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Rodriguez L, Brown KM, Lindsay C, Remmert JE, Oslin DW. Three Lessons Learned About Power and Improving Recruitment of Underrepresented Populations in Clinical Trials. Psychiatr Serv 2024:appips20230189. [PMID: 38369885 DOI: 10.1176/appi.ps.20230189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
This Open Forum is relevant for investigators who conduct research with historically understudied and marginalized populations. The authors introduce a U.S. Department of Veterans Affairs clinical trial that experienced challenges with recruitment of African American or Black veterans and was terminated for not achieving its recruitment goals. The role of power dynamics in clinical research is discussed, specifically how unequal distributions of power may create recruitment challenges. The authors summarize three lessons learned and offer recommendations for sharing power equitably between investigators and potential participants. By recounting these experiences, the authors seek to promote culturally sensitive, veteran-centered approaches to recruitment in future clinical trials.
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Affiliation(s)
- Lauren Rodriguez
- Mental Illness Research, Education, and Clinical Center (MIRECC) (Rodriguez, Oslin), Center for Health Equity Research and Promotion (Brown, Lindsay), and Veterans Community Advisory Board (VCAB) (Brown, Lindsay), Corporal Michael J. Crescenz Medical Center, U.S. Department of Veterans Affairs (VA), Philadelphia; Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, New York (Remmert); Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Oslin)
| | - Kimberly M Brown
- Mental Illness Research, Education, and Clinical Center (MIRECC) (Rodriguez, Oslin), Center for Health Equity Research and Promotion (Brown, Lindsay), and Veterans Community Advisory Board (VCAB) (Brown, Lindsay), Corporal Michael J. Crescenz Medical Center, U.S. Department of Veterans Affairs (VA), Philadelphia; Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, New York (Remmert); Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Oslin)
| | - Charles Lindsay
- Mental Illness Research, Education, and Clinical Center (MIRECC) (Rodriguez, Oslin), Center for Health Equity Research and Promotion (Brown, Lindsay), and Veterans Community Advisory Board (VCAB) (Brown, Lindsay), Corporal Michael J. Crescenz Medical Center, U.S. Department of Veterans Affairs (VA), Philadelphia; Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, New York (Remmert); Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Oslin)
| | - Jocelyn E Remmert
- Mental Illness Research, Education, and Clinical Center (MIRECC) (Rodriguez, Oslin), Center for Health Equity Research and Promotion (Brown, Lindsay), and Veterans Community Advisory Board (VCAB) (Brown, Lindsay), Corporal Michael J. Crescenz Medical Center, U.S. Department of Veterans Affairs (VA), Philadelphia; Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, New York (Remmert); Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Oslin)
| | - David W Oslin
- Mental Illness Research, Education, and Clinical Center (MIRECC) (Rodriguez, Oslin), Center for Health Equity Research and Promotion (Brown, Lindsay), and Veterans Community Advisory Board (VCAB) (Brown, Lindsay), Corporal Michael J. Crescenz Medical Center, U.S. Department of Veterans Affairs (VA), Philadelphia; Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, New York (Remmert); Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Oslin)
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Mikulski MF, Terzo M, Jacquez Z, Beckerman Z, Brown KM. Duty Hours on Surgery Clerkship: From Compliance Nightmare to Leadership and Professional Development Opportunity. J Surg Educ 2023; 80:797-805. [PMID: 37019710 DOI: 10.1016/j.jsurg.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 02/16/2023] [Accepted: 03/17/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVE To evaluate the impact of an innovative leadership development initiative in the core surgery clerkship that addressed duty hours compliance and time-off requests. DESIGN A combination of deductive and inductive analysis of medical student reflections written after rotating on Acute Care Surgery over 2 academic years (2019-2020 and 2020-2021) was performed. Reflections were part of criteria to receive honors and a prompt was given to discuss their experience in creating their own call schedules. We utilized a combined deductive and inductive process to identify predominant themes within the reflections. Once established, we quantitatively identified frequency and density of themes cited, along with qualitative analysis to determine barriers and lessons learned. SETTING Dell Seton Medical Center, Dell Medical School at The University of Texas at Austin, a tertiary academic facility. PARTICIPANTS There were 96 students who rotated on Acute Care Surgery during the study period, 64 (66.7%) of whom completed the reflection piece. RESULTS We identified 10 predominant themes through the combined deductive and inductive processes. Barriers were cited by most students (n = 58, 91%), with communication being the most commonly discussed theme when cited with a mean 1.96 references per student. Learned leadership skills included: communication, independence, teamwork, negotiating skills, reflection of best practices by residents, and realizing the importance of duty hours. CONCLUSIONS Transferring duty hour scheduling responsibilities to medical students resulted in multiple professional development opportunities while decreasing administrative burden and improving adherence to duty hour requirements. This approach requires further validation, but may be considered at other institutions seeking to improve the leadership and communication skills of its students, while improving adherence to duty hour restrictions.
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Affiliation(s)
- Matthew F Mikulski
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, Texas; Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin & Dell Children's Medical Center, Austin, Texas.
| | - Madison Terzo
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, Texas
| | - Zachary Jacquez
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, Texas
| | - Ziv Beckerman
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, Texas; Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin & Dell Children's Medical Center, Austin, Texas; Duke Cardiothoracic Surgery Clinic, Durham, North Carolina
| | - Kimberly M Brown
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, Texas
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Schommer L, Mikulski MF, Goodgame B, Brown KM. Racial Disparities in Breast Cancer Presentation and Diagnosis in COVID-Era Central Texas. J Surg Res 2023; 288:79-86. [PMID: 36948036 PMCID: PMC10026721 DOI: 10.1016/j.jss.2023.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 01/22/2023] [Accepted: 02/18/2023] [Indexed: 03/24/2023]
Abstract
INTRODUCTION The COVID-19 pandemic has significantly impacted the diagnosis of breast cancer (BC). With a large Hispanic/Latinx population, early revocation of mask mandates, and lower vaccination rate than many other states, this study explores the relationship between COVID-19 and the presentation and diagnosis of BC patients in the unique socio-politico-economic context of Central Texas. METHODS This study is a retrospective review of the Seton Medical Center Austin tumor registry for BC patients from March 1, 2019 to March 2, 2021. We compared demographics, insurance status, clinical and pathologic stage, and time from diagnosis to intervention between "pre-COVID" (March 1, 2019- March 1, 2020) and "post-COVID" (March 2, 2020-March 2, 2021). We utilized descriptive, univariate, and multivariable logistic regression statistics. RESULTS There were 781 patients diagnosed with BC, with 113 fewer post-COVID compared to pre-COVID. The proportion of Black patients diagnosed with BC decreased post-COVID compared with pre-COVID (10.1%-4.5%, P = 0.002). When adjusting for other factors, uninsured and underinsured patients had increased odds of presenting with late-stage BC (odds ratio:5.40, P < 0.001). There was also an association between presenting with stage 2 or greater BC and delayed time-to-intervention. CONCLUSIONS Although fewer women overall were diagnosed with BC post-COVID, the return to baseline diagnoses has yet to be seen. We identified a pandemic-related decrease in BC diagnoses in Black women and increased odds of late-stage cancer among uninsured patients, suggesting a disparate relationship between COVID-19 and health care access and affordability. Outreach and screening efforts should address strategies to engage Black and uninsured patients.
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Affiliation(s)
- Lana Schommer
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, Texas.
| | - Matthew F Mikulski
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, Texas; Texas Center for Pediatric and Congenital Heart Disease, Dell Medical School, The University of Texas at Austin, Austin, Texas
| | - Boone Goodgame
- Departments of Oncology and Internal Medicine, Dell Medical School, The University of Texas at Austin, Austin, Texas
| | - Kimberly M Brown
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, Texas
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Kaminstein DS, Brown KM. Conceptualizing the Carrying Function of Community Advisory Boards. The Journal of Applied Behavioral Science 2023. [DOI: 10.1177/00218863231155490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Community Advisory Boards (CABs) often, “carry” important ideas and concepts for the larger organization of which they are a part. The word “carry” in this context, means that a person or group expresses verbal and nonverbal messages that inform others of what the institution acknowledges, and also what it cannot bear to feel or talk about. These expressions may include attitudes and expectations, values, risks, or disowned features and qualities. A group can contain, “carry,” and express formal, informal, and unconscious issues for a department or system. In this article, we situate our theoretical underpinning of this carrying function by relying on a number of literatures: identified patient, splitting and projection, parallel process, and container and contained. Specifying and examining the dynamics of what CABs carry for an institution can prevent common pitfalls for these groups, such as mistrust, feelings of disrespect, lack of productivity, and thwarted expectations.
