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Carter MM, Whitrock JN, Pratt CG, Shaughnessy EA, Meier TM, Barrord MF, Hanseman DJ, Reyna CR, Heelan AA, Lewis JD. ASO Visual Abstract: Nationwide Analysis of Locoregional Management for Ductal Carcinoma In Situ (DCIS) in Males-An NCDB Analysis of the Surgical Approach to DCIS in Males. Ann Surg Oncol 2024; 31:1663-1664. [PMID: 38127211 DOI: 10.1245/s10434-023-14783-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Affiliation(s)
- Michela M Carter
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Jenna N Whitrock
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Catherine G Pratt
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Elizabeth A Shaughnessy
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Teresa M Meier
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michelle F Barrord
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Department of Radiation Oncology, Kettering Health Cancer Center, Kettering, OH, USA
| | - Dennis J Hanseman
- Division of Research and Biostatistics, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Chantal R Reyna
- Division of Surgical Oncology, Department of Surgery, Loyola University Chicago's Stritch School of Medicine, Maywood, IL, USA
| | - Alicia A Heelan
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jaime D Lewis
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Carter MM, Whitrock JN, Pratt CG, Shaughnessy EA, Meier TM, Barrord MF, Hanseman DJ, Reyna CR, Heelan AA, Lewis JD. Nationwide Analysis of Locoregional Management for Ductal Carcinoma In Situ in Males: An NCDB Analysis of the Surgical Approach to DCIS in Males. Ann Surg Oncol 2024; 31:1599-1607. [PMID: 37978114 DOI: 10.1245/s10434-023-14579-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 09/08/2023] [Accepted: 10/25/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Limited data exist regarding the optimal locoregional approach for males with ductal carcinoma in situ (DCIS). This study examined trends in management and survival for males with DCIS. METHODS The National Cancer Database (NCDB) was queried for males with a diagnosis of DCIS from 2006 to 2017. Patients were categorized by locoregional management. Continuous variables were evaluated by Kruskal-Wallis and categorical variables by chi-square or Fisher's exact test. Univariable and multivariable logistic regressions were performed to evaluate for predictors of patients receiving partial mastectomy (PM) with radiation. Survival was analyzed by Kaplan-Meier. RESULTS Between 2006 and 2017, 711 males with DCIS were identified. Most received mastectomy alone (57.1%). No change was observed in management approach from 2006 to 2017. Patients who underwent mastectomy alone were mostly hormone-positive (95.9% were estrogen-positive, 90.9% were progesterone-positive), although this cohort was least likely to receive hormone therapy (17.2%). Among those who underwent PM with radiation, only 61% of those who were hormone-positive received hormone therapy. Univariable analysis demonstrated that those of black race had lower odds of receiving PM with radiation (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.36-0.84), which persisted in the multivariable analysis with control for age and tumor size (OR, 0.32; 95% CI, 0.15-0.67). Overall survival did not differ significantly between the four treatment methods (p = 0.08). CONCLUSIONS The management approach to male DCIS did not change from 2006 to 2017. Survival did not differ between treatment methods. Demographic and clinicopathologic features, including race, may influence locoregional treatments received, and further studies are needed to further understand this.
