bluuebunny/crossref_metadata_2025 huggingface dataset:
Adherence to Physical Activity Guidelines in Breast Cancer Survivors
Authors: Smith Savanna G. , Chagpar Anees B.
Published: June 2020

Physical activity in breast cancer survivors has been shown to improve outcomes. This study evaluated breast cancer patients’ adherence to physical activity guidelines in a population-based study. Data from the 2007 National Health Interview Survey were used to compare adherence to physical activity guidelines in patients with breast cancer with the general population. Statistical analyses were performed using SUDAAN software. In 2007, 327 breast cancer survivors and 23,030 others from the general population were surveyed. Breast cancer survivors were significantly older than the general population (mean age 64.9 vs 45.6 years, P < 0.001) and tended to be female (99.4 vs 51.2%, P < 0.001). Despite being significantly more likely to have interacted with a healthcare professional within the past year (96.7 vs 82.1%, P < 0.001), fewer breast cancer survivors reported following physical activity guidelines than nonbreast cancer survivors (4.64 vs 12.0%, P < 0.001). Controlling for age, gender, and interaction with healthcare providers, breast cancer survivors were no more likely to follow physical activity guidelines than the general population (OR: 0.73; 95% CI: 0.41-1.30, P = 0.282). Despite more interaction with healthcare providers, breast cancer survivors are no more likely to adhere to activity guidelines than the general population.
MRI as an Adjunct to Cervical Spine Clearance: A Utility Analysis
Authors: Soult Michael C. , Weireter Leonard J. , Britt Rebecca C. , Collins Jay N. , Novosel Timothy J. , Reed Scott F. , Britt L. D.
Published: June 2020

Cervical spine (CS) injury occurs in 1 to 3 per cent of blunt trauma patients. The goal of this study is to evaluate the use of magnetic resonance imaging (MRI) as an adjunct to CS computed tomography (CT) in the presence of persistent pain with a normal physical examination or obtundation. A retrospective chart review was performed on 389 blunt trauma patients undergoing both CS CT and MRI between 2007 and 2010. Abnormal CT findings were found in 199. The remaining 190 patients with normal CT scans underwent MRI for persistent pain (109), neurologic symptoms (57), or obtundation (24). Motor vehicle crashes predominated (50%) followed by falls (19%) and motorcycle crashes (12%). In the patients with persistent pain, CT showed no acute injury (89%) with subsequent MRI demonstrating ligamentous edema or injury not seen on CT in 12 per cent of patients. No patient required an operation for CS instability. All the obtunded patients demonstrated localizing motion of four extremities. MRI of these patients demonstrated ligamentous edema or injury not seen on CT in 20 per cent of patients. No obtunded patient had CS instability or needed operative intervention. A localizing physical examination in conjunction with normal CS CT safely precludes a CS injury requiring cervical fixation. MRI does not add substantially to this decision-making and the cervical collar can be safely removed.
Improving Quality of Surgical Care and Outcomes: Factors Impacting Surgical Site Infection after Colorectal Resection
Authors: Shaffer Virginia Oliva , Baptiste Caitlin D. , Liu Yuan , Srinivasan Jahnavi K. , Galloway John R. , Sullivan Patrick S. , Staley Charles A. , Sweeney John F. , Sharma Joe , Gillespie Theresa W.
Published: June 2020

Surgical site infections (SSIs) result in patient morbidity and increased costs. The purpose of this study was to determine reasons underlying SSI to enable interventions addressing identified factors. Combining data from the American College of Surgeons National Surgical Quality Improvement Project with medical record extraction, we evaluated 365 patients who underwent colon resection from January 2009 to December 2012 at a single institution. Of the 365 patients, 84 (23%) developed SSI. On univariate analysis, significant risk factors included disseminated cancer, ileostomy, patient temperature less than 36°C for greater than 60 minutes, and higher glucose level. The median number of cases per surgeon was 36, and a case volume below the median was associated with a higher risk of SSI. On multivariate analysis, significant risks associated with SSI included disseminated cancer (odds ratio [OR], 4.31; P < .001); surgery performed by a surgeon with less than 36 cases (OR, 2.19; P = .008); higher glucose level (OR, 1.06; P 5.017); and transfusion of five units or more of blood (OR, 3.26; P 5.029). In this study we found both modifiable and unmodifiable factors associated with increased SSI. Identifying modifiable risk factors enables targeting specific areas to improve the quality of care and patient outcomes.
Evaluating One Day versus Two Days Preoperative Lymphoscintigraphy Protocols for Sentinel Lymph Node Biopsy in Breast Cancer
Authors: Mount Michael G. , White Nicholas R. , Nguyen Christophe L. , Orr Richard K. , Hird Robert B.
Published: June 2020