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Affiliation(s)
- Dana S. Kaminstein
- VA Center for Health Equity Research and Promotion, Crescenz VA Medical Center, Philadelphia, PA, USA
- Graduate School of Education, University of Pennsylvania, Philadelphia, PA, USA
| | - Kimberly M. Brown
- VA Center for Health Equity Research and Promotion, Crescenz VA Medical Center, Philadelphia, PA, USA
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Mikulski MF, Beckerman Z, Jacques ZL, Terzo M, Brown KM. Measuring what matters: identifying assessments that reflect learning on the core surgical clerkship. Global Surg Educ 2022; 1:43. [PMID: 38013711 PMCID: PMC9483865 DOI: 10.1007/s44186-022-00047-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 09/02/2022] [Accepted: 09/10/2022] [Indexed: 11/27/2022]
Abstract
Purpose There are various assessments used during the core surgical clerkship (CSC), each of which may be influenced by factors external to the CSC or have inherent biases from an equity lens. In particular, the National Board of Medical Examiners' Clinical Subject Exams ("Shelf") is used heavily and may not reflect clerkship curriculum or clinical learning. Methods This is a retrospective review of medical student characteristics and assessments during the CSC from July 2017-June 2021. Assessment methods included: subjective Clinical Performance Assessments (CPA), Shelf, Objective Structured Clinical Examinations, and a short-answer in-house examination (IHE) culminating in a Final Grade (FG) of Honors/Pass/Fail. A Shelf score threshold for Honors was added in academic years 2020-2021. Descriptive, univariate, and multivariable logistic and linear regression statistics were utilized. Results We reviewed records of 192 students. Of these, 107 (55.7%) were female, median age was 24 [IQR: 23-26] years, and most were White/Caucasian (N = 106, 55.2%). Univariate analysis showed the number of Exceeds Expectations obtained on CPA to be influenced by surgical subspecialty taken (p = 0.013) and academic year (p < 0.001). Shelf was influenced by students' race (p = 0.009), timing of CSC before or after Internal Medicine (67.9 ± 7.3 vs 72.9 ± 7.1, p < 0.001), and Term taken (increasing from 66.0 ± 8.7 to 73.4 ± 7.5, p < 0.001). IHE scores did not have any external associations. After adjustment with multivariable logistic and linear regressions, CPA and IHE did not have external associations, but higher scores were obtained on Shelf exam in Terms 3, 5, and 6 (by 4.62 [95% CI 0.86-8.37], 4.92 [95% CI 0.53-9.31], and 7.56 [95% CI 2.81-12.31] points, respectively. Odds of FG honors were lower when Shelf threshold was implemented (OR 0.17 [95% CI 0.06-0.50]), and increased as students got older (OR 1.14 [95% CI 1.01-1.30]) or on specific subspecialties, such as vascular surgery (OR 7.06 [95% CI 1.21-41.26]). Conclusions The Shelf is substantially influenced by temporal associations across Terms and timing in relation to other clerkships, such as Internal Medicine. An IHE reflective of a clerkship's specified curriculum may be a more equitable summative assessment of the learning that occurs from the CSC curriculum, with fewer biases or influences external to the CSC. Supplementary Information The online version contains supplementary material available at 10.1007/s44186-022-00047-8.
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Affiliation(s)
- Matthew F. Mikulski
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX USA
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin and Dell Children’s Medical Center, 4900 Mueller Blvd, Suite 3S.003, Austin, TX 78712 USA
| | - Ziv Beckerman
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX USA
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin and Dell Children’s Medical Center, 4900 Mueller Blvd, Suite 3S.003, Austin, TX 78712 USA
| | - Zachary L. Jacques
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX USA
| | - Madison Terzo
- Dell Medical School, The University of Texas at Austin, Austin, TX USA
| | - Kimberly M. Brown
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX USA
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Abstract
Although many successful Community Advisory Boards (CABs) are discussed in the literature, some articles report that community members feel they are treated as token participants, or that their voices are not heard. This article describes the initial steps we took in designing an effective and empowered CAB, the underlying group dynamics principles we employed to formulate this CAB, and the structure and processes we instituted. We focused on how to build decision-making procedures that support and enhance the group’s function and effectiveness over the long term. Additionally, we considered how we might intervene when these features become out of balance. Though the literature on CABs often talks about power dynamics, explanations of what is meant by this label are rare. We resolved to explore these dynamics and to design a CAB that would operate successfully in full recognition of power dynamics.
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Affiliation(s)
- Kimberly M. Brown
- Center for Health Equity Research and Promotion, Cpl. Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Lorrie Walker
- VA Central Western Massachusetts Healthcare System, Leeds, MA, USA
| | - Dana S. Kaminstein
- Center for Health Equity Research and Promotion, Cpl. Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
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Kim GJ, Clark MJ, Meyerson SL, Bohnen JD, Brown KM, Fryer JP, Szerlip N, Schuller M, Kendrick DE, George B. Mind the Gap: The Autonomy Perception Gap in the Operating Room by Surgical Residents and Faculty. J Surg Educ 2020; 77:1522-1527. [PMID: 32571692 DOI: 10.1016/j.jsurg.2020.05.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 05/25/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Examine the concordance of perceived operative autonomy between attendings and resident trainees. DESIGN Faculty and trainees rated trainee operative autonomy using the 4-level Zwisch scale over a variety of cases and training years. The respective ratings were then compared to explore the effects of experience, gender, case complexity, trainee, trainer, and other covariates to perceived autonomy. SETTING This study was conducted over 14 general surgery programs in the United States, members of the Procedural Learning and Safety Collaborative. PARTICIPANTS Participants included faculty and categorical trainees from 14 general surgery programs. RESULTS A total of 8681 observations was obtained. The sample included 619 unique residents and 457 different attendings. A total of 598 distinct procedures was performed. In 60% of the cases, the autonomy ratings between trainees and attendings were concordant, with only 3.5% of cases discrepant by more than 1 level. An autonomy perception gap was modeled based on the discrepancy between the trainee and attending Zwisch ratings for the same case. The mean Zwisch score expected for a trainee was lower than the attending across all scenarios. Trainees were more likely to perceive relatively more autonomy in the second half of the year. The autonomy perception gap decreased with increasing case complexity. As trainees gained experience, the perception gap increased with trainees underestimating autonomy. CONCLUSIONS Trainees and attendings generally demonstrated concordance on autonomy perception scores. However, in 40% of cases, a perception gap exists between trainee and attending with the trainee generally underestimating autonomy. The gap worsens as the trainee progresses through residency. This perception gap suggests that attendings and trainees could be better aligned on teaching goals and expectations.
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Affiliation(s)
- Grace J Kim
- Department of Surgery, Center for Surgical Training and Research, University of Michigan, Ann Arbor, Michigan.
| | - Michael J Clark
- Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor, Michigan
| | - Shari L Meyerson
- Department of Surgery, University of Kentucky, Lexington, Kentucky
| | - Jordan D Bohnen
- Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Kimberly M Brown
- Department of Surgery and Perioperative Care, UT Austin Dell Medical School, Austin, Texas
| | - Jonathan P Fryer
- Department of Surgery, Northwestern University, Chicago, Illinois
| | - Nicholas Szerlip
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Mary Schuller
- Department of Surgery, Northwestern University, Chicago, Illinois
| | - Daniel E Kendrick
- Department of Surgery, Center for Surgical Training and Research, University of Michigan, Ann Arbor, Michigan
| | - Brian George
- Department of Surgery, Center for Surgical Training and Research, University of Michigan, Ann Arbor, Michigan
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Brown KM, Albania MF, Samra JS, Kelly PJ, Hugh TJ. Propensity score analysis of non-anatomical versus anatomical resection of colorectal liver metastases. BJS Open 2019; 3:521-531. [PMID: 31388645 PMCID: PMC6677098 DOI: 10.1002/bjs5.50154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 01/24/2019] [Indexed: 12/14/2022] Open
Abstract
Background There are concerns that non‐anatomical resection (NAR) worsens perioperative and oncological outcomes compared with those following anatomical resection (AR) for colorectal liver metastases (CRLM). Most previous studies have been biased by the effect of tumour size. The aim of this study was to compare oncological outcomes after NAR versus AR. Methods This was a retrospective study of consecutive patients who underwent CRLM resection with curative intent from 1999 to 2016. Data were retrieved from a prospectively developed database. Survival and perioperative outcomes for NAR and AR were compared using propensity score analyses. Results Some 358 patients were included in the study. Median follow‐up was 34 (i.q.r. 16–68) months. NAR was associated with significantly less morbidity compared with AR (31·1 versus 44·4 per cent respectively; P = 0·037). Larger (hazard ratio (HR) for lesions 5 cm or greater 1·81, 95 per cent c.i. 1·13 to 2·90; P = 0·035) or multiple (HR 1·48, 1·03 to 2·12; P = 0·035) metastases were associated with poor overall survival (OS). Synchronous (HR 1·33, 1·01 to 1·77; P = 0·045) and multiple (HR 1·51, 1·14 to 2·00; P = 0·004) liver metastases, major complications after liver resection (HR 1·49, 1·05 to 2·11; P = 0·026) or complications after resection of the primary colorectal tumour (HR 1·51, 1·01 to 2·26; P = 0·045) were associated with poor disease‐free survival (DFS). AR was prognostic for poor OS only in tumours smaller than 30 mm, and R1 margin status was not prognostic for either OS or DFS. NAR was associated with a higher rate of salvage resection than AR following intrahepatic recurrence. Conclusions NAR has at least equivalent oncological outcomes to AR while proving to be safer. NAR should therefore be the primary surgical approach to CRLM, especially for lesions smaller than 30 mm.
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Affiliation(s)
- K M Brown
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital and North Shore Private Hospital, St Leonards Sydney New South Wales Australia.,Discipline of Surgery, Northern Clinical School, University of Sydney Sydney New South Wales Australia
| | - M F Albania
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital and North Shore Private Hospital, St Leonards Sydney New South Wales Australia
| | - J S Samra
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital and North Shore Private Hospital, St Leonards Sydney New South Wales Australia.,Faculty of Medicine and Health Sciences Macquarie University Sydney New South Wales Australia
| | - P J Kelly
- Sydney School of Public Health, University of Sydney Sydney New South Wales Australia
| | - T J Hugh
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital and North Shore Private Hospital, St Leonards Sydney New South Wales Australia.,Discipline of Surgery, Northern Clinical School, University of Sydney Sydney New South Wales Australia
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Antal CJ, Yeomans PD, East R, Hickey DW, Kalkstein S, Brown KM, Kaminstein DS. Transforming Veteran Identity Through Community Engagement: A Chaplain–Psychologist Collaboration to Address Moral Injury. Journal of Humanistic Psychology 2019. [DOI: 10.1177/0022167819844071] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Chris J. Antal
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Peter D. Yeomans
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Rotunda East
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Douglas W. Hickey
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Solomon Kalkstein
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | | | - Dana S. Kaminstein
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- University of Pennsylvania, Philadelphia, PA, USA
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Diab K, Kochat S, McClintic J, Stevenson HL, Agle SC, Olino K, Tyler DS, Brown KM. Development of a Model for Training and Assessing Open Image-Guided Liver Tumor Ablation. J Surg Educ 2019; 76:554-559. [PMID: 30121166 DOI: 10.1016/j.jsurg.2018.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 06/25/2018] [Accepted: 07/19/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Image-guided microwave ablation (MWA) is a technically demanding procedure, involving advanced visual-spatial perception skills. This study sought to create and evaluate a low-cost model and training curriculum for open ultrasound-guided liver tumor MWA. METHODS Simulated tumors were created, implanted into bovine livers, and visualized by ultrasound. A high-fidelity abdominal model was constructed, with a total cost of $30. Experienced physicians in MWA performed simulated ablations and evaluated the model. Expert performance metrics were established and served as targets for our training curriculum. These included time, number of passes, number of repositionings, and percentage of tumor ablated. Next, 8 novice trainees completed our deliberate practice curriculum. Participants' performances were recorded throughout. RESULTS Physicians completed a structured feedback questionnaire rating the model's realism and training utility at 8/10 and 10/10, respectively. Tumors appeared hyperechoic and were clearly visualized on ultrasound. Trainees performed a total of 32 ablations. Our trainees' performance improved significantly in all outcomes of interest in the postcurriculum ablations compared to precurriculum ablations. CONCLUSION We have created a cost-effective, high-fidelity model of MWA, with a deliberate practice curriculum. Trainees can practice to proficiency with clear target metrics prior to participating in clinical cas.