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Affiliation(s)
- Michela M Carter
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Jenna N Whitrock
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Catherine G Pratt
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Elizabeth A Shaughnessy
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Teresa M Meier
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michelle F Barrord
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Department of Radiation Oncology, Kettering Health Cancer Center, Kettering, OH, USA
| | - Dennis J Hanseman
- Division of Research and Biostatistics, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Chantal R Reyna
- Division of Surgical Oncology, Department of Surgery, Loyola University Chicago's Stritch School of Medicine, Maywood, IL, USA
| | - Alicia A Heelan
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jaime D Lewis
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS) Research Group, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Hammaker AC, Dodwad SJM, Salyer CE, Adams SD, Foote DC, Ivascu FA, Kader S, Abelson JS, Al Yafi M, Sutton JM, Smith S, Postlewait LM, Stopenski SJ, Nahmias JT, Harvey J, Farr D, Callahan ZM, Marks JA, Elsaadi A, Campbell SJ, Stahl CC, Hanseman DJ, Patel P, Woeste MR, Martin RCG, Patel JA, Newcomb MR, Greenwell K, Meister KM, Etheridge JC, Cho NL, Thrush CR, Kimbrough MK, Nasim BW, Willis RE, George BC, Quillin RC, Cortez AR. A multi-institutional study from the US ROPE Consortium examining factors associated with directly entering practice upon residency graduation. Surgery 2022; 172:906-912. [PMID: 35788283 DOI: 10.1016/j.surg.2022.05.033] [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] [Received: 03/01/2022] [Revised: 05/16/2022] [Accepted: 05/30/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND There is concern regarding the competency of today's general surgery graduates as a large proportion defer independent practice in favor of additional fellowship training. Little is known about the graduates who directly enter general surgery practice and if their operative experiences during residency differ from graduates who pursue fellowship. METHODS Nineteen Accreditation Council for Graduate Medical Education-accredited general surgery programs from the US Resident OPerative Experience Consortium were included. Demographics, career choice, and case logs from graduates between 2010 to 2020 were analyzed. RESULTS There were 1,264 general surgery residents who graduated over the 11-year period. A total of 248 (19.6%) went directly into practice and 1,016 (80.4%) pursued fellowship. Graduates directly entering practice were more likely to be a high-volume resident (43.1% vs 30.5%, P < .01) and graduate from a high-volume program (49.2% vs 33.0%, P < .01). Direct-to-practice graduates performed 53 more cases compared with fellowship-bound graduates (1,203 vs 1,150, P < .01). On multivariable analysis, entering directly into practice was positively associated with total surgeon chief case volume (odds ratio = 1.47, 95% confidence interval 1.18-1.84, P < .01) and graduating from a US medical school (odds ratio = 2.54, 95% confidence interval 1.45-4.44, P < .01) while negatively associated with completing a dedicated research experience (odds ratio = 0.31, 95% confidence interval 0.22-0.45, P < .01). CONCLUSION This is the first multi-institutional study exploring resident operative experience and career choice. These data suggest residents who desire immediate practice can tailor their experience with less research time and increased operative volume. These data may be helpful for programs when designing their experience for residents with different career goals.
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Affiliation(s)
- Austin C Hammaker
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH. https://twitter.com/HammakerAustin
| | - Shah-Jahan M Dodwad
- Department of Surgery, McGovern Medical School at UTHealth, Houston, TX. https://twitter.com/shahofsurgery
| | - Christen E Salyer
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH. https://twitter.com/salyerchristen
| | - Sasha D Adams
- Department of Surgery, McGovern Medical School at UTHealth, Houston, TX. https://twitter.com/SashaTrauma
| | - Darci C Foote
- Department of Surgery, Beaumont Health, Royal Oak, MI
| | | | - Sarah Kader
- Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA
| | - Jonathan S Abelson
- Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA. https://twitter.com/jabelsonmd
| | - Motaz Al Yafi
- Department of Surgery, University of Toledo, Toledo, OH
| | - Jeffrey M Sutton
- Department of Surgery, Division of Surgical Oncology, Medical University of South Carolina, Charleston, SC. https://twitter.com/J_M_Sutton
| | | | | | | | - Jeffry T Nahmias
- Department of Surgery, University of California, Irvine, Orange, CA. https://twitter.com/jnahmias1
| | - Jalen Harvey
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas TX. https://twitter.com/JHarvMD20
| | - Deborah Farr
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas TX. https://twitter.com/DVFelaine
| | - Zachary M Callahan
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA. https://twitter.com/zmcallahan
| | - Joshua A Marks
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Ali Elsaadi
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Samuel J Campbell
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX
| | | | - Dennis J Hanseman
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH
| | - Purvi Patel
- Department of Surgery, Loyola University, Maywood, IL. https://twitter.com/pppatelmd
| | | | | | - Jitesh A Patel
- Department of Surgery, University of Kentucky, Lexington, KY. https://twitter.com/Patel_Wildcat
| | | | | | | | | | - Nancy L Cho
- Department of Surgery, Brigham and Women's Hospital, Boston, MA. https://twitter.com/NancyLCho
| | - Carol R Thrush
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Mary K Kimbrough
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR. https://twitter.com/kimbrough_katie
| | - Bilal Waqar Nasim
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Ross E Willis
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Brian C George
- Department of Surgery, Center for Surgical Training and Research (CSTAR), University of Michigan, Ann Arbor, MI. https://twitter.com/bcgeorge
| | - Ralph C Quillin
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH
| | - Alexander R Cortez
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH.