Sentinel lymph node biopsy (SLNB) is used to detect axillary lymph node metastases in breast cancer. Preoperative radiocolloid injection with lymphoscintigraphy (PL) is performed before SLNB. Few comparisons between 1- and 2-day PL protocols exist. Opponents of a 2-day protocol have expressed concerns of radiotracer washout to nonsentinel nodes. Proponents cite lack of scheduling conflicts between PL and surgery. A total of 387 consecutive patients with clinically node-negative breast cancer underwent SLNB with PL. Lymphoscintigraphy images were obtained within 30 minutes of radio-colloid injection. Axillary lymph node dissection was performed if the sentinel lymph node (SLN) could not be identified. Data were collected regarding PL technique and results. In all, 212 patients were included in the 2-day PL group and 175 patients in the 1-day PL group. Lymphoscintigraphy identified an axillary sentinel node in 143/212 (67.5%) of patients in the 2-day group and 127/175 (72.5%) in the 1-day group ( P = 0.28). SLN was identified at surgery in 209/212 (98.6%) patients in the 2-day group and 174/175 (99.4%) in the 1-day group ( P = 0.41). An average of 3 SLN was found at surgery in the 2-day group compared with 3.15 in the 1-day group ( P = 0.43). SLN was positive for metastatic disease in 54/212 (25.5%) patients in the 2-day group compared with 40/175 (22.9%) in the 1-day group ( P = 0.55). A 2-day lymphoscintigraphy protocol allows reliable detection of the SLN, of positive SLN and equivalent SLN harvest compared with a 1-day protocol. The timing of radiocolloid injection before SLNB can be left at the discretion of the surgeon.
Journalism and Academic Surgery: The Denver Post and the American Surgeon
Authors: Nakayama Don K.
Published: June 2020

Publication in professional journals is where advancements in surgery are reported and verified. Thus academic surgery holds common ground with journalism, where the principles of service, communication, and integrity are the basis of their public trust and standing in society. Writing for the Denver Post the author learned lessons that are relevant to academic surgery. Facts have to be solid. There are important issues to be discussed. Articles have to be interesting and not tiresome to read. And if it's something new—the essence of news—get it out there first. The American Surgeon embodies the same principles. The journal is a place where members of the Southeastern Surgical Congress discuss important matters, like surgical education, and share stories of interest, like a Japanese surgeon trying to treat victims of nuclear war. It is accessible yet disciplined, dedicated to advancing our field and fostering fellowship and communication among its members.
General Surgery Resident Vascular Operative Experience in the Era of Endovascular Surgery and Vascular Fellowships
Authors: Yan Huan , Maximus Steven , Kim Jerry J. , Smith Brian , Kim Dennis , Koopmann Matthew , DeVirgilio Christian
Published: June 2020

Advances in endovascular surgery have resulted in a decline in major open arterial reconstructions nationwide. Our objective is to investigate the effect of endovascular surgery on general surgery resident experience with open vascular surgery. Between 2004 and 2014, 112 residents graduated from two academic institutions in Southern California. Residents were separated into those who graduated in 2004 to 2008 (period 1) and in 2009 to 2014 (period 2). Case volumes of vascular procedures were compared using two-sample t test. A total of 43 residents were in period 1 and 59 residents were in period 2. In aggregate, there was no significant difference in open cases recorded between the two periods (84 vs 87, P = 0.194). Subgroup analysis showed period 2 recorded significantly fewer cases of open aneurysm repair (5 vs 3, P < 0.001), cerebrovascular (14 vs 10, P = 0.007), and peripheral obstructive procedures (16 vs 13, P = 0.017). Dialysis access procedures constituted the largest group of procedures and remained similar between the two periods (35 vs 42, P = 0.582). General surgery residents experienced a significant decline in several index open major arterial reconstruction cases. This decline was offset by maintenance of dialysis access procedures. If the trend continues, future general surgeons will not be proficient in open vascular procedures.
Double Prosthetic Repair for Complex Incisional Hernia Repair: Long-term Results and Evolution of the Technique
Authors: Moreno-Egea Alfredo
Published: June 2020

No single approach has emerged as the best way to close complex incisional hernias. The aim of this report is to present the long-term results with a double prosthetic repair. In this prospective observational study over 12 years (Group 1, 8 years; Group 2, 4 years), the following data were collected: age, gender, previous surgery, comorbidities, situation and size of defect, hospital stay, postoperative complications, and recurrence. There were 53 lateral cases and 31 midline cases. About 88.6 per cent of the lateral defects were repaired without needing to approach the intraabdominal cavity (Type I), whereas in the patients with large medial defects this was only achieved in 6.5 per cent of the cases (93.5% required a Type II). The average length of the defects was 18 cm. Global morbidity was 18 per cent early, and 7 per cent late. The statistical analysis over time shows significant differences in the operative time, hospital stay, and consumption of analgesics ( P < 0.001). The recurrence rate has not varied despite the modifications to the technique (use of lighter meshes and fixation with tacks and glue). Complex abdominal wall defects can be corrected using the double prosthetic repair technique with low morbidity rates and with practically no long-term recurrence. The combination of two meshes reduces their density and the use of combined fixation (tacks + glue) improves postoperative recovery.
Vital Signs Strongly Predict Massive Transfusion Need in Geriatric Trauma Patients
Authors: Fligor Scott C. , Hamill Mark E. , Love Katie M. , Collier Bryan R. , Lollar Dan , Bradburn Eric H.
Published: June 2020