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Affiliation(s)
- Kaled Diab
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
| | - Suhas Kochat
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
| | - James McClintic
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
| | - Heather L Stevenson
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
| | - Steven C Agle
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
| | - Kelly Olino
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
| | - Douglas S Tyler
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
| | - Kimberly M Brown
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas.
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McClintic JA, Snyder CL, Brown KM. Curricular Innovation in the Surgery Clerkship: Can Assessment Methods Influence Development of Critical Thinking and Clinical Skills? J Surg Educ 2018; 75:1236-1244. [PMID: 29545129 DOI: 10.1016/j.jsurg.2018.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 02/14/2018] [Accepted: 02/20/2018] [Indexed: 05/13/2023]
Abstract
OBJECTIVE Although key clinical skills have been defined in the Core Entrustable Professional Activities, there is a need to improve medical school curricula with standardized training opportunities and assessments of these skills. Thus, we aimed to develop an innovative curriculum that emphasized critical thinking and clinical skills. We hypothesized that we would be able to observe measurable improvement on assessments of students' critical thinking and clinical skills after the implementation of the new curriculum. DESIGN Prospective, Quasi-Experimental study with the use of historical controls. SETTING This study took place through the third-year surgical clerkship at the University of Texas Medical Branch at the Galveston, Houston, and Austin, Texas, locations. PARTICIPANTS A total of 214 students taking the third-year surgical clerkship for the first time during the periods of interest were included. RESULTS Although the students with traditional curriculum improved 9.5% on a short answer exam from preclerkship to postclerkship completion, the students with new curriculum improved by 40%. Students under the new curriculum performed significantly better on the Objective Structured Clinical Exam; however, their shelf scores were lower. CONCLUSIONS Under this new curriculum and grading system, we demonstrated that students can be incentivized to improve critical thinking and clinical skills, but this needs to be balanced with knowledge-based incentives.
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Affiliation(s)
- James A McClintic
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas.
| | - Clifford L Snyder
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
| | - Kimberly M Brown
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
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Aggarwal R, Brown KM, de Groen PC, Gallagher AG, Henriksen K, Kavoussi LR, Peng GCY, Ritter EM, Silverman E, Wang KK, Andersen DK. Simulation Research in Gastrointestinal and Urologic Care-Challenges and Opportunities: Summary of a National Institute of Diabetes and Digestive and Kidney Diseases and National Institute of Biomedical Imaging and Bioengineering Workshop. J Clin Gastroenterol 2017; Publish Ahead of Print. [PMID: 28562441 DOI: 10.1097/mcg.0000000000000862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
A workshop on ''Simulation Research in Gastrointestinal and Urologic Care: Challenges and Opportunities'' was held at the National Institutes of Health in June 2016. The purpose of the workshop was to examine the extent to which simulation approaches have been used by skilled proceduralists (not trainees) caring for patients with gastrointestinal and urologic diseases. The current status of research findings in the use and effectiveness of simulation applications was reviewed, and numerous knowledge gaps and research needs were identified by the faculty and the attendees. The paradigm of ''deliberate practice,'' rather than mere repetition, and the value of coaching by experts was stressed by those who have adopted simulation in music and sports. Models that are most useful for the adoption of simulation by expert clinicians have yet to be fully validated. Initial studies on the impact of simulation on safety and error reduction have demonstrated its value in the training domain, but the role of simulation as a strategy for increased procedural safety remains uncertain in the world of the expert practitioner. Although the basic requirements for experienced physicians to acquire new skills have been explored, the widespread availability of such resources is an unrealized goal, and there is a need for well-designed outcome studies to establish the role of simulation in improving the quality of health care.
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Affiliation(s)
- Rajesh Aggarwal
- *Department of Surgery and Steinberg Center for Simulation and Interactive Learning, Faculty of Medicine, McGill University, Montreal, Quebec, Canada †Department of Surgery and Perioperative Care, Dell Medical School, University of Texas, Austin, TX ‡Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Minnesota, Minneapolis, MN §ASSERT Center, College of Medicine and Health, University College Cork, Ireland, and Faculty of Life and Health Sciences, Ulster University, Belfast, UK ¶Agency for Healthcare Research and Quality, Rockville, MD ∥Department of Urology, Northwell Hofstra School of Medicine, Nassau, NY **National Institute of Biomedical Imaging and Bioengineering, National Institutes of Health, Bethesda, MD ††Department of Surgery, Uniformed Services University for the Health Sciences, Bethesda, MD ‡‡Department of Surgery, Tufts University School of Medicine, Boston, MA §§Division of Gastroenterology and Hepatology, Department of Medicine, Mayo School of Medicine, Rochester, MN ¶¶Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
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Perone JA, Fankhauser GT, Adhikari D, Mehta HB, Woods MB, Tyler DS, Brown KM. It depends on your perspective: Resident satisfaction with operative experience. Am J Surg 2016; 213:253-259. [PMID: 27776758 DOI: 10.1016/j.amjsurg.2016.09.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 08/08/2016] [Accepted: 09/24/2016] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Resident satisfaction is a key performance metric for surgery programs; we studied factors influencing resident satisfaction in operative cases, and the concordance of faculty and resident perceptions on these factors. METHODS Resident and faculty were separately queried on satisfaction immediately following operative cases. Statistical significance of the associations between resident and faculty satisfaction and case-related factors were tested by Chi-square or Fisher's exact test. RESULTS Residents and faculty were very satisfied in 56/87 (64%) and 36/87 (41%) of cases respectively. Resident satisfaction was associated with their perceived role as surgeon (p < 0.04), performing >50% of the case (p < 0.01), autonomy (p < 0.03), and PGY year 4-5(p < 0.02). Faculty taking over the case was associated with both resident and faculty dissatisfaction. Faculty satisfaction was associated with resident preparation (p < 0.01), faculty perception of resident autonomy (p < 0.01), and faculty familiarity with resident's skills (p < 0.01). CONCLUSIONS Resident and faculty satisfaction are associated with the resident's competent performance of the case, suggesting interventions to optimize resident preparation for a case or faculty's ability to facilitate resident autonomy will improve satisfaction with OR experience.
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Affiliation(s)
- Jennifer A Perone
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Grant T Fankhauser
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Deepak Adhikari
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Hemalkumar B Mehta
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Majka B Woods
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Douglas S Tyler
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Kimberly M Brown
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA.
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Gardner AK, DeMoya MA, Tinkoff GH, Brown KM, Garcia GD, Miller GT, Zaidel BW, Korndorffer JR, Scott DJ, Sachdeva AK. Using simulation for disaster preparedness. Surgery 2016; 160:565-70. [DOI: 10.1016/j.surg.2016.03.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 03/11/2016] [Indexed: 01/22/2023]
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Abstract
PURPOSE Whilst situs inversus is associated with intestinal malrotation and volvulus particularly in infants, this is the first known report of acute intestinal obstruction in an adult patient with a situs anomaly specifically due to a congenital transmesenteric hernia. CASE A 54-year-old woman presented with a 12-h history of progressive abdominal pain. Contrast-enhanced computed tomography scan of the abdomen revealed an incidental finding of situs inversus abdominus, ischemic small bowel obstruction and a potential occlusive thrombus of the superior mesenteric artery. At operation, the cause of intestinal obstruction was found to be secondary to herniation of the intestine through a congenital mesenteric defect. The hernia was reduced and a strong pulse was subsequently felt in the distal superior mesenteric artery. The patient required resection of a segment of compromised small bowel, and was later anastomosed at a planned second laparotomy. Her laparostomy was closed using an absorbable BioA mesh. CONCLUSION A high index of suspicion and low threshold for exploratory surgery should be maintained in patients with major congenital abdominal anomalies presenting with an acute abdomen.
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Affiliation(s)
- K M Brown
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, University of Sydney, St Leonards, Sydney, NSW, 2065, Australia.
| | - J S Gundara
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, University of Sydney, St Leonards, Sydney, NSW, 2065, Australia
| | - A Mittal
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, University of Sydney, St Leonards, Sydney, NSW, 2065, Australia
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Gardner AK, Scott DJ, Willis RE, Van Sickle K, Truitt MS, Uecker J, Brown KM, Marks JM, Dunkin BJ. Is current surgery resident and GI fellow training adequate to pass FES? Surg Endosc 2016; 31:352-358. [DOI: 10.1007/s00464-016-4979-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 05/09/2016] [Indexed: 12/01/2022]
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Abstract
BACKGROUND Laparoscopic liver resection is rapidly expanding with more than 9500 cases performed worldwide. While initial series reported non-anatomic resection of benign peripheral hepatic lesions, approximately 50-65 % of laparoscopic liver resections are now being done for malignant tumors, primarily hepatocellular carcinoma (HCC) or colorectal cancer liver metastases (mCRC). METHODS We performed a literature review of published studies evaluating outcomes of major laparoscopic liver resection, defined as three or more Couinaud segments. RESULTS Initial fears of adverse oncologic outcomes or tumor seeding have not been demonstrated, and dozens of studies have reported comparable 5-year disease-free and overall survival between laparoscopic and open resection of HCC or mCRC in case-cohort and propensity score-matched analyses. Increased experience has led to laparoscopic anatomic liver resections including laparoscopic major hepatectomy. A steep learning curve of 45-60 cases is evident for laparoscopic hepatic resection. CONCLUSION Laparoscopic major hepatectomy is safe and effective in the treatment of benign and malignant liver tumors when performed in specialized centers with dedicated teams. Comparable to other complex laparoscopic surgeries, laparoscopic major hepatectomy has a learning curve of 45-60 cases.
