INTRODUCTION Within a large, statewide collaborative, significant improvement in surgical quality have been appreciated (9.0% reduction in morbidity for elective general and vascular surgery). Our group has not noted such quality improvement in the care of patients who had emergency operations. With this work, we aim to describe the scope of emergency surgical care within the Michigan Surgical Quality Collaborative (MSQC), variations in outcomes among hospitals, and variations in adherence to evidence based process measures. Overall, these data will form a basis for a broad based quality improvement initiative within Michigan. METHODS We report morbidity, mortality, and costs of emergency and elective general and vascular surgery cases (n= 190,826) within 34 hospitals participating in the MSQC from 2005 to 2010. Adjusted hospital specific outcomes were calculated using a step-wise multivariable logistic regression model. Adjustment covariates included patient specific co-morbidities and case complexity. Hospitals were also compared based on their adherence to evidence based process measures (measures at the patient level for each case – SCIP 1 and 2 compliance). RESULTS Emergency procedures account for approximately 11% of total cases, yet they represented 47% of mortalities and 28% of surgical complications. The complication-specific cost to payers was $126 million for emergency cases and $329 million for elective cases. Adjusted patient outcomes varied widely within MSQC hospitals; morbidity and mortality rates ranged from 16.3% to 33.9% and 4.0% to 12.4%, respectively. The variation among hospitals was not correlated with volume of emergency cases and case complexity. Hospital performance in emergency surgery was found to not depend on its share of emergent cases, but rather was found to directly correlate with its performance in elective surgery. For emergency colectomies, there was wide variation in compliance with SCIP 1 and 2 measures, and overall compliance (42.0%) was markedly lower than elective colon surgery (81.7%). CONCLUSION(S) Emergency surgical procedures are an important target for future quality improvement efforts within Michigan. Future work will identify best practices within high-performing hospitals and disseminate these practices within the collaborative.

Studies suggest that abnormalities in glutamate and GABA signaling contribute to deficits in schizophrenia and related conditions and that these neurochemical abnormalities produce changes in electroencephalographic (EEG) indices, including event-related potentials and event-related power within specific frequency ranges. Furthermore, clinical studies suggest that a subset of EEG biomarkers is associated with symptoms. This review addresses the relationship between EEG and behavior in preclinical models of N-methyl-d-aspartate (NMDA)-receptor hypofunction, as well as how these models can be used to screen therapies. Data from schizophrenia patients are juxtaposed with data from animal models, and EEG and behavioral data from mice with disruption of NMDA receptors in excitatory and/or inhibitory neurons are then compared to the pattern observed in schizophrenia. Also discussed are results following exposure to potential therapeutic agents, including GABAB agonists. Furthermore, evidence demonstrates that elevated resting gamma power is associated with deficits in social interactions. Consistent with elevated baseline noise, excitatory neurons from transgenic mice show increased intrinsic excitability in in vitro-slice patch-clamp studies across model systems. GABAB receptor agonists reduce this excitability, improve gamma-band responses, and reverse behavioral deficits in mice. Data suggest that baseline gamma power is associated with social function and GABAB agonists may be useful for schizophrenia. Translational EEG biomarkers reflect target engagement and can contribute to the design of more efficient drug trials, likely accelerating the development of new therapeutics for central nervous system disorders.

Operative hysteroscopy intravascular absorption syndrome is an iatrogenic syndrome caused by absorption of hypo-osmolar distension medium during hysteroscopy, which can lead to rapid hyponatremia with resulting cerebral and pulmonary edema. We present a case of a 47-year-old female who underwent hysteroscopic myomectomy at an outpatient ambulatory surgical center who was brought to the emergency department with dyspnea, hypoxia, and altered mental status. Workup showed hyponatremia with cerebral edema on computed tomography of the head and pulmonary edema on chest radiograph. The patient improved after resuscitation with intravenous saline and supplemental oxygen, and she was discharged home the next day.