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Vaysburg DM, Cortez AR, Hanseman DJ, Delman AM, Morris C, Kassam AF, Kutz D, Lewis J, Van Haren RM, Quillin RC. An analysis of applicant competitiveness to general surgery, surgical subspecialties, and integrated programs. Surgery 2021; 170:1087-1092. [PMID: 33879334 DOI: 10.1016/j.surg.2021.03.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/27/2021] [Accepted: 03/12/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND General surgery was once the gateway into a career in surgery. Over time, surgical subspecialties developed separate residency programs, and recently, integrated programs have emerged. It is unknown what impact the presence of surgical subspecialties and integrated programs have had on general surgery. Our objective was to evaluate match trends and quantify competitiveness of the general surgery, integrated programs, and surgical subspecialties matches. METHODS National Residency Matching Program match data and applicant characteristics from 2010 through 2020 were analyzed for US senior allopathic applicants. Integrated programs were defined as plastic and vascular surgery, and surgical subspecialties were defined as otolaryngology, orthopedic surgery, and neurosurgery. Trends were evaluated using linear regression, programs were compared on 10 metrics by Wilcoxon rank-sum tests, and a logistic regression was used to rank each specialty match. RESULTS The number of US senior applicants per position to integrated programs decreased and approached that of general surgery and surgical subspecialties, but the median number of applicants per position to general surgery was lower than to surgical subspecialties or integrated programs (1.21 interquartile range). Our logistic regression showed United States Medical Licensing Examination scores, research experience, Alpha Omega Alpha Honor Society membership, and graduation from a top medical school to be the most important factors in the match, and our weighted rank score found general surgery (2.85) to be less competitive than surgical subspecialties (1.92) or integrated programs (1.17). CONCLUSION Throughout the last decade, integrated programs and surgical subspecialties have matched more competitive applicants based on the most significant predictors of the match. Moving forward, it is important that general surgery strives to attract the best and brightest out of medical school.
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Affiliation(s)
- Dennis M Vaysburg
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, OH. https://twitter.com/DMVaysburg
| | - Alexander R Cortez
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, OH. https://twitter.com/AlexCortezMD
| | - Dennis J Hanseman
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, OH
| | - Aaron M Delman
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, OH. https://twitter.com/AaronDelman
| | - Christopher Morris
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, OH
| | - Al-Faraaz Kassam
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, OH. https://twitter.com/afkassam
| | - David Kutz
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, OH
| | - Jaime Lewis
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, OH. https://twitter.com/JaimeDLewis
| | - Robert M Van Haren
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, OH; Division of Thoracic Surgery, University of Cincinnati, OH. https://twitter.com/rvanharen
| | - R Cutler Quillin
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, OH.
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Levinsky NC, Byrne MM, Hanseman DJ, Cortez AR, Guitron J, Starnes SL, Van Haren RM. Opioid Dependence After Lung Cancer Resection: Institutional Analysis of State Prescription Drug Database. World J Surg 2020; 45:887-896. [PMID: 33221948 DOI: 10.1007/s00268-020-05865-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND The national opioid epidemic is a public health crisis. Thoracic surgery has also been associated with high incidence of new persistent opioid use. Our purpose was to describe the incidence and predictors of opioid use after lung cancer resection. METHODS Retrospective review of lung cancer resections from 2015 to 2018 was performed using the Ohio Automated Rx Reporting System. Opioid dosing was recorded as milligram morphine equivalents (MME). Patients were stratified by preoperative opioid use. Chronic preoperative opioid users (opioid dependent) filled > 120 days supply of opioid pain medication in the 12 months prior to surgery; intermittent opioid users filled < 120 days. Chronic postoperative opioid users continued monthly use after 180 days postoperatively. RESULTS 137 patients underwent resection. 16.1% (n = 22) were opioid dependent preoperatively, 29.2% (n = 40) were intermittent opioid users, and 54.7% (n = 75) were opioid naïve. Opioid dependent patients had higher daily inpatient opioid use compared to intermittent users and opioid naïve (43[30.0-118.1] MME vs 17.9[3.5-48.8] MME vs 8.8[2.1-25.0] MME, p < 0.001). Twenty-six percent (n = 35) of all patients were opioid users beyond 180 days postoperatively. Variables associated with opioid use > 180 days were: chronic preoperative opioid use (OR 23.8, p < 0.01), daily inpatient opioid requirement (1.02, p < 0.01), and neoadjuvant chemotherapy (28.2, p < 0.01). CONCLUSIONS A quarter of patients are opioid dependent after lung cancer resection. This is due to both preexisting and new persistent opioid use. Improved strategies are needed to prevent chronic pain and opioid dependence after lung cancer resection.