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Affiliation(s)
- Kimberly M Brown
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - David A Geller
- Liver Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA. .,UPMC Liver Cancer Center, UPMC Montefiore, 3459 Fifth Ave, 7 South, Pittsburgh, PA, 15213-2582, USA.
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Hsu JL, Korndorffer JR, Brown KM. Force feedback vessel ligation simulator in knot-tying proficiency training. Am J Surg 2016; 211:411-5. [DOI: 10.1016/j.amjsurg.2015.09.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 08/11/2015] [Accepted: 09/25/2015] [Indexed: 10/22/2022]
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Willis RE, Dent DL, Love JD, Kempenich JW, Uecker J, Brown KM, Thomas JS, Gomez PP, Adams AJ, Admire JR, Sprunt JM, Kahrig KM, Wiggins-Dohlvik K. Predicting and enhancing American Board of Surgery In-Training Examination performance: does writing questions really help? Am J Surg 2015; 211:361-8. [PMID: 26687960 DOI: 10.1016/j.amjsurg.2015.08.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 07/20/2015] [Accepted: 08/19/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND The generative learning model posits that individuals remember content they have generated better than materials created by others. The goals of this study were to evaluate question generation as a study method for the American Board of Surgery In-Training Examination (ABSITE) and determine whether practice test scores and other data predict ABSITE performance. METHODS Residents (n = 206) from 6 general surgery programs were randomly assigned to one of the two study conditions. One group wrote questions for practice examinations. All residents took 2 practice examinations. RESULTS There was not a significant effect of writing questions on ABSITE score. Practice test scores, United States Medical Licensing Examination Step 1 scores, and previous ABSITE scores were significantly correlated with ABSITE performance. CONCLUSIONS The generative learning model was not supported. Performance on practice tests and other data can be used for early identification of residents at risk of performing poorly on the ABSITE.
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Affiliation(s)
- Ross E Willis
- Department of Surgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA.
| | - Daniel L Dent
- Department of Surgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - Joseph D Love
- University of Texas Health Science Center at Houston, Houston, TX, USA
| | | | - John Uecker
- University of Texas Southwestern at Austin, Austin, TX, USA
| | | | | | - Pedro P Gomez
- Department of Surgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - Andrew J Adams
- Department of Surgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - John R Admire
- Department of Surgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - Julie M Sprunt
- University of Texas Southwestern at Austin, Austin, TX, USA
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Brown KM, Elliott SJ, Leatherdale ST, Robertson-Wilson J. Searching for rigour in the reporting of mixed methods population health research: a methodological review. Health Educ Res 2015; 30:811-839. [PMID: 26491072 DOI: 10.1093/her/cyv046] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 09/11/2015] [Indexed: 06/05/2023]
Abstract
The environments in which population health interventions occur shape both their implementation and outcomes. Hence, when evaluating these interventions, we must explore both intervention content and context. Mixed methods (integrating quantitative and qualitative methods) provide this opportunity. However, although criteria exist for establishing rigour in quantitative and qualitative research, there is poor consensus regarding rigour in mixed methods. Using the empirical example of school-based obesity interventions, this methodological review examined how mixed methods have been used and reported, and how rigour has been addressed. Twenty-three peer-reviewed mixed methods studies were identified through a systematic search of five databases and appraised using the guidelines for Good Reporting of a Mixed Methods Study. In general, more detailed description of data collection and analysis, integration, inferences and justifying the use of mixed methods is needed. Additionally, improved reporting of methodological rigour is required. This review calls for increased discussion of practical techniques for establishing rigour in mixed methods research, beyond those for quantitative and qualitative criteria individually. A guide for reporting mixed methods research in population health should be developed to improve the reporting quality of mixed methods studies. Through improved reporting, mixed methods can provide strong evidence to inform policy and practice.
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Affiliation(s)
- K M Brown
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON N2L 3G1,
| | - S J Elliott
- Department of Geography and Environmental Management, University of Waterloo, Waterloo, ON N2L 3G1 and
| | - S T Leatherdale
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON N2L 3G1
| | - J Robertson-Wilson
- Department of Kinesiology & Physical Education, Wilfrid Laurier University, Waterloo, ON N2L 3C5, Canada
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Gardner AK, Willis RE, Dunkin BJ, Van Sickle KR, Brown KM, Truitt MS, Uecker JM, Gentry L, Scott DJ. What do residents need to be competent laparoscopic and endoscopic surgeons? Surg Endosc 2015; 30:3050-9. [PMID: 26487226 DOI: 10.1007/s00464-015-4597-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 09/21/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite numerous efforts to ensure that surgery residents are adequately trained in the areas of laparoscopy and flexible endoscopy, there remain significant concerns that graduates are not comfortable performing many of these procedures. METHODS Online surveys were sent to surgery residents (98 items, PGY1-5 Categorical) and faculty (78 items, general surgery, and gastrointestinal specialties) at seven institutions. De-identified data were analyzed under an IRB-approved protocol. RESULTS Ninety-five faculty and 121 residents responded, with response rates of 65 and 52 %, respectively. Seventy-three percent of faculty indicated that competency of their graduating residents were dramatically or slightly worse than previous graduates. Only 29 % of graduating residents felt very comfortable performing advanced laparoscopic (AL) cases and 5 % performing therapeutic endoscopy (TE) cases immediately after graduation. Over half of interns expressed a need for fellowship to feel comfortable performing AL and TE procedures, and this need did not decrease as residents neared graduation. For these procedures, residents receive only "little to some" autonomy, as reported by both faculty and PGY5s. Residents reported that current curricula for laparoscopy and endoscopy consist primarily of clinical experience. Both residents and faculty, though, reported considerable value in other training modalities, including simulations, live animal laboratories, cadavers, and additional didactics. CONCLUSIONS These data indicate that both residents and faculty perceive significant competency gaps for both laparoscopy and flexible endoscopy, with the most notable shortcomings for advanced and therapeutic cases, respectively. Improvement in resident training methods in these areas is warranted.
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Affiliation(s)
- Aimee K Gardner
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA.
| | - Ross E Willis
- Department of Surgery, University of Texas Health Sciences Center, San Antonio, TX, USA
| | - Brian J Dunkin
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Kent R Van Sickle
- Department of Surgery, University of Texas Health Sciences Center, San Antonio, TX, USA
| | - Kimberly M Brown
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Michael S Truitt
- Department of Surgery, Dallas Methodist Hospital, Dallas, TX, USA
| | - John M Uecker
- Department of Surgery, University of Texas Southwestern Medical Center at Austin, Austin, TX, USA
| | - Lonnie Gentry
- Department of Surgery, Baylor University Medical Center at Dallas, Dallas, TX, USA
| | - Daniel J Scott
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
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Abstract
Training to excellence in the conduct of surgical procedures has many similarities to the acquisition and mastery of technical skills in elite-level music and sports. By using coaching techniques and strategies gleaned from analysis of professional music ensembles and athletic training, surgical educators can set conditions that increase the success rate of training to elite performance. This article describes techniques and strategies used in both music and athletic coaching, and it discusses how they can be applied and integrated into surgical simulation and education.
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Affiliation(s)
- Elliott Silverman
- Department of Surgery, Walter Reed National Military Medical Center, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; The Choral Arts Society of Washington, DC, 5225 Wisconsin Ave, Washington, DC 20015, USA.
| | - Scott A Tucker
- The Choral Arts Society of Washington, DC, 5225 Wisconsin Ave, Washington, DC 20015, USA
| | - Solveig Imsdahl
- The Choral Arts Society of Washington, DC, 5225 Wisconsin Ave, Washington, DC 20015, USA
| | - Justin A Charles
- The Choral Arts Society of Washington, DC, 5225 Wisconsin Ave, Washington, DC 20015, USA
| | | | - Mercy D Wagner
- Department of Surgery, Walter Reed National Military Medical Center, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Kimberly M Brown
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77554-0737, USA
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Hsu JL, Korndorffer JR, Brown KM. Design of vessel ligation simulator for deliberate practice. J Surg Res 2015; 197:231-5. [PMID: 25840488 DOI: 10.1016/j.jss.2015.02.068] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Revised: 02/16/2015] [Accepted: 02/27/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Surgical residents develop technical skills at variable rates, often based on random chance of cases encountered. One such skill is tying secure knots without exerting excessive force. This study describes the design of a simulator using a force sensor to measure instantaneous forces exerted on a blood vessel analog during vessel ligation and the development of expert-derived performance goals. MATERIALS AND METHODS Vessel ligations were performed on Silastic tubing at an offset from a Vernier Force Sensor. Nine experts (surgical faculty and senior residents) and 10 novices (junior residents) were recruited to each perform 10 vessel ligations (two square knots each) with two-handed and one-handed techniques. Internal consistency for the series of vessel ligations was tested with Cronbach alpha. Maximum forces exerted by novices and experts were compared using Student t-test. RESULTS Internal consistency across the 10 ligations on the simulator was excellent (Cronbach alpha = 0.91). The expert group on average exerted a significantly lower maximum force when compared with novices while performing two-handed (0.76 ± 0.39 N versus 1.12 ± 0.49 N, P < 0.01) and one-handed (0.84 ± 0.32 N versus 1.36 ± 0.44 N, P < 0.01) vessel ligations. CONCLUSIONS Although the expert group performed vessel ligations with significantly lower peak force than the novice group, there were novices who performed at the expert level. This is consistent with the conceptual framework of milestones and suggests that the skill of gentle knot-tying can be measured and develops at different chronologic levels of training in different individuals. This simulator can be used as part of a deliberate practice curriculum with instantaneous visual feedback.
