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Background: Many surgical disciplines have demonstrated superior outcomes when procedures are performed at "high-volume". Esophagomyotomy is commonly performed for achalasia, however it's unclear what constitutes "high-volume" for this procedure, and if individual procedure volume and outcome are related. We identified physicians performing esophagomyotomy, stratified them by individual case volume, and examined their outcomes with the hypothesis that high-volume surgeons will be associated with improved outcomes as compared to low-volume surgeons., Methods: The 2015-2019 Florida Agency for Health Care Administration (AHCA) inpatient dataset was queried for esophagomyotomy. Surgeons who performed ≥ 10 procedures during the study period were placed into the high-volume cohort, and those performing < 10 into the low-volume cohort. Groups were compared by length of stay, discharge disposition, and postoperative complications. Patient demographics were evaluated using student's t test and chi square test, p < 0.05 considered significant., Results: Six hundred and sixty-two procedures performed by 135 surgeons were identified. The mean number of esophagomyotomies per surgeon was 4.9 (Range 1-147). The high-volume group (n = 12) performed 362 of the 662 procedures (55%), while the low-volume group (n = 123) performed the remaining 300 (45%). Patients of high-volume physicians had decreased length of stay (1.4 ± 0.8 days vs 4.9 ± 6.7 days, p = 0.01) and were more likely to be discharged to home following surgery (92.8% vs 86.0, p = 0.04). High volume physicians also had statistically significant differences in rates of urinary tract infection (1.4% vs 4.0%, p = 0.034), postoperative malnutrition (5.8% vs 11.0%, p = 0.015), and postoperative fluid and electrolyte disorders (5.5% vs 13.3%, p < 0.0001)., Conclusion: Surgeons who perform higher volumes of esophagomyotomies are associated with decreased length of stay, higher likelihood of patient discharge to home, and decreased rates of some postoperative complications. This research should prompt further inquiry into defining what constitutes a high-volume center in foregut surgery and their role in improving patient outcomes., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Angiographic reperfusion after endovascular thrombectomy in acute ischemic stroke is commonly graded using volume-based reperfusion scores such as the modified thrombolysis in cerebral infarct score. The location of non-reperfused regions is not included in modified thrombolysis in cerebral infarct score. We studied the predictive ability of an eloquence-based reperfusion score., Methods: Consecutive cases of endovascular thrombectomy for anterior circulation strokes performed between January 2018 and April 2020 were included. Digital subtraction angiograms were reviewed by two blinded neurointerventionalist operators. Incomplete reperfusion was further classified by lobar regions lacking reperfusion to create various cohorts. Outcomes were graded four to seven days post-procedure with the National Institute of Health Stroke Scale (NIHSS) and 90 days post-procedure with the modified Rankin Scale., Results: One hundred patients were identified. Via multivariate analysis, we found that frontal lobe non-reperfusion (mean difference (MD) = -1.60, p  = 0.002) and occipital lobe non-reperfusion (MD = -1.68, p  = 0.001) were associated with worse mental status improvement while left-sided stroke (MD = 2.02, p  < 0.001) featured better improvement post-thrombectomy. Occipital lobe non-reperfusion (MD = -0.734, p  = 0.009) was associated with the worse improvement of visual fields. The non-reperfusion of the frontal lobe was associated with a 1.732-worse NIHSS hemibody strength score (95% confidence interval (95%CI) = -3.39 to -0.072, p  = 0.041). Worse improvement in NIHSS scores was found to be associated with frontal lobe non-reperfusion (MD = -5.34, 95%CI = -9.52 to -1.18, p  = 0.013) and occipital lobe non-reperfusion (MD = -6.35, 95%CI = -10.4 to -2.31, p  = 0.002). Odds of achieving modified Rankin Scale of 0-2 at 90 days were decreased with frontal lobe non-reperfusion (odds ratio (OR) = 0.279, 95%CI = 0.090-0.869, p  = 0.028) and left laterality (OR = 0.376, 95%CI = 0.153-0.922, p  = 0.033)., Conclusions: Eloquence-based reperfusion assessment is an important predictor for functional outcomes after thrombectomy.

Background and Purpose: The modified Thrombolysis in Cerebral Infarct (mTICI) score is used to grade angiographic outcome after endovascular thrombectomy. We sought to identify factors that decrease the accuracy of intraprocedural mTICI., Methods: We performed a 2-center retrospective cohort study comparing operator (n=6) mTICI scores to consensus scores from blinded adjudicators. Groups were also assessed by dichotomizing mTICI scores to 0–2a versus 2b–3., Results: One hundred thirty endovascular thrombectomy procedures were included. Operators and adjudicators had a pairwise agreement in 96 cases (73.8%). Krippendorff α was 0.712. Multivariate analysis showed endovascular thrombectomy overnight (odds ratio [OR]=3.84 [95% CI, 1.22–12.1]), lacking frontal (OR, 5.66 [95 CI, 1.36–23.6]), or occipital (OR, 7.18 [95 CI, 2.12–24.3]) region reperfusion, and higher operator mTICI scores (OR, 2.16 [95 CI, 1.16–4.01]) were predictive of incorrectly scoring mTICI intraprocedurally. With dichotomized mTICI scores, increasing number of passes was associated with increased risk of operator error (OR, 1.93 [95 CI, 1.22–3.05])., Conclusions: In our study, mTICI disagreement between operator and adjudicators was observed in 26.2% of cases. Interventions that took place between 22:30 and 4:00, featured frontal or occipital region nonperfusion, higher operator mTICI scores, and increased number of passes had higher odds of intraprocedural mTICI inaccuracy.

Objective: To assess the potential effects of rapid bedside blood analysis on patient management in the ED., Methods: A prospective, nonrandomized clinical study was conducted over a consecutive ten-month period (August 1992 to May 1993). Blood samples drawn from a convenience sample of 960 patients for analysis of Na+, K+, Cl-, BUN, glucose, and/or hematocrit (Hct) were simultaneously analyzed by portable clinical analyzer (PCA) and by routine methods in the central laboratory. Caregivers were blinded to the PCA values; patient care was based solely on central laboratory results. Physicians were surveyed after the completion of patient care., Results: The PCA results were available 31 minutes (mean) sooner than were the central laboratory results for Hct, 43 minutes faster for Na+, K+, and Cl-, and 44 minutes faster for BUN and glucose. Except for Hct and glucose, the values obtained from the PCA were not significantly different from the central clinical blood analyzer laboratory values. When surveyed, the physicians caring for the patients reported that had the PCA results been available, a different or an earlier therapeutic approach would have resulted in 9.5% of the cases. The decision to release or admit the patient was based on one or more of the laboratory values for 10.7% of patients sampled. In no case in this series did a physician report that final ED clinical outcome would have been affected., Conclusions: In our ED, the PCA yielded faster reporting of laboratory values. These earlier results might have reduced the length of stay in the ED for 17.3% of patients studied. Selective use of a handheld portable analyzer might decrease time to therapeutic interventions and time to disposition.