Early recognition of massive transfusion (MT) requirement in geriatric trauma patients presents a challenge, as older patients present with vital signs outside of traditional thresholds for hypotension and tachycardia. Although many systems exist to predict MT need in trauma patients, none have specifically evaluated the geriatric population. We sought to evaluate the predictive value of presenting vital signs in geriatric trauma patients for prediction of MT. We retrospectively reviewed geriatric trauma patients presenting to our Level I trauma center from 2010 to 2013 requiring full trauma team activation. The area under the receiver operating characteristic curve was calculated to assess discrimination of arrival vital signs for MT prediction. Ideal cutoffs with high sensitivity and specificity were identified. A total of 194 patients with complete data were analyzed. Of these, 16 patients received MT. There was no difference between the MT and non-MT groups in sex, age, or mechanism. Systolic blood pressure, pulse pressure, diastolic blood pressure, and shock index all were strongly predictive of MT need. Interestingly, we found that heart rate does not predict MT. MT in geriatric trauma patients can be reliably and simply predicted by arrival vital signs. Heart rate may not reflect serious hemorrhage in this population.
Patient and Surgical Factors Contributing to Perioperative Infection in Complex Lower Extremity Trauma
Authors: Burtt Karen E. , Rounds Alexis D. , Leland Hyuma A. , Alluri Ram K. , Patel Ketan M. , Carey Joseph N.
Published: June 2020

Infections in the traumatized lower extremity are a significant source of morbidity and expense. Outcomes after vascularized soft tissue reconstruction were analyzed to determine impact on infection rates. A retrospective review of a prospectively maintained database was performed, including 114 trauma patients requiring soft tissue reconstruction of lower extremity injuries at an urban Level I tertiary referral center from 2008 to 2015. Patient characteristics and perioperative outcomes were analyzed. After trauma, 39 (34.2%) patients developed wound infections, of which 74.4 per cent of infections occurred before soft tissue coverage. Isolated lower extremity injury yielded a 4-fold increase in the incidence of infection. Infection rates doubled in patients who smoked, sustained a fall, had a proximal third of the lower leg wound, or underwent external fixation. Comorbid diabetes, underlying fracture, and wound size were not predictive of infection. Overall, there was a 97.4 per cent rate of limb salvage after soft tissue reconstruction. In patients with infection before soft tissue reconstruction, a salvage rate of 96.6 per cent was achieved. Soft tissue reconstruction in the traumatized and infected lower extremity resulted in high limb salvage success rates, demonstrating vascularized tissue transfer in lower extremity injuries is effective in treating lower extremity infection.
Building the Nonuniversity, Tertiary Care Center Hepatobiliary and Pancreatic Surgery Practice: Structural and Financial Considerations
Authors: Baker Erin H. , Siddiqui Imran , Vrochides Dionisios , Iannitti David A. , Martinie John B. , Rorabaugh Lauren , Jeyarajah D. Rohan , Swan Ryan Z.
Published: June 2020

Early in their careers, many new surgeons lack the background and experience to understand essential components needed to build a surgical practice. Surgical resident education is often devoid of specific instruction on the business of medicine and practice management. In particular, hepatobiliary and pancreatic (HPB) surgeons require many key components to build a successful practice secondary to significant interdisciplinary coordination and a scope of complex surgery, which spans challenging benign and malignant disease processes. In the following, we describe the required clinical and financial components for developing a successful HPB surgery practice in the nonuniversity tertiary care center. We discuss significant financial considerations for understanding community need and hospital investment, contract establishment, billing, and coding. We summarize the structural elements and key personnel necessary for establishing an effectual HPB surgical team. This article provides useful, essential information for a new HPB surgeon looking to establish a surgical practice. It also provides insight for health-care administrators as to the value an HPB surgeon can bring to a hospital or health-care system.
What is the Optimal Timing for Liver Surgery of Resectable Synchronous Liver Metastases from Colorectal Cancer?
Authors: Inoue Yoshihiro , Imai Yoshiro , Osumi Wataru , Shimizu Tetsunosuke , Asakuma Mitsuhiro , Hirokawa Fumitoshi , Hayashi Michihiro , Uchiyama Kazuhisa
Published: June 2020

The optimal timing of the surgical strategy for colorectal cancer (CRC) presenting with resectable synchronous liver metastases remains unclear and controversial. The aim of this study was to compare simultaneous with staged resection, with respect to morbidity, mortality, and prognosis, including recurrence. A total of 107 patients who underwent initial hepatic resection for resectable synchronous liver metastasis from colorectal cancer were retrospectively analyzed. The 5-year disease-free survival rates were 16.4 per cent in the simultaneous group, and 24.0 per cent in the staged group (P = 0.5486). The 5-year overall survival rates were 70.7 per cent in the simultaneous group and 67.9 per cent in the staged group (P = 0.8254). Perioperative chemotherapy did not have a significant effect. Tumor depth of CRC (≥pT4) was the only key factor influencing prognosis. Postoperative intestinal anastomotic leakage occurred in nine patients (8.4%). On multivariate analysis, simultaneous surgery was shown to be the only independent risk factor for the occurrence of postoperative intestinal anastomotic leakage (P = 0.0163). In conclusion, neither timing of hepatic resection (simultaneous or staged) nor perioperative chemotherapy represented significant prognostic factors. The simultaneous surgery was the only independent risk factor for intestinal anastomotic leakage. Therefore, we recommend staged hepatic surgery for synchronous CRC and liver metastasis from colorectal cancer.
Disparities in Rural Breast Cancer Care: Factors Affecting Choice of Breast Reconstruction in a West Virginia Tertiary Care Hospital
Authors: Holliday Tyler L. , Suggs Patrick D. , Thompson Stephanie N. , Richmond Bryan K.
Published: June 2020