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Affiliation(s)
- Nick C Levinsky
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Matthew M Byrne
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Dennis J Hanseman
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | | | - Julian Guitron
- Division of Thoracic Surgery, Department of Surgery, University of Cincinnati, 231 Albert Sabin Way ML-0558, Medical Sciences Building, Room 2472, Cincinnati, OH, USA
| | - Sandra L Starnes
- Division of Thoracic Surgery, Department of Surgery, University of Cincinnati, 231 Albert Sabin Way ML-0558, Medical Sciences Building, Room 2472, Cincinnati, OH, USA
| | - Robert M Van Haren
- Division of Thoracic Surgery, Department of Surgery, University of Cincinnati, 231 Albert Sabin Way ML-0558, Medical Sciences Building, Room 2472, Cincinnati, OH, USA.
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Abstract
There are several methods to mitigate the pain that results from thoracic surgery. All of them may be associated with complications. We analyzed the morbidities associated with epidural and subpleural catheter analgesia in patients undergoing pulmonary resections for lung cancer. We conducted a retrospective review of our prospective lung cancer outcomes database for all patients undergoing lobectomy for lung cancer through a thoracotomy or thoracoscopy. All patients had either an epidural or subpleural catheter placed for pain control. One hundred twenty-nine patients met the inclusion criteria. Patients were stratified based on age and pain management technique and the 30-day outcomes were examined. Ninety-three patients had epidural catheters placed and 36 received subpleural catheters. Baseline demographics were similar except for two variables; the subpleural catheter group had a larger proportion of thoracoscopic surgery and more pack-years smoked. Patients in the epidural group were more likely to experience postoperative pruritus and had longer intensive care unit stays but were less likely to use a patient-controlled anesthesia pump. Patients in the subpleural group were more likely to develop intestinal complications. When a subset analysis was done by age (younger than 70 vs 70 years or older), there were no significant differences in postoperative outcomes in the older group. The younger cohort had more pruritus and longer intensive care unit stays in the epidural group. The differences between subpleural and epidural catheters are minimal across all ages and nonexistent for geriatric patients. Thus, the choice of pain management should be determined by individual patient characteristics and risk factors rather than based on age alone.