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Affiliation(s)
- Justin L Hsu
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
| | - James R Korndorffer
- Department of Surgery, Tulane University School of Medicine, New Orleans, Los Angeles
| | - Kimberly M Brown
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas.
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Wadt KAW, Aoude LG, Johansson P, Solinas A, Pritchard A, Crainic O, Andersen MT, Kiilgaard JF, Heegaard S, Sunde L, Federspiel B, Madore J, Thompson JF, McCarthy SW, Goodwin A, Tsao H, Jönsson G, Busam K, Gupta R, Trent JM, Gerdes AM, Brown KM, Scolyer RA, Hayward NK. A recurrent germline BAP1 mutation and extension of the BAP1 tumor predisposition spectrum to include basal cell carcinoma. Clin Genet 2014; 88:267-72. [PMID: 25225168 DOI: 10.1111/cge.12501] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 08/28/2014] [Accepted: 09/10/2014] [Indexed: 02/03/2023]
Abstract
We report four previously undescribed families with germline BRCA1-associated protein-1 gene (BAP1) mutations and expand the clinical phenotype of this tumor syndrome. The tumor spectrum in these families is predominantly uveal malignant melanoma (UMM), cutaneous malignant melanoma (CMM) and mesothelioma, as previously reported for germline BAP1 mutations. However, mutation carriers from three new families, and one previously reported family, developed basal cell carcinoma (BCC), thus suggesting inclusion of BCC in the phenotypic spectrum of the BAP1 tumor syndrome. This notion is supported by the finding of loss of BAP1 protein expression by immunochemistry in two BCCs from individuals with germline BAP1 mutations and no loss of BAP1 staining in 53 of sporadic BCCs consistent with somatic mutations and loss of heterozygosity of the gene in the BCCs occurring in mutation carriers. Lastly, we identify the first reported recurrent mutation in BAP1 (p.R60X), which occurred in three families from two different continents. In two of the families, the mutation was inherited from a common founder but it arose independently in the third family.
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Affiliation(s)
- K A W Wadt
- Department of Clinical Genetics, Rigshospitalet, Copenhagen, Denmark
| | - L G Aoude
- QIMR Berghofer Medical Research Institute, Genetics and Computational Biology, Brisbane, Australia.,University of Queensland, Brisbane, Australia
| | - P Johansson
- QIMR Berghofer Medical Research Institute, Genetics and Computational Biology, Brisbane, Australia
| | - A Solinas
- Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, Australia
| | - A Pritchard
- QIMR Berghofer Medical Research Institute, Genetics and Computational Biology, Brisbane, Australia
| | - O Crainic
- Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, Australia
| | - M T Andersen
- Department of Clinical Genetics, Rigshospitalet, Copenhagen, Denmark
| | - J F Kiilgaard
- Department of Ophthalmology, Glostrup Hospital, University of Copenhagen, Copenhagen, Denmark
| | - S Heegaard
- Department of Ophthalmology, Glostrup Hospital, University of Copenhagen, Copenhagen, Denmark.,Eye Pathology Institute, Department of Neuroscience and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - L Sunde
- Department of Clinical Genetics, Aarhus University Hospital, Aarhus, Denmark
| | - B Federspiel
- Department of Pathology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - J Madore
- Melanoma Institute Australia, North Sydney, Australia
| | - J F Thompson
- Melanoma Institute Australia, North Sydney, Australia.,Sydney Medical School, The University of Sydney, Sydney, Australia
| | - S W McCarthy
- Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, Australia.,Melanoma Institute Australia, North Sydney, Australia.,Sydney Medical School, The University of Sydney, Sydney, Australia
| | - A Goodwin
- Department of Cancer Genetics, Royal Prince Alfred Hospital, Sydney, Australia
| | - H Tsao
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA
| | - G Jönsson
- Department of Clinical Sciences Lund, Division of Oncology, Lund University, Lund, Sweden
| | - K Busam
- Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - R Gupta
- Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, Australia.,Sydney Medical School, The University of Sydney, Sydney, Australia
| | - J M Trent
- Translational Genomics Research Institute, Phoenix, AZ, USA
| | - A-M Gerdes
- Department of Clinical Genetics, Rigshospitalet, Copenhagen, Denmark
| | - K M Brown
- Laboratory of Translational Genomics, National Cancer Institute, Bethesda, MD, USA
| | - R A Scolyer
- Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, Australia.,Melanoma Institute Australia, North Sydney, Australia.,Sydney Medical School, The University of Sydney, Sydney, Australia
| | - N K Hayward
- QIMR Berghofer Medical Research Institute, Genetics and Computational Biology, Brisbane, Australia
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Affiliation(s)
- Kimberly M Brown
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA.
| | - Celia Chao
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA.
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Vargas GM, Parmar AD, Sheffield KM, Tamirisa NP, Brown KM, Riall TS. Impact of liver-directed therapy in colorectal cancer liver metastases. J Surg Res 2014; 191:42-50. [PMID: 24990539 DOI: 10.1016/j.jss.2014.05.070] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 05/20/2014] [Accepted: 05/23/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND There is a paucity of data on the current management and outcomes of liver-directed therapy (LDT) in older patients presenting with stage IV colorectal cancer (CRC). The aim of the study was to evaluate treatment patterns and outcomes in use of LDT in the setting of improved chemotherapy. METHODS We used Cancer Registry and linked Medicare claims to identify patients aged ≥66 y undergoing surgical resection of the primary tumor and chemotherapy after presenting with stage IV CRC (2001-2007). LDT was defined as liver resection and/or ablation-embolization. RESULTS We identified 5500 patients. LDT was used in 34.9% of patients; liver resection was performed in 1686 patients (30.7%), and ablation-embolization in 554 patients (10.1%), with 322 patients having both resection and ablation-embolization. Use of LDT was negatively associated with increasing year of diagnosis (odds ratio [OR] = 0.96, 95% confidence interval [CI] 0.93-0.99), age >85 y (OR = 0.61, 95% CI 0.45-0.82), and poor tumor differentiation (OR = 0.73, 95% CI 0.64-0.83). LDT was associated with improved survival (median 28.4 versus 21.1 mo, P < 0.0001); however, survival improved for all patients over time. We found a significant interaction between LDT and period of diagnosis and noted a greater survival improvement with LDT for those diagnosed in the late (2005-2007) period. CONCLUSIONS Older patients with stage IV CRC are experiencing improved survival over time, independent of age, comorbidity, and use of LDT. However, many older patients deemed to be appropriate candidates for resection of the primary tumor and receipt of systemic chemotherapy did not receive LDT. Our data suggest that improved patient selection may be positively impacting outcomes. Early referral and optimal selection of patients for LDT has the potential to further improve survival in older patients presenting with advanced colorectal cancer.
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Affiliation(s)
- Gabriela M Vargas
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas.
| | - Abhishek D Parmar
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas; Department of Surgery, The University of California, Oakland, California
| | - Kristin M Sheffield
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
| | - Nina P Tamirisa
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas; Department of Surgery, The University of California, Oakland, California
| | - Kimberly M Brown
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
| | - Taylor S Riall
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
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Jinkins LJ, Parmar AD, Han Y, Duncan CB, Sheffield KM, Brown KM, Riall TS. Current trends in preoperative biliary stenting in patients with pancreatic cancer. Surgery 2013; 154:179-89. [PMID: 23889947 DOI: 10.1016/j.surg.2013.03.016] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 03/28/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Sufficient evidence suggests that preoperative biliary stenting is associated with increased complication rates after pancreaticoduodenectomy. METHODS Surveillance, Epidemiology, and End Results (SEER) and linked Medicare claims data (1992-2007) were used to identify patients with pancreatic cancer who underwent pancreaticoduodenectomy. We evaluated trends in the use of preoperative biliary stenting, timing of physician visits relative to stenting, and time to surgical resection and symptoms in stented and unstented patients. RESULTS Pancreaticoduodenectomy was performed in 2,573 patients, and 52.6% of patients underwent preoperative biliary stenting (N = 1,354). Of these, 75.3% underwent endoscopic stenting only, 18.9% received a percutaneous stent, and 5.8% underwent both procedures. The overall stenting rate increased from 29.6% of patients between 1992 and 1995 to 59.1% between 2004 and 2007 (P < .0001). Preoperative stenting was more common in patients with jaundice, cholangitis, pruritus, or coagulopathy (P < .05 for all). Of stented patients, 77.7% had had a stent placed prior to seeing a surgeon. Stenting prior to surgical consultation was associated with longer indwelling stent time compared to stenting after surgical consultation (37.3 vs 27.0 days, P < .0001). In addition, stented patients had longer times from surgeon visit to pancreatectomy than those who had not received stents (24.2 days vs 17.2 days, P < .0001). CONCLUSION Use of preoperative biliary stenting doubled between 1992 and 2007 despite evidence that stenting is associated with increased perioperative infectious complications. The majority of stenting occurred prior to surgical consultation and is associated with significant delay in time to operation. Surgeons should be involved early in order to prevent unnecessary stenting and improve outcomes.