The decision to pursue immediate postmastectomy breast reconstruction (IBR) is not uniform across all groups of women in the United States. We sought to investigate if the challenges of caring for a socioeconomically and geographically challenged rural population affected the incidence of IBR and to identify predictive factors of IBR in this population. Using our institution's cancer registry, we conducted a 10-year review of women with early-stage, unilateral breast cancer who received mastectomy. Demographics, insurance status, comorbidities, and surgeon graduation year were compared for patients receiving IBR versus no reconstruction. Variables with P < 0.05 on univariate analysis were included into a multivariate logistic regression model to determine independent predictors of IBR. From 2006 to 2015, 53/423 (12.5%) patients underwent IBR. On multivariate analysis, three factors independently predicted the decision to undergo IBR: age (P = 0.004), insurance type (P = 0.034), and use of contralateral prophylactic mastectomy (CPM, P < 0.001). Our data indicate that age, insurance type, and utilization of CPM influence the decision to pursue reconstruction. Additionally, the rate of IBR was found to be much lower in our West Virginia population than reported nationally, suggesting disparities in the care of women with early-stage, unilateral breast cancer in a rural population, even in a tertiary care environment.
Minimally Invasive versus Open Simultaneous Resections of Colorectal Cancer and Synchronous Liver Metastases: A Meta-Analysis
Authors: Guo Yulin , Gao Yunhe , Chen Guijin , Li Chen , Dong Guanglong
Published: June 2020

The aim of this meta-analysis was to compare the efficacy and safety of simultaneous resections between the minimally invasive approach (MIA) and the open approach (OA) for patients with colorectal cancer (CRC) and synchronous colorectal liver metastases (SCRLM). A systematic search was conducted in the Cochrane Library, PubMed, EMBASE and Ovid databases (until May 5, 2016). Studies comparing the perioperative results and long-term outcomes for patients undergoing simultaneous CRC and SCRLM resections between the two approaches were evaluated. Six studies were identified, which included 164 minimally invasive and 213 open simultaneous resections of CRC and SCRLM. MIA was associated with lesser surgical blood loss (mean difference = -155.85 mL; 95% confidence interval: -305.64 to -6.06, P = 0.04) and shorter length of postoperative stay (mean difference = -3.16 days; 95% confidence interval: -4.00 to -2.31, P < 0.00001.). The other perioperative results, including operating time, operative blood transfusion, intestinal function recovery time, and postoperative complications, did not differ significantly. No significant difference in the disease-free survival and overall survival rates between the two approaches was observed. In conclusion, compared with the OA, the MIA for simultaneous CRC and SCRLM resections is safe and effective for the treatment of SCRLM with lesser surgical blood loss and shorter length of postoperative stay. The MIA may be an alternative to the OA for simultaneous CRC and SCRLM resections for appropriately selected patients with resectable SCRLM.
Management Approaches for Enterocutaneous Fistulas
Authors: Heimroth Jamie , Chen Eric , Sutton Erica
Published: June 2020

There are very few clinical studies that highlight a definitive and comprehensive guideline for the management of enterocutaneous fistulas. Most accepted guidelines are found in textbooks and are taken from expert advice and case reports. The goal of this review is to highlight advancements relevant to the management of enterocutaneous fistulas from the recent two to three years. Although strong evidence-based guidelines are lacking, the consensus is that a multidisciplinary team working with a clear treatment plan targeting multiple aspects of management can maximize patient outcomes.
Association of Increasing Frailty with Detrimental Outcomes after Pancreatic Resection
Authors: Guyton Rodney Lane , Mosquera Catalina , Spaniolas Konstantinos , Fitzgerald Timothy L.
Published: June 2020

An association between detrimental outcomes and frailty has been documented; however, the impact specific to pancreatic surgery is unknown. Using NSQIP data, patients were classified as non-, mildly, moderately, or severely frail. A total of16,028 patients were included inthe study; most of the patients were white (78.5%) and underwent pancreaticoduodenectomy (PD) (67%). Complications occurred in 17.6 per cent cases, and the median length of stay (LOS) was 11.89 days. Prolonged LOS and mortality occurred in 9.1 and 2.3 per cent of the cases. In the PD group, most of the patients were mildly frail (40.6%), followed by nonfrail (39.83%), whereas in the distal pancreatectomy (DP) group, the majority were nonfrail (43.82%), followed by mildly frail (39.37%) ( P < 0.0001). The 30-day complications, mortality, and LOS were significantly higher in patients undergoing PD compared with DP (19.5 vs 14.3%, 2.8 vs 1.2%, and 13.4 vs 8.7 days, respectively; P < 0.0001). PD conferred a significantly higher risk of death in all frailty groups compared with DP [nonfrail: odds ratio (OR) 1.76, mildly frail: OR 1.03, moderately frail: OR 2.03, P < 0.05], with the exception of severely frail patients. Compared with DP, PD conferred a significant risk of complication in all the frailty groups. Increases in frailty are associated with poorer outcomes after pancreatectomy.
Payer Source Associated with Disparities in Procedural, but Not Surgical, Care in a Trauma Population
Authors: Berg Gina M. , Searight Maggie , Sorell Ryan , Lee Felecia A. , Hervey Ashley M. , Harrison Paul
Published: June 2020