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Affiliation(s)
- Kathryn E. Engelhardt
- Division of Thoracic Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Sandra L. Starnes
- Division of Thoracic Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Veterans’ Affairs Medical Center, Cincinnati, Ohio
| | - Dennis J. Hanseman
- Division of Trauma and Critical Care, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Center for Sustainment of Trauma and Readiness Skills, U.S. Air Force, Cincinnati, OH
| | - Julian Guitron
- Division of Thoracic Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Veterans’ Affairs Medical Center, Cincinnati, Ohio
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Liu X, Hanseman DJ, Champagne CM, Bray GA, Qi L, Williamson DA, Anton SD, Sacks FM, Tong J. Predicting Weight Loss Using Psychological and Behavioral Factors: The POUNDS LOST Trial. J Clin Endocrinol Metab 2020; 105:dgz236. [PMID: 31802116 PMCID: PMC7067534 DOI: 10.1210/clinem/dgz236] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 12/04/2019] [Indexed: 12/15/2022]
Abstract
CONTEXT Eating habits and food craving are strongly correlated with weight status. It is currently not well understood how psychological and behavioral factors influence both weight loss and weight regain. OBJECTIVE To examine the associations between psychological and behavioral predictors with weight changes and energy intake in a randomized controlled trial on weight loss. DESIGN AND SETTING The Prevention of Obesity Using Novel Dietary Strategies is a dietary intervention trial that examined the efficacy of 4 diets on weight loss over 2 years. Participants were 811 overweight (body mass index, 25-40.9 kg/m2; age, 30-70 years) otherwise healthy adults. RESULTS Every 1-point increase in craving score for high-fat foods at baseline was associated with greater weight loss (-1.62 kg, P = .0004) and a decrease in energy intake (r = -0.10, P = .01) and fat intake (r = -0.16, P < .0001) during the weight loss period. In contrast, craving for carbohydrates/starches was associated with both less weight loss (P < .0001) and more weight regain (P = .04). Greater cognitive restraint of eating at baseline was associated with both less weight loss (0.23 kg, P < .0001) and more weight regain (0.14 kg, P = .0027), whereas greater disinhibition of eating was only associated with more weight regain (0.12 kg, P = .01). CONCLUSIONS Craving for high-fat foods is predictive of greater weight loss, whereas craving for carbohydrates is predictive of less weight loss. Cognitive restraint is predictive of less weight loss and more weight regain. Interventions targeting different psychological and behavioral factors can lead to greater success in weight loss.
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Affiliation(s)
- Xiaoran Liu
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | | | - George A Bray
- Pennington Biomedical Research Center, Baton Rouge, Louisiana
| | - Lu Qi
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana
| | | | - Stephen D Anton
- Department of Aging & Geriatric Research, University of Florida, Gainesville, Florida
| | - Frank M Sacks
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jenny Tong
- Department of Medicine, Division of Endocrinology, Metabolism, and Nutrition, Duke Molecular Physiology Institute, Durham, North Carolina
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Dhar VK, Hanseman DJ, Young G, Browne D, Makley AT, Sussman JJ, Goodman MD. Does Geographical Bias Impact the Match for General Surgery Residents? J Surg Educ 2020; 77:260-266. [PMID: 31677980 DOI: 10.1016/j.jsurg.2019.09.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 07/13/2019] [Revised: 09/08/2019] [Accepted: 09/30/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE As the competitiveness of applicants for general surgery residency grows, it is becoming challenging for programs to differentiate qualified candidates with a genuine interest in matching at their institution. The purpose of this study was to examine geographic trends in the general surgery match in order to elicit regional biases and optimize applicant interview selection strategies. DESIGN In this single-center retrospective study, geographical information regarding birth place, college, medical school, and final match institution for general surgery residency applicants was examined. SETTING This study was set at the University of Cincinnati College of Medicine. PARTICIPANTS All general surgery residency applicants interviewing at our institution between 2015-2017 were included. METHODS Academic variables and geographical information were collected for all applicants in the cohort. Statistical analyses were performed using chi-square and logistic regression techniques to determine any association between geography and match outcomes. RESULTS Of 198 applicants included in the analysis, approximately 25% matched at an institution located in the same state as their medical school. Total 75% of applicants matched at a residency program located less than 640 miles away from either their birth place, college, or medical school, while only 15% matched at an institution located over 1000 miles away and 4% matched over 2000 miles away. When examining applicant characteristics, there were no significant differences in gender, clerkship grade, United States Medical Licensing Exam scores, Alpha Omega Alpha Honor Society membership, or quality of recommendation letters between applicants who matched in the lowest and highest quartiles of distance to final residency program location. CONCLUSIONS A significant proportion of general surgery applicants matched at institutions located in a region near either their birth place, college, or medical school. Given the limited number of interviews able to be offered by institutions and the associated opportunity costs, general surgery programs should consider regional biases when evaluating residency applicants.
