Havens JM, Columbus AB, Olufajo OA, Askari R, Salim A, Christopher KB. Association of Model for End-Stage Liver Disease Score With Mortality in Emergency General Surgery Patients. JAMA Surg. 2016 Jul 20;151(7):e160789. doi: 10.1001/jamasurg.2016.0789.
Results: A total of 13 552 EGS patients received critical care; of these, 707 (5%) (mean [SD] age at hospital admission, 56.6 [14.2] years; 64% male; 79% white) had CLD and data to determine MELD score at ICU admission. The median MELD score was 14 (interquartile range, 10-20). Overall 90-day mortality was 30.1%. The adjusted odds ratio of 90-day mortality for each 10-point increase in MELD score was 1.63 (95% CI, 1.34-1.98). A decrease in MELD score of more than 3 in the 48 hours following ICU admission was associated with a 2.2-fold decrease in 90-day mortality (odds ratio = 0.46; 95% CI, 0.22-0.98).
Conclusions and relevance: In this study, MELD score was associated with 90-day mortality following EGS in patients with CLD. The MELD score can be used as a prognostic factor in this patient population and should be used in preoperative risk prediction models and when counseling EGS patients on the risks and benefits of operative intervention.
Commentary: Zarrinpar A. Mind MELD or Ignore It at Your Peril. JAMA Surg. 2016 Jul 20;151(7):e160839. doi: 10.1001/jamasurg.2016.0839.
Havens JM, Columbus AB, Seshadri AJ, et al. Risk stratification tools in emergency general surgery. Trauma Surg Acute Care Open. 2018 Apr 29;3(1):e000160.
The use of risk stratification tools (RST) aids in clinical triage, decision making and quality assessment in a wide variety of medical fields. Although emergency general surgery (EGS) is characterized by a comorbid, physiologically acute patient population with disparately high rates of perioperative morbidity and mortality, few RST have been explicitly examined in this setting. We examined the available RST with the intent of identifying a tool that comprehensively reflects an EGS patients perioperative risk for death or complication.
Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020 Mar 11. doi: 10.1016/S0140-6736(20)30566-3. [Epub ahead of print]
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“191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03-1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61-12·23; p<0·0001), and d-dimer greater than 1 μg/L (18·42, 2·64-128·55; p=0·0033) on admission. Median duration of viral shedding was 20·0 days (IQR 17·0-24·0) in survivors, but SARS-CoV-2 was detectable until death in non-survivors. The longest observed duration of viral shedding in survivors was 37 days.”
Rueckert J. Elimination of the Autopsy Requirement by CMS. N Engl J Med. 2020 Feb 13;382(7):683-684.
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The autopsy plays a vital role in quality assurance by providing education and feedback to clinicians regarding diagnostic accuracy, therapeutic efficacy, and medical complications. At our institution, we promote a culture of transparency. Discrepant cases are discussed with the treating physicians and families and are also presented at conferences on morbidity and mortality, to educate a broad audience. As is the case at other academic institutions, our autopsy service provides extensive support of cutting-edge research efforts and hence is not “obsolete.”
CMS is making a mistake. A robust autopsy service plays an important role in providing and maintaining high-quality patient care. By eliminating the autopsy requirement, we are burying opportunities for improvement. The autopsy should be supported, not undermined.