Trauma centers are legally bound by Emergency Medical Treatment and Active Labor Act to provide equal treatment to trauma patients, regardless of payer source. However, evidence has suggested that disparities in trauma care exist. This study investigated the relationships between payer source and procedures (total, diagnostic, and surgical) and the number of medical consults in an adult trauma population. This is a 10-year retrospective trauma registry study at a Level I trauma facility. Payer source of adult trauma patients was identified, demographics and variables associated with trauma outcomes were abstracted, and multivariate logistic regression tests were used to determine statistical differences in the number of procedures and medical consults. Of the 12,870 records analyzed, 69.1 per cent of patients were commercially insured, 21.2 per cent were uninsured, and 9.6 per cent had Medicaid. After controlling for patient- and injury-related variables, the commercially insured received more total procedures (4.30) than the uninsured (3.35) or those with Medicaid (3.34), and more diagnostic (2.59) procedures than the uninsured (2.03) or those with Medicaid (2.04). There was not a difference in the number of surgical procedures or medical consults among payer sources. This study noted that disparities (measured by the number of procedures received) compared by payer source existed in the care of trauma patients. However, for medical consults and definitive care (measured by surgical procedures), disparities were not observed. Future research should focus on secondary factors that influence levels of care such as patient-level factors (health literacy) and trauma program policies.
Lung Cancer Screening in the Community Setting: Challenges for Adoption
Authors: Randhawa Simran , Drizin Gary , Kane Tracy , Song Grace Y. , Reilly Thomas , Jarrar Doraid
Published: June 2020

Secondary prevention of lung cancer by screening a high-risk population with low-dose CT (LDCT) of the chest has been shown to save lives. Our Institution offered a free screening program in 2013. The program was promoted through flyers, radio programs, face-to-face information sessions, and a multidisciplinary lung symposium. A lung navigator confirmed the eligibility of patients according to National Lung Screening Trial (NLST) criteria. Data were, prospectively, collected over a 12-month period using Lung-RADs (Lung Imaging Reporting and Data System). After one year, an online survey was sent out to all primary care and referring physicians in the network. One hundred and sixty-nine patients were found to be eligible for screening. Sixty-five per cent were black, 44 per cent white, 9 per cent Hispanic, and 6 per cent were Asian. Sixty per cent patients were referred by their physician. Thirty-one were Lung-RADs 1 (18.3%), 116 were Lung-RADs 2 (68.6%), 16 were Lung-RADs 3 (9.5%), and six were Lung-RADs 4 (3.6%). At the end of the study period, the survey showed that 100 per cent of the providers were aware of the screening program but 15 per cent never referred a patient. Time constraints and requirement for precertification were cited as potential barriers to referral. Twenty-six per cent of providers were unaware that LDCT was recommended by the U.S. Preventive Services Task Force on par with colonoscopy and mammography. The NLST showed that screening with LDCT could reduce lung cancer mortality by 20 per cent. Significant concerns exist about the generalizability of these results and the applicability of screening programs in the community.
“Yes, I Shot the President, but His Physicians Killed Him.” The Assassination of President James A. Garfield
Authors: Ehrhardt John D. , O'Leary J. Patrick , Nakayama Don K.
Published: June 2020

President James A. Garfield suffered two gunshots on July 2, 1881, but did not die until 80 days later of complications from sepsis. He might have survived had his injuries not been contaminated, either by the gunshots themselves or the interventions that followed. “Yes, I shot the president,” said Charles Guiteau, Garfield's assassin, “but his physicians killed him.” The drama of Garfield's struggle to survive his injuries evoked enormous national interest, a harbinger of the medical dramas and documentaries of today. D. Willard Bliss, a former Civil War surgeon, and his handpicked consultants underwent daily scrutiny by the professional community and lay press. As the President died because of his injuries, the surgeons’ reputations suffered. A primary criticism was the supposed lack of antiseptic interventions in Garfield's care, especially when probing the wound with unwashed hands. Inserting a finger into the wound, however, was a basic part of examination of a gunshot wound at the time. Many American surgeons had not accepted Listerian antisepsis at the time of the event, and aseptic techniques, such as scrupulous handwashing and surgical gloves, had not yet been developed. In the context of surgical practice of the era, his surgeons followed the standards of care of the time.
Patient-Reported Outcomes and Readmission after Ileostomy Creation in Older Adults
Authors: Kandagatla Pridvi , Nikolian Vahagn C. , Matusko Niki , Mason Shayna , Regenbogen Scott E. , Hardiman Karin M.
Published: June 2020

Because of the concern about risk of poor outcome, ileostomy creation is sometimes avoided in older adults. We sought to evaluate the effect of a rigorous postoperative pathway and checklist on readmission and self-efficiacy in older surgical patients. After implementing a self-care checklist and standardized care pathway at our institution, we performed a retrospective review of patients between June 2013 and June 2016 and compared characteristics and outcomes for patients aged <65 and ≥65 years. Using logistic regression, we identified independent predictors of readmission. We also conducted a survey of patient self-efficacy after discharge to assess independence. There were 288 younger patients and 72 older patients. The older group had more patients with an American Society of Anesthesiologists >2 (53.0% vs 81.4%, P < 0.01) and were more likely to have had surgery for cancer (22.9% vs 48.5%, P < 0.01). In the multivariable analyses, age was not a predictor of readmission but American Society of Anesthesiologist and length of stay were. In the 57 patients surveyed after discharge, we found that older and younger patients reported similar self-efficacy scores. In our study, older and younger patients have similar rates of readmission and similar ability to independently care for their themselves after ileostomy creation.
Comparing the Incidences of Occult Contralateral Hernia under Laparo-Endoscopic Techniques and of Contralateral Metachronous Hernia after a Unilateral Groin Hernia Repair in Open Technique
Authors: Imai Yoshiro , Hiramatsu Masako , Kobayashi Toshihiro , Tsunematsu Ichiro , Emiko Kono , Sakane Junna , Suzuki Yusuke
Published: June 2020