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Affiliation(s)
- Lindsay J Jinkins
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX 77555-0541, USA
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Vargas GM, Sheffield KM, Parmar AD, Han Y, Brown KM, Riall TS. Physician follow-up and observation of guidelines in the post treatment surveillance of colorectal cancer. Surgery 2013; 154:244-55. [PMID: 23889952 DOI: 10.1016/j.surg.2013.04.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Accepted: 04/04/2013] [Indexed: 01/21/2023]
Abstract
BACKGROUND Guidelines for post resection surveillance of colorectal cancer recommend a collection of the patient's history and physical examination, testing for carcinoembryonic antigen (CEA), and colonoscopy. No consistent guidelines exist for the use of abdominal computed tomography (CT) and position emission tomography (PET)/PET-CT. The goal of our study was to describe current trends, the impact of oncologic follow-up on guideline adherence, and the patterns of use of nonrecommended tests. METHODS We used Texas Cancer Registry-Medicare-linked data (2000-2009) to identify physician visits, CEA testing, colonoscopy, abdominal CT, and PET/PET-CT scans in patients ≥ 66 years old with stage I-III colorectal cancer who underwent curative resection. Compliance with guidelines was assessed with a composite measure of physician visits, CEA tests, and colonoscopy use from start of surveillance. RESULTS In patients who survived 3 years, the overall compliance with guidelines was 25.1%. In patients seen regularly by a medical oncologist, compliance with guidelines increased to 61.5% compared with 8.8% for those not seen by a medical oncologist regularly (P < .0001). The use of abdominal CT and PET/PET-CT increased from 57.5% and 9.5%, respectively, in 2001 to 65.8% and 24.6% (P < .0001) in 2006. Patients who saw a medical oncologist were more likely to get cross-sectional imaging than those who did not (P < .0001). CONCLUSION Compliance with current minimum guidelines for post treatment surveillance of colorectal cancer is low and the use of nonrecommended testing has increased over time. Both compliance and use of nonrecommended tests are markedly increased in patients seen by a medical oncologist. The comparative effectiveness of CT and PET/PET-CT in the surveillance of colorectal cancer patients needs further examination.
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Affiliation(s)
- Gabriela M Vargas
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX 77555-0541, USA
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Brown KM, Moore BT, Sorensen GB, Boettger CH, Tang F, Jones PG, Margolin DJ. Patient-reported outcomes after single-incision versus traditional laparoscopic cholecystectomy: a randomized prospective trial. Surg Endosc 2013; 27:3108-15. [PMID: 23519495 DOI: 10.1007/s00464-013-2914-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 03/03/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Single-incision laparoscopic cholecystectomy (SILC) is a newer approach that may be a safe alternative to traditional laparoscopic cholecystectomy (TLC) based on retrospective and small prospective studies. As the demand for single-incision surgery may be driven by patient perceptions of benefits, we designed a prospective randomized study using patient-reported outcomes as our end points. METHODS Patients deemed candidates for either SILC or TLC were offered enrollment in the study. After induction of anesthesia, patients were randomized to SILC or TLC. Preoperative characteristics and operative data were recorded, including length of stay (LOS). Pain scores in recovery and for 48 h and satisfaction with wound appearance at 2 and 4 weeks were reported by patients. We used the gastrointestinal quality of life index (GIQLI) survey preoperatively and at 2 and 4 weeks postoperatively to assess recovery. Procedural and total hospital costs per case were abstracted from hospital billing systems. RESULTS Mean age of the study group was 44.1 years (±14.8), 87% were Caucasian, and 77% were female, with no difference between groups. Operative times were longer for SILC (median = 57 vs. 47 min, p = 0.008), but mean LOS was similar (6.8 ± 4.2 h SILC vs. 6.2 ± 4.8 h TLC, p = 0.59). Operating room cost and encounter cost were similar. GIQLI scores were not significantly different preoperatively or at 2 or 4 weeks postoperatively. Patients reported higher satisfaction with wound appearance at 2 weeks with SILC. There were no differences in pain scores in recovery or in the first 48 h, although SILC patients required significantly more narcotic in recovery (19 mg morphine equivalent vs. 11.5, p = 0.03). CONCLUSIONS SILC is a longer operation but can be done at the same cost as TLC. Recovery and pain scores are not significantly different. There may be an improvement in patient satisfaction with wound appearance. Both procedures are valid approaches to cholecystectomy.
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Benarroch-Gampel J, Sheffield KM, Duncan CB, Brown KM, Han Y, Townsend CM, Riall TS. Preoperative laboratory testing in patients undergoing elective, low-risk ambulatory surgery. Ann Surg 2012; 256:518-28. [PMID: 22868362 PMCID: PMC3488956 DOI: 10.1097/sla.0b013e318265bcdb] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Routine preoperative laboratory testing for ambulatory surgery is not recommended. METHODS Patients who underwent elective hernia repair (N = 73,596) were identified from the National Surgical Quality Improvement Program (NSQIP) database (2005-2010). Patterns of preoperative testing were examined. Multivariate analyses were used to identify factors associated with testing and postoperative complications. RESULTS A total of 46,977 (63.8%) patients underwent testing, with at least one abnormal test recorded in 61.6% of patients. In patients with no NSQIP comorbidities (N = 25,149) and no clear indication for testing, 54% received at least one test. In addition, 15.3% of tested patients underwent laboratory testing the day of the operation. In this group, surgery was done despite abnormal results in 61.6% of same day tests. In multivariate analyses, testing was associated with older age, ASA (American Society of Anesthesiologists) class >1, hypertension, ascites, bleeding disorders, systemic steroids, and laparoscopic procedures. Major complications (reintubation, pulmonary embolus, stroke, renal failure, coma, cardiac arrest, myocardial infarction, septic shock, bleeding, or death) occurred in 0.3% of patients. After adjusting for patient and procedure characteristics, neither testing nor abnormal results were associated with postoperative complications. CONCLUSIONS Preoperative testing is overused in patients undergoing low-risk, ambulatory surgery. Neither testing nor abnormal results were associated with postoperative outcomes. On the basis of high rates of testing in healthy patients, physician and/or facility preference and not only patient condition currently dictate use. Involvement from surgical societies is necessary to establish guidelines for preoperative testing.
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MacGregor S, Brown KM, Stark M, Gartside M, Woods S, Bonazzi V, Aoude L, Dutton-Regester K, Tyagi S, Liu J, Duffy DL, Palmer J, Cust A, Schmid H, Symmons J, Holland E, Agha-Hamilton C, Holohan K, Youngkin D, Gillanders E, Jenkins MA, Kelly J, Whiteman DC, Kefford R, Giles G, Armstrong B, Aitken J, Hopper J, Montgomery G, Schmidt C, Trent JM, Martin NG, Mann GJ, Hayward NK. From GWAS to genome sequencing: complementary approaches to identify melanoma predisposition genes. Hered Cancer Clin Pract 2012. [PMCID: PMC3327126 DOI: 10.1186/1897-4287-10-s2-a46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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Riall TS, Brown KM. Individualizing care for locoregional pancreatic cancer? J Surg Res 2012; 179:41-4. [PMID: 22221606 DOI: 10.1016/j.jss.2011.10.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Revised: 10/13/2011] [Accepted: 10/26/2011] [Indexed: 11/16/2022]
Affiliation(s)
- Taylor S Riall
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX 77555-0541, USA.
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Affiliation(s)
- Kimberly M Brown
- University of Pittsburgh Liver Cancer Center, Pittsburgh, Pennsylvania 15213, USA
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Joseph S, Moore BT, Sorensen GB, Earley JW, Tang F, Jones P, Brown KM. Single-incision laparoscopic cholecystectomy: a comparison with the gold standard. Surg Endosc 2011; 25:3008-15. [PMID: 21487878 DOI: 10.1007/s00464-011-1661-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Accepted: 02/20/2011] [Indexed: 12/20/2022]
Abstract
BACKGROUND Single-incision laparoscopic cholecystectomy (SILC) may be a comparable alternative to conventional multiport laparoscopic cholecystectomy (LC). This study compared procedural outcomes and costs between SILC and LC. METHODS A retrospective review of patients undergoing SILC over an 8-month period was performed. A cohort of LC patients from the same surgeons over the preceding 8 months was used as historic controls. Demographics, comorbidities, diagnosis, operative data, pain control in the recovery room, complications, length of hospital stay, and cost were compared between the two groups. RESULTS Of the 285 patients, 177 underwent LC and 108 underwent SILC. The mean age was 49.7 years for the LC patients and 48.2 years for the SILC patients (p = 0.44). Two of the LC patients underwent conversion to open surgery. None of SILC patients were converted to open procedure, although nine had additional ports placed. After multivariate adjustment, SILC was associated with a 15% longer operative time (p = 0.053) and a 66% shorter hospital stay (p = 006) than LC. Biliary dyskinesia and biliary colic were independently associated with shorter operative times and a reduced hospital stay. No significant differences were noted in pain score, narcotics used in the postanesthesia care unit (PACU), 30-day complication rates (1.7 vs 1.9%; p = 1), hospital charges, or cost between the two groups. CONCLUSIONS Single-incision LC is safe, significantly reduces the hospital stay, and is an acceptable alternative to traditional LC. Although further study is warranted, initial results indicate that SILC may offer the most benefit for outpatient procedures.
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Affiliation(s)
- Sigi Joseph
- Department of Surgery, University of Missouri, Kansas City, USA
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Blackstock KL, Ingram J, Burton R, Brown KM, Slee B. Understanding and influencing behaviour change by farmers to improve water quality. Sci Total Environ 2010; 408:5631-8. [PMID: 19464728 DOI: 10.1016/j.scitotenv.2009.04.029] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2009] [Revised: 04/15/2009] [Accepted: 04/20/2009] [Indexed: 05/12/2023]
Abstract
Diffuse pollution from agriculture remains a significant challenge to many countries seeking to improve and protect their water environments. This paper reviews literature relating to the provision of information and advice as a mechanism to encourage farmers to mitigate diffuse pollution. The paper presents findings from a literature review on influencing farmer behaviour and synthesizes three main areas of literature: psychological and institutional theories of behaviour; shifts in the approach to delivery of advice (from knowledge transfer to knowledge exchange); and the increased interest in heterogeneous farming cultures. These three areas interconnect in helping to understand how best to influence farmer behaviour in order to mitigate diffuse pollution. They are, however, literatures that are rarely cited in the water management arena. The paper highlights the contribution of the 'cultural turn' taken by rural social scientists in helping to understand collective and individual voluntary behaviour. The paper explores how these literatures can contribute to the existing understanding of water management in the agricultural context, particularly: when farmers question the scientific evidence; when there are increased calls for collaborative planning and management; and when there is increased value placed on information as a business commodity. The paper also highlights where there are still gaps in knowledge that need to be filled by future research - possibly in partnership with farmers themselves. Whilst information and advice has long been seen as an important part of diffuse pollution control, increasing climate variability that will require farmers to practice adaptive management is likely to make these mechanisms even more important.
