can be effective in other software reliability problem domains, where they have been largely ignored.

In the Czech Republic a market research was carried out in the year 1997, using a questionnaire campaign, concentrating on the mapping of conditions for the introduction of interactive broadband systems, which would provide potential users, together with voice services, access to the Internet, to services on demand, e.g. VoD, AoD, to electronic shopping, etc. The evaluation included technical furnishings of households and technical readiness of users, the interest in information and, based on analysis of the economical situation in the Czech Republic, also the willingness and ability to pay for services offered. It was concluded that the subscribers of cable television networks represent a prospective group.

Autopsy findings and studies of pulmonary function, including pulmonary mechanics, air distribution, compliance, resistance, and hemodynamics in the intact animal indicate that anatomic and functional changes in the replanted growing lung do not significantly vary from those reported in adult dogs. Significant functional changes included a marked decrease in oxygen uptake and increased pulmonary vascular resistance. Since an increase in pulmonary vascular resistance was also found in animals without evidence of anatomic anomalies, pulmonary hypertension in these animals must, therefore, be related to factors other than obstruction to flow. Whether or not the increased pulmonary vascular resistance in the replanted lung may be secondary to a lack of regrowth of divided nerves is not clearly established. Lung volume distribution, as well as ventilation distribution, as evidenced by nitrogen washout data, were not significantly effected. Growth of vascular and bronchial anastomoses was slightly reduced, but the anastomotic obstructions found were due to technical error or complications rather than to failure of growth. Left pulmonary growth after replantation continued and was found to be significantly reduced only if complete obliteration of the pulmonary artery occurred.