The aim of this study was to evaluate the utility of immediate repair of a contralateral occult hernia at the same time as incipient hernia repair. A total of 693 patients were diagnosed preoperatively with a unilateral groin hernia from January 2006 to December 2017. The open technique was used for 541 patients, and the laparo-endoscopic technique was used for 152 patients. The incidences of occult contralateral hernia confirmed during surgery under laparo-endoscopic techniques and those of contralateral metachronous hernia after a unilateral groin hernia repair with open technique were compared. Fifty-one (9.4%) of 541 patients underwent a contralateral metachronous hernia repair after unilateral groin hernia repair. Twenty-three (15.1%) of 152 patients had occult contralateral hernias using laparo-endoscopic techniques. There was a significant difference in the incidence of contralateral metachronous hernia and that of occult contralateral hernia (P = 0.02). It is concluded that finding and repairing an occult contralateral hernia at the time of laparoendoscopic technique has the advantage of avoiding a second operation. However, it has been considered overtreatment to repair all patients with an occult contralateral hernia.
Primary Hyperparathyroidism: Redefining Cure
Authors: Rudin Anatoliy V. , McKenzie Travis J. , Wermer Roberta , Thompson Geoffrey B. , Lyden Melanie L.
Published: June 2020

Primary hyperparathyroidism is the most common cause of hypercalcemia. Follow-up can be resource-intensive and costly. The aim of this study was to determine if there is a subset of patients who can be defined cured earlier than six months. This was a retrospective study of patients who underwent parathyroidectomy between January 2012 and March 2014. Patients with a history of multiple endocrine neoplasia syndrome, and secondary or tertiary hyperparathyroidism were excluded. Patients with normal preoperative calcium and parathyroid hormone (PTH) and those without six months follow-up were excluded. Patients were divided into two groups: cured and not cured. Data analysis was performed between the two groups. A total of 509 patients were screened, and 214 met our inclusion criteria: 202 in the cured category and 12 in the not cured category (94% cure rate). There was no significant difference between age, gland weight, or pre-operative PTH. There was a statistically significant difference between final intraoperative PTH (IOPTH) (37 vs 55, P = 0.008) and per cent PTH decrease (69 vs 43%, P < 0.0001). There was a significant difference between intraoperative cure rate (P < 0.0006), imaging concordance (P = 0.0115), and solitary versus multiglandular disease (P = 0.0151). Subgroup analysis in patients with concordant imaging, solitary parathyroid adenoma, and IOPTH decrease by 50 per cent to normal or near-normal correlated with a six-month cure rate of 97 per cent. Patients with primary hyperparathyroidism with concordant imaging, single-adenoma pathology, and IOPTH decrease by 50 per cent to normal or near-normal levels (15–65 pg/mL) can be considered cured and may need less frequent follow-up.
Comparing Surgical Site Infection for Open and Endoscopic Component Separation
Authors: Palmer Derek S. , Mcdaniel Conner C. , Samra Navdeep S. , Griffen F. Dean
Published: June 2020

In March 2016, we reported the SSI rate at LSU Health for all abdominal wall hernia repairs performed between 2011 and 2013. Among the 263 repairs, the infection rate averaged 6.8 per cent. Given the diversity of repairs, this global percentage lacks relevance, but looking at subsets provides meaningful insights. For example, SSI was 1.8 per cent among 55/263 laparoscopic repairs and 8.2 per cent among 206/263 open repairs. The infection rate of 26.3 per cent among the 19 open component separation cases was especially noteworthy and bothersome. Even though there was no mortality in any subset, the vast majority of the morbidity and costs involved repairs with open component separations. A meta-analysis published in 2016 revealed a likely SSI benefit for the endoscopic component separation technique (ECST) over the open CST. Since that report, we have focused our quality improvement efforts on this subset of challenging cases and have replaced CST with ECST. Our data now include results from 33 hernia repairs with either CSTor ECST that were performed between November 2011 and April 2018. Twenty-four of 33 patients had CSTwith an SSI rate of 37.5 per cent (9 of 24). Nine of 33 had ECST with 0 per cent SSI (P value = 0.039). These results mirror the findings reported in the meta-analysis.
Meta-Analysis of Quantitative Dynamic Contrast-Enhanced MRI for the Assessment of Neoadjuvant Chemotherapy in Breast Cancer
Authors: Jun Wei , Cong Wang , Xianxin Xie , Daqing Jiang
Published: June 2020