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Affiliation(s)
- K L Blackstock
- Socio-Economics Research Group, Macaulay Land Use Research Institute, Craigiebuckler, Aberdeen, AB15 8QH, United Kingdom.
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Brown KM, Shoup M. Multidisciplinary approach to cancer care. Surgical clinics of North America. Preface. Surg Clin North Am 2009; 89:xv-xvi. [PMID: 19186226 DOI: 10.1016/j.suc.2009.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Kimberly M Brown
- Department of Surgery, University of Missouri-Kansas City, Saint Luke's Hospital, 4401 Wornall Road, Suite 420, Kansas City, MO 64108, USA.
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Quiros RM, Valianou M, Kwon Y, Brown KM, Godwin AK, Cukierman E. Ovarian normal and tumor-associated fibroblasts retain in vivo stromal characteristics in a 3-D matrix-dependent manner. Gynecol Oncol 2008; 110:99-109. [PMID: 18448156 DOI: 10.1016/j.ygyno.2008.03.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2008] [Revised: 03/07/2008] [Accepted: 03/14/2008] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Due to a lack of experimental systems, little is known about ovarian stroma. Here, we introduce an in vivo-like 3-D system of mesenchymal stromal progression during ovarian tumorigenesis to support the study of stroma permissiveness in human ovarian neoplasias. METHODS To sort 3-D cultures into 'normal,' 'primed' and 'activated' stromagenic stages, 29 fibroblastic cell lines from 5 ovarian tumor samples (tumor ovarian fibroblasts, TOFs) and 14 cell lines from normal prophylactic oophorectomy samples (normal ovarian fibroblasts, NOFs) were harvested and characterized for their morphological, biochemical and 3-D culture features. RESULTS Under 2-D conditions, cells displayed three distinct morphologies: spread, spindle, and intermediate. We found that spread and spindle cells have similar levels of alpha-SMA, a desmoplastic marker, and consistent ratios of pFAKY(397)/totalFAK. In 3-D intermediate cultures, alpha-SMA levels were virtually undetectable while pFAKY(397)/totalFAK ratios were low. In addition, we used confocal microscopy to assess in vivo-like extracellular matrix topography, nuclei morphology and alpha-SMA features in the 3-D cultures. We found that all NOFs presented 'normal' characteristics, while TOFs presented both 'primed' and 'activated' features. Moreover, immunohistochemistry analyses confirmed that the 3-D matrix-dependent characteristics are reminiscent of those observed in in vivo stromal counterparts. CONCLUSIONS We conclude that primary human ovarian fibroblasts maintain in vivo-like (staged) stromal characteristics in a 3-D matrix-dependent manner. Therefore, our stromal 3-D system offers a tool that can enhance the understanding of both stromal progression and stroma-induced ovarian tumorigenesis. In the future, this system could also be used to develop ovarian stroma-targeted therapies.
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Affiliation(s)
- Roderick M Quiros
- Basic Science, Fox Chase Cancer Center, Philadelphia, PA 19111-2497, USA
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Brown KM, Siripurapu V, Davidson M, Cohen SJ, Konski A, Watson JC, Li T, Ciocca V, Cooper H, Hoffman JP. Chemoradiation followed by chemotherapy before resection for borderline pancreatic adenocarcinoma. Am J Surg 2008; 195:318-21. [PMID: 18308038 DOI: 10.1016/j.amjsurg.2007.12.017] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2007] [Revised: 12/11/2007] [Accepted: 12/11/2007] [Indexed: 12/15/2022]
Abstract
BACKGROUND For patients with borderline resectable pancreatic cancer, preoperative chemoradiation and standalone chemotherapy may allow for R0 resection and improved survival. METHODS A retrospective review of patients with borderline resectable pancreatic cancer treated with preoperative chemoradiation and standalone chemotherapy was undertaken. Clinical variables, including disease-free and overall survival, were collected. Univariate analysis was used to identify factors impacting survival. RESULTS Thirteen patients with borderline resectable pancreatic cancer were treated with preoperative chemoradiation and chemotherapy. Morbidity and mortality were 38% and 0. There were 2 R1 and 11 R0 resections. Nine patients are alive with a median follow-up of 20 months. Five patients recurred at a median of 4 months. Tumor fibrosis < or = 60% was associated with recurrence and poor survival. CONCLUSIONS Preoperative chemoradiation and chemotherapy allow a select group of patients with borderline resectable pancreatic cancer to undergo an R0 or R1 resection with acceptable morbidity and mortality. Tumor response may be associated with survival.
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Affiliation(s)
- Kimberly M Brown
- Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Ave Philadelphia, PA 19027, USA
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Kim KH, Brown KM, Harris PV, Langston JA, Cherry JR. A Proteomics Strategy To Discover β-Glucosidases from Aspergillus fumigatus with Two-Dimensional Page In-Gel Activity Assay and Tandem Mass Spectrometry. J Proteome Res 2007; 6:4749-57. [DOI: 10.1021/pr070355i] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Kee-Hong Kim
- Novozymes, Inc., 1445 Drew Avenue, Davis California 95618
| | | | - Paul V. Harris
- Novozymes, Inc., 1445 Drew Avenue, Davis California 95618
| | | | - Joel R. Cherry
- Novozymes, Inc., 1445 Drew Avenue, Davis California 95618
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Abstract
Pancreatic cancer is the fourth leading cause of cancer deaths in the United States. Surgical resection offers the only hope of cure, though the addition of chemoradiation in the adjuvant setting has been shown to improve survival over surgery alone. Many patients are unable to receive adjuvant therapy due to prolonged postoperative recovery. For this reason, administration of chemoradiation preoperatively (neoadjuvant) has been proposed as an alternative to postoperative treatment. In patients with resectable disease, neoadjuvant therapy results in similar survivals compared to postoperative therapy, with a greater proportion of patients able to complete treatment. For selected patients with borderline or unresectable disease, neoadjuvant therapy offers the potential for tumor downstaging and increasing the likelihood of a margin-negative resection. This article reviews the use of neoadjuvant therapy in the treatment of pancreatic cancer.
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Hurtuk MG, Devata S, Brown KM, Oshima K, Aranha GV, Pickleman J, Shoup M. Should all patients with duodenal adenocarcinoma be considered for aggressive surgical resection? Am J Surg 2007; 193:319-24; discussion 324-5. [PMID: 17320527 DOI: 10.1016/j.amjsurg.2006.09.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2006] [Revised: 09/20/2006] [Accepted: 09/20/2006] [Indexed: 12/17/2022]
Abstract
BACKGROUND Long-term survival for duodenal adenocarcinoma is inconsistent in the literature, and the biology of duodenal adenocarcinoma is poorly understood. METHODS One institution's experience with duodenal adenocarcinoma from 1984 to 2005 is reviewed. Clinicopathologic data were analyzed, and overall survival was estimated using Kaplan-Meier curves with log-rank test. RESULTS Of the 52 patients, 35 (67%) underwent potentially curative surgery; 31 survived the postoperative period and were included in the analysis. Of these, the median survival was 34 months (range 6 to 186 months) compared with 13 months (range 1 to 24 months) for those not undergoing curative surgery (P < or = .001). Clinicopathologic factors favoring long-term survival were tumor size >3.5 cm (P < or = .001) and T-stage < or =4 (P = .014). CONCLUSIONS Clinicopathologic factors important to survival in duodenal cancer are T4 tumor status and tumor size. Interestingly, larger tumors were less likely to be invasive, and patients with these tumors had improved survival. The biology of this cancer is poorly understood; therefore, aggressive resection for all duodenal adenocarcinomas is recommended for all patients medically fit to undergo resection.
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Affiliation(s)
- M G Hurtuk
- Division of Surgical Oncology, Department of Surgery, Loyola University Medical Center, 2160 S. First Ave., Maywood, IL 60153, USA
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Abstract
INTRODUCTION Traditional resections for pancreatic malignancies include distal pancreatectomy with splenectomy and pancrearicoduodenectomy (PD). Alternative resections for benign pancreatic disease are used to minimize the resection of normal pancreatic and splenic parenchyma. This study describes the use of central pancreatectomy (CP) in 10 patients. METHODS A retrospective chart review of all patients undergoing CP between May 1999 and February 2004 was undertaken. RESULTS Ten patients (eight female, two male) underwent CP for benign pancreatic disease. Median age was 59 years (range 21-75). Eight patients presented with abdominal pain, two of whom also had weight loss. One patient each presented with hypoglycemia and as an incidental finding. Median operative time was 255 min (range 160-380 min). Proximal pancreatic remnant was stapled in five and oversewn in five. Distal pancreatic remnant was managed with pancreaticojejunostomy in six patients and pancreatjcogastrostomy in four patients. There were no 30-day mortalities. Pancreatic fistula developed in four patients (40%), and all resolved without operative intervention. All patients are alive with no recurrence and no new endocrine or exocrine dysfunction. CONCLUSION CP has similar morbidity and mortality rates to traditional pancreatic resections and may offer a lower incidence of diabetes and exocrine insufficiency.