The purpose of this meta-analysis was to determine the value of quantitative dynamic contrast-enhanced (DCE) MRI (DCE-MRI) in evaluating the response of breast cancer to neoadjuvant chemotherapy (NAC). PubMed, Embase, and Cochrane Library databases (from building to July 31, 2018) were searched to collect articles about the therapeutic evaluation of NAC using the quantitative DCE-MRI in patients with breast cancer. The sensitivities and specificities of quantitative DCE-MRI in the evaluation of NAC for breast cancer were extracted from the articles. Meta-DiSc1.4 was applied to evaluate the efficacy of the sensitivity and specificity; forest figure and summary receiver operating characteristics (SROC) were created. A total of 356 articles were enrolled in this study, including 739 cases in total, in which 218 cases were effective and the other 521 cases were ineffective to NAC, considering the pathological results as the gold standard. The sensitivity and specificity in the included 14 articles of quantitative DCE-MRI ( Ktrans, kep, and ve) in comprehensively evaluating NAC for breast cancer were 84 per cent (95% confidence interval (CI): 78–88%) and 83 per cent (95% CI: 79–86%), respectively. The area under SROC was 0.899 (95% CI: 0.867–0.943). The sensitivity and specificity in the three articles of Ktrans evaluating NAC for breast cancer were 84.1 per cent (95% CI: 71.0–92.1%) and 81.3 per cent (95% CI: 70.5%-88.5%), respectively. The area under SROC was 0.899 (95% CI: 0.834–0.962). Our study confirmed that the quantitative DCE-MRI is able to monitor NAC treatment for breast cancer because of its high sensitivity and specificity. However, there is a high degree of heterogeneity in published studies, highlighting the lack of standardization in the field.
Postmastectomy Radiotherapy: Barriers to Implementation in a Disparate Population
Authors: Gan Tong , Huang Bin , Chen Quan , Mcgrath Patrick C. , Evers B. Mark , Marcinkowski Emily F.
Published: June 2020

Appalachian Kentucky (AK) has a disproportionally high breast cancer mortality rate. Postmastectomy radiotherapy (PMRT) in N2/N3 nodal disease improves survival and locoregional recurrence. We evaluated Kentucky patient compliance to the quality measure of PMRT received within one year of diagnosis. A population-based retrospective review of patients who received mastectomy with N2/N3 nodal disease from 2006 to 2015 was obtained through the Kentucky Cancer Registry. A total of 1489 patients met the inclusion criteria. Of these, 1104 (66.6%) received PMRT. AK patients were less likely to receive PMRT (58.3%) than non-AK patients (70%, P < 0.001). After adjusting for significant factors, private insurance, education level, treatment center, and receipt of adjuvant chemotherapy were independently associated with PMRT compliance. Patients who received PMRT had improved overall survival (OS, P < 0.0001) and disease-free survival (DFS, P < 0.0001). Appalachian status was not a major factor in OS ( P = 0.1929) or DFS ( P = 0.5840). Nearly two decades after the recommendation of PMRT, compliance remains poor in Kentucky. PMRT continues to be a major factor in survival and recurrence in this population. Interventions focusing on improving insurance coverage, education level, and guideline adherence in nonacademic centers are needed to improve compliance.
Predictors of Trauma High Resource Consumers in a Mature Trauma System
Authors: Morgan Madison E. , Bradburn Eric H. , Vernon Tawnya M. , Gross Brian , Jammula Shreya , Cook Alan D. , Covaci Andrea , Rogers Frederick B.
Published: June 2020

Background

Extended hospital length of stay (LOS) is widely associated with significant healthcare costs. Since LOS is a known surrogate for cost, we sought to evaluate outliers. We hypothesized that particular characteristics are likely predictive of trauma high resource consumers (THRC) and can be used to more effectively manage care of this population.

Methods

The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003-2017 for all adult (age ≥15) trauma patients admitted to accredited trauma centers in Pennsylvania. THRC were defined as patients with hospital LOS two standard deviations above the population mean or ≥22 days (p<0.05). Patient demographics, comorbid conditions and clinical variables were compared between THRC and non-THRC to identify potential predictor variables. A multilevel mixed-effects logistic regression model controlling for age, gender, injury severity, admission Glasgow coma score, systolic blood pressure, and injury year assessed the adjusted impact of clinical factors in predicting THRC status. The National Trauma Data Bank (NTDB) was retrospectively queried from 2014-2016 for all adult (age ≥15) trauma patients admitted to state-accredited trauma centers and likewise were assessed for factors associated with THRC.

Results

A total of 465,601 patients met inclusion criteria [THRC: 16,818 (3.6%); non-THRC 448,783 (96.4%)]. Compared to non-THRC counterparts, THRC patients were significantly more severely injured (median ISS: 9 vs. 22, p<0.001). In adjusted analysis, gunshot wound (GSW) to the abdomen, undergoing major surgery and reintubation along with injury to the spine, upper or lower extremities were significantly associated with THRC. From the NTDB, 2 323 945 patients met inclusion criteria. In adjusted analysis, GSW to the abdomen was significantly associated with THRC. Penetrating injury overall was associated with decreased risk of being a THRC in the NTDB dataset. Those who had either GSW to abdomen, surgery, or reintubation required significantly longer LOS (p<0.001).

Conclusions

Reintubation, major surgery, gunshot wound to abdomen, along with injury to the spine, upper or lower extremities are all strongly predictive of THRC. Understanding the profile of the THRC will allow clinicians and case management to proactively put processes in place to streamline care and potentially reduce costs and LOS.
Direct Democracy in Education: How Ballot Initiatives Challenge Equal Opportunity and Risk Tyrannizing Underrepresented Students
Authors: Farley Amy N.
Published: June 2020

States have increasingly used ballot initiatives to legislate education policy in recent years, although the consequences for educational equity and justice have been underexamined. This article investigates the extent to which ballot initiatives disproportionately affect traditionally minoritized students, with particular attention to two phenomena: tyranny of the majority and racial threat hypothesis. Results across models consistently find that minority-targeted education initiatives pass at significantly higher rates than those that do not target minoritized students, and they garner considerably more yes votes regardless of passage. For states with more people of color, this effect is magnified, suggesting the potential for tyranny of the majority may increase when there are greater proportions of people of color within a state. This research contributes to the body of literature regarding the impact of state-level policy on education and sheds light on the benefits and potentially negative consequences of the ballot initiative process as an education policy making tool, particularly for our nation’s most disadvantaged students.
Improvement of Norm Score Quality via Regression-Based Continuous Norming
Authors: Lenhard Wolfgang , Lenhard Alexandra
Published: June 2020

The interpretation of psychometric test results is usually based on norm scores. We compared semiparametric continuous norming (SPCN) with conventional norming methods by simulating results for test scales with different item numbers and difficulties via an item response theory approach. Subsequently, we modeled the norm scores based on random samples with varying sizes either with a conventional ranking procedure or SPCN. The norms were then cross-validated by using an entirely representative sample of N = 840,000 for which different measures of norming error were computed. This process was repeated 90,000 times. Both approaches benefitted from an increase in sample size, with SPCN reaching optimal results with much smaller samples. Conventional norming performed worse on data fit, age-related errors, and number of missings in the norm tables. The data fit in conventional norming of fixed subsample sizes varied with the granularity of the age brackets, calling into question general recommendations for sample sizes in test norming. We recommend that test norms should be based on statistical models of the raw score distributions instead of simply compiling norm tables via conventional ranking procedures.
Duration of Antibiotic Therapy for General Medicine and General Surgery Patients Throughout Transitions of Care: An Antibiotic Stewardship Opportunity for Noninfectious Disease Pharmacists
Authors: Brower Kristin I. , Hecke Ariel , Mangino Julie E. , Gerlach Anthony T. , Goff Debra A.
Published: June 2020

Background

Overuse of antibiotics from the inpatient to outpatient setting is an antibiotic stewardship initiative where noninfectious disease (ID) pharmacists can have a large impact. Our purpose was to evaluate antibiotic durations across transitions of care from the inpatient to outpatient setting.

Methods

This is a single-center, retrospective cohort analysis evaluating antibiotic durations from the inpatient and outpatient setting in adult patients admitted to general surgery and medicine services at an academic medical center between January 1, 2017 and September 20, 2017. The primary outcome was to assess total antibiotic duration for patients with uncomplicated and complicated urinary tract infections (UTI, cUTI), community-acquired pneumonia (CAP), and hospital-acquired pneumonia (HAP). Outpatient electronic discharge prescriptions were used to calculate intended antibiotic duration upon transitions of care. Excessive duration of therapy was defined as >3 days—UTI, >5 days—CAP, and >7 days—cUTI or HAP.

Results

One hundred and one patients met inclusion criteria. Overall, most of the patients (81%) had antibiotics longer than recommended with only 3% receiving less than the recommended duration. Median total duration of therapy compared with recommended duration specified in national guidelines was UTI: 10 days [ 7 – 10 ], cUTI: 12 days [7.5-12.5], CAP: 7 days [ 7 – 9 ], HAP: 10 days [ 8 – 12 ]. The median antibiotic duration was shorter in patients with no cultures or culture negative results compared with patients with positive cultures for all indications (UTI: 10.3 vs 10.8 days, cUTI: 9 vs 12 days, CAP: 8 vs 9.1 days, HAP: 10.5 vs 19.8 days). Overall, the recommended duration of antibiotics was completed while inpatient in 34.7%, but varied by infection. More patients with UTI or cUTI completed recommended duration of therapy while inpatient vs for CAP or HAP (53.8% vs 28%, P = .03). Eighty percent of those with UTI, 18.2% with cUTI, 25.6% with CAP, and 31.2% with HAP had already received the recommended duration of treatment, or more, on day of hospital discharge.

Conclusions

The median duration of antibiotic therapy for all indications evaluated was longer than recommended in national guidelines. Opportunities for stewardship by non-ID pharmacists to impact postdischarge antimicrobial use at transitions of care have been identified.
Intelligent energy scheduling in a microgrid with custom power devices
Authors: Pramila V , Chandramohan S
Published: June 2020

The increasing penetration of distributed generators may harm power system and its control and operations. The microgrid offers a better solution for the issues in grid operation. Undergraduate electrical engineering and postgraduate power system and power electronics students need to understand the working of microgrid with renewable energy resources along with the optimization and scheduling of power quality custom power devices. To cater better understanding of the microgrid with renewable resources, wind, solar, distributed generators, distributed energy storage devices, DSTATCOM, and plug-in electric vehicle charging load are included in this work presented. In this paper, multiobjective optimization for the operation of microgrid to account for uncertainties in a stochastic energy resources management system is considered. Nonlinear constraint optimization to reduce the running cost, losses, and voltage variations is focused for the optimization. Loss sensitivity analysis is used to find the location wind, solar, distributed generators, distributed energy storage devices, and DSTATCOM. Firefly algorithm is used to optimize the size of distributed generators and DSTATCOM. Optimization reduced the loss, power taken from the grid and improves the voltages in the system. This paper is self-explanatory to the undergraduate and postgraduate students to understand the power flow analysis of microgrid with hybrid renewable energies and optimization technique.