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Affiliation(s)
- Kimberly M. Brown
- Department of Surgery, Loyola University Medical CenterMaywood ILUSA
| | - Margo Shoup
- Department of Surgery, Loyola University Medical CenterMaywood ILUSA
| | - Adam Abodeely
- Department of Surgery, Loyola University Medical CenterMaywood ILUSA
| | - Pam Hodul
- Department of Surgery, Loyola University Medical CenterMaywood ILUSA
| | - John J. Brems
- Department of Surgery, Loyola University Medical CenterMaywood ILUSA
| | - Gerard V. Aranha
- Department of Surgery, Loyola University Medical CenterMaywood ILUSA
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Brown KM, Baltazar GA, Hamilton MB. Reconciling nuclear microsatellite and mitochondrial marker estimates of population structure: breeding population structure of Chesapeake Bay striped bass (Morone saxatilis). Heredity (Edinb) 2005; 94:606-15. [PMID: 15829986 DOI: 10.1038/sj.hdy.6800668] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Comparative analyses of nuclear and organelle genetic markers may help delineate evolutionarily significant units or management units, although population differentiation estimates from multiple genomes can also conflict. Striped bass (Morone saxatilis) are long-lived, highly migratory anadromous fish recently recovered from a severe decline in population size. Previous studies with protein, nuclear DNA and mitochondrial DNA (mtDNA) markers produced discordant results, and it remains uncertain if the multiple tributaries within Chesapeake Bay constitute distinct management units. Here, 196 young-of-the-year (YOY) striped bass were sampled from Maryland's Choptank, Potomac and Nanticoke Rivers and the north end of Chesapeake Bay in 1999 and from Virginia's Mataponi and Rappahannock Rivers in 2001. A total of 10 microsatellite loci exhibited between two and 27 alleles per locus with observed heterozygosities between 0.255 and 0.893. The 10-locus estimate of R(ST) among the six tributaries was -0.0065 (95% confidence interval -0.0198 to 0.0018). All R(ST) and all but one theta estimates for pairs of populations were not significantly different from zero. Reanalysis of Chesapeake Bay striped bass mtDNA data from two previous studies estimated population differentiation between theta=-0.002 and 0.160, values generally similar to mtDNA population differentiation predicted from microsatellite R(ST) after adjusting for reduced effective population size and uniparental inheritance in organelle genomes. Based on mtDNA differentiation, breeding sex ratios or gene flow may have been slightly male biased in some years. The results reconcile conflicting past studies based on different types of genetic markers, supporting a single Chesapeake Bay management unit encompassing a panmictic striped bass breeding population.
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Affiliation(s)
- K M Brown
- Department of Biology, Georgetown University, Washington DC 20057-1229, USA
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Brown KM, Tompkins AJ, Yong S, Aranha GV, Shoup M. Pancreaticoduodenectomy is curative in the majority of patients with node-negative ampullary cancer. ACTA ACUST UNITED AC 2005; 140:529-32; discussion 532-3. [PMID: 15967899 DOI: 10.1001/archsurg.140.6.529] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
HYPOTHESIS Survival following resection for ampullary carcinoma may be influenced by 1 or more clinical or pathologic variables. DESIGN Retrospective medical records review. SETTING Academic tertiary care center. PATIENTS From July 1, 1991, through April 30, 2004, 72 patients (31 males and 41 females) were treated for ampullary carcinoma at Loyola University Medical Center, Maywood, Ill. Of these, 51 patients who underwent potentially curative pancreaticoduodenectomy were studied. INTERVENTIONS Whipple procedure for attempted cure in 51 patients with ampullary adenocarcinoma. MAIN OUTCOME MEASURES The effects of clinical and pathologic factors on disease-specific survival were analyzed using log-rank and a multivariate Cox proportional hazards model. RESULTS The median age of the 51 patients (25 males and 26 females) was 69 years (age range, 38-90 years). Median operative time was 6 hours (range, 4-12 hours), and median estimated blood loss was 800 mL (range, 350-7500 mL). Thirty-day mortality was 2% (1 of 51 patients). Twenty-seven had node-negative disease, 34 cases were T1/T2, and 23 were well differentiated. Median follow-up for patients still alive was 42 months (range, 2-147 months); overall 5-year disease-specific survival was 58%. Five-year survival was 78% (21/27) in node-negative patients, 73% (25/34) for T1/T2 patients, and 76% (17/23) for well-differentiated tumors compared with 25% for node-positive, 8% for T3/T4, and 36% for poorly or moderately differentiated tumors (P<.01). On multivariate analysis, only node-negative disease maintained significance (hazard ratio, 5.2; 95% confidence interval, 1.2-21.9). In all groups, there were no deaths due to disease after 3 years of survival was reached. CONCLUSION Pancreaticoduodenectomy is curative in 80% of patients with node-negative ampullary carcinomas. Once 3-year survival is reached, long-term survival can be expected.
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Affiliation(s)
- Kimberly M Brown
- Department of Surgery, Section of Surgical Oncology, Loyola University Medical Center, Maywood, IL 60153, USA
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Brown KM, Domin C, Aranha GV, Yong S, Shoup M. Increased preoperative platelet count is associated with decreased survival after resection for adenocarcinoma of the pancreas. Am J Surg 2005; 189:278-82. [PMID: 15792750 DOI: 10.1016/j.amjsurg.2004.11.014] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2004] [Revised: 11/19/2004] [Accepted: 11/19/2004] [Indexed: 12/21/2022]
Abstract
BACKGROUND Platelets are thought to participate in tumor metastasis. However, the relationship between platelet count and prognosis in pancreatic cancer remains unresolved. METHODS A chart review of patients undergoing resection for pancreatic adenocarcinoma was undertaken. Demographic, perioperative, and outcome data were collected. Kaplan-Meier survival and Cox regression analyses were used to determine the impact of preoperative platelet count on survival. RESULTS Between June 1995 and March 2003, 109 patients (63% male) with a median age of 68 years (range 42 to 85 years) underwent resection for pancreatic cancer. Univariate analysis demonstrated that platelet count, lymph node or margin status, and histology were associated with survival. In multivariate analysis, the association between increased platelet count and poor survival maintained significance. CONCLUSIONS Increased preoperative platelet count is associated with adverse survival outcome in patients undergoing resection for pancreatic cancer. Antiplatelet medications warrant further study in an attempt to improve survival in these patients.
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Affiliation(s)
- Kimberly M Brown
- Department of Surgery, Section of Surgical Oncology, Loyola University Medical Center, 2160 South First Ave., 3rd Floor, Bldg. 110, Maywood, IL 60153, USA
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Rabin DL, Thompson B, Brown KM, Judson MA, Huang X, Lackland DT, Knatterud GL, Yeager H, Rose C, Steimel J. Sarcoidosis: social predictors of severity at presentation. Eur Respir J 2004; 24:601-8. [PMID: 15459139 DOI: 10.1183/09031936.04.00070503] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
To determine relationships among social predictors and sarcoidosis severity at presentation, demographic characteristics, socioeconomic status, and barriers to care, A Case-Control Etiologic Study of Sarcoidosis (ACCESS) was set up. Patients self-reported themselves to be Black or White and were tissue-confirmed incident cases aged > or =l8-yrs-old (n=696) who had received uniform assessment procedures within one of 10 medical centres and were studied using standardised questionnaires and physical, radiographical, and pulmonary function tests. Severity was measured by objective disease indicators, subjective measures of dyspnoea and short form-36 subindices. The results of the study showed that lower income, the absence of private or Medicare health insurance, and other barriers to care were associated with sarcoidosis severity at presentation, as were race, sex, and age. Blacks were more likely to have severe disease by objective measures, while women were more likely than males to report subjective measures of severity. Older individuals were more likely to have severe disease by both measures. In conclusion, it was found that low income and other financial barriers to care are significantly associated with sarcoidosis severity at presentation even after adjusting for demographic characteristics of race, sex, and age.
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Affiliation(s)
- D L Rabin
- Division of Community Health Care Studies, Georgetown University School of Medicine, 3800 Reservoir Road, N.W, Kober-Cogan 418, Washington DC, 20007, USA.
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Abstract
Experimental evidence implicates Fas ligand-mediated keratinocyte apoptosis as an underlying mechanism of toxic epidermal necrolysis syndrome (TEN). In vitro studies indicate a potential role for immunoglobulin (Ig) therapy in blocking Fas ligand signaling, thus reducing the severity of TEN. Anecdotal reports have described successful treatment of TEN patients with Ig; however, no study to date has analyzed outcome data in a large series of patients treated with Ig using institutional controls. The SCORTEN severity-of-illness score ranks severity and predicts prognosis in TEN patients using age, heart rate, TBSA slough, history of malignancy, and admission blood urea nitrogen, serum bicarbonate, and glucose levels. A retrospective chart review was performed that included all patients treated for TEN at our burn center since 1997. Ig therapy was instituted for all patients with biopsy-proven TEN beginning in January 2000. Twenty-one TEN patients were treated before Ig (no-Ig group), and 24 patients have been treated with Ig. SCORTEN data were collected, as well as length of stay (LOS) and status upon discharge. Each patient was given a SCORTEN of 0 to 6, with 1 point each for age greater than 40, TBSA slough greater than 10%, history of malignancy, admission BUN greater than 28 mg/dl, HCO3 less than 20 mg/dl, and glucose greater then 252 mg/dl. Outcome was compared between patients treated with Ig and without Ig. Overall mortality for patients treated before Ig was 28.6% (6/21), and with Ig, mortality was 41.7%% (10/24). There was no significant difference in age or TBSA slough. The average SCORTEN between the groups was equivalent (2.2 in no-Ig group vs 2.7 in Ig group, P = 0.3), and no group of patients with any SCORTEN score showed a significant benefit from Ig therapy. Overall LOS as well as LOS for survivors was longer in the Ig group. This series represents the largest single-institution analysis of TEN patient outcome after institution of Ig therapy. Our data do not show a significant improvement in mortality for TEN patients treated with Ig at any level of severity and may indicate a potential detriment in using Ig. Ig should not be given to TEN patients outside of a clinical trial. A multicenter, prospective, double-blinded randomized trial is necessary and urgently indicated to determine whether Ig therapy is beneficial or harmful in the care of TEN patients.
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Affiliation(s)
- K M Brown
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois 60153, USA
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