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Affiliation(s)
- Vikrom K Dhar
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Dennis J Hanseman
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Gilda Young
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Deborah Browne
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Amy T Makley
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jeffrey J Sussman
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Michael D Goodman
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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Cortez AR, Winer LK, Kassam AF, Hanseman DJ, Kuethe JW, Quillin RC, Potts JR. See None, Do Some, Teach None: An Analysis of the Contemporary Operative Experience as Nonprimary Surgeon. J Surg Educ 2019; 76:e92-e101. [PMID: 31130507 DOI: 10.1016/j.jsurg.2019.05.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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: 03/12/2019] [Revised: 04/08/2019] [Accepted: 05/13/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE The operative experience of today's general surgery resident has changed, but little is known about the modern experience as nonprimary surgeon. We set out to explore changes in the operative experience of general surgery residents as first assistant (FA) and teaching assistant (TA). DESIGN, SETTING, AND PARTICIPANTS This is a review of ACGME national operative log reports from 1990 to 2018. TA and FA cases were analyzed. Statistical analysis was performed using polynomial regression analysis and Kruskal-Wallis test. Statistical significance was set at p < 0.05. RESULTS 30,260 individuals completed general surgery residency during the study period with medians of 951 (interquartile range: 929-974) total major, 63 (31-184) FA, and 32 (25-48) TA cases. As a proportion of total cases completed, FA cases decreased from 21.8% of the total operative experience in 1990 to 2.5% in 2018, and TA cases declined from 7.4% of the total operative experience in 1990 to 3.5% in 2018. Regression modeling demonstrated that both operative roles decreased over time, but at a progressively decreasing rate, with FA cases reaching a "floor" around 2010 and TA cases reaching a "breakpoint" in 2008 at which time operative volume rebounded and began to increase. Among the core general surgery domains of abdomen and alimentary tract, compositional analysis revealed a decrease across each of the 11 operative subcategories (all p < 0.05) for FA, and for TA, a decrease in 6 of the 11 operative subcategories (stomach, small intestine, large intestine, anorectal, hernia, and biliary, all p < 0.05). CONCLUSIONS Over the past 3 decades, the resident operative experience as nonprimary surgeon has decreased dramatically, with today's residents graduating with fewer FA and TA cases. As surgical training has traditionally relied heavily on an apprenticeship model for learning technical skills, it is essential that surgical educators recognize and rectify these trends.
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Affiliation(s)
- Alexander R Cortez
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio.
| | - Leah K Winer
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Al-Faraaz Kassam
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Dennis J Hanseman
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Joshua W Kuethe
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Ralph Cutler Quillin
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - John R Potts
- Accreditation Council for Graduate Medical Education, Chicago, Illinois
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10
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Cortez AR, Winer LK, Kassam AF, Hanseman DJ, Kuethe JW, Sussman JJ, Quillin RC. Exploring the relationship between burnout and grit during general surgery residency: A longitudinal, single-institution analysis. Am J Surg 2019; 219:322-327. [PMID: 31623881 DOI: 10.1016/j.amjsurg.2019.09.041] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [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: 05/07/2019] [Revised: 08/24/2019] [Accepted: 09/30/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND How burnout changes during general surgery residency remains unknown. METHODS From 2015 to 2018, general surgery residents completed the Maslach Burnout Inventory and Grit Scale. Statistical analyses were adjusted for repeated measures and compared to the incoming intern level. RESULTS Fifty-five residents participated in this study. Burnout rates varied by program level, with an increased risk occuring in the third clinical year (OR = 11.7, p = 0.03). Emotional exhaustion (EE) peaked during the first and third clinical years, depersonalization (DP) peaked during the first and second clinical years, and personal achievement (PA) reached a nadir during the third clinical year (all p < 0.05). Residents with burnout had lower grit scores compared to those without burnout (3.71 vs 4.02, p < 0.01). Increasing grit was linearly associated with decreasing EE, decreasing DP, and increasing PA (all p < 0.05). CONCLUSIONS Burnout varies throughout surgical residency, and grit is inversely related to burnout.
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Affiliation(s)
- Alexander R Cortez
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA.
| | - Leah K Winer
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Al-Faraaz Kassam
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Dennis J Hanseman
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Joshua W Kuethe
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Jeffrey J Sussman
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - R Cutler Quillin
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
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11
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Cortez AR, Winer LK, Kim Y, Hanseman DJ, Athota KP, Quillin RC. Predictors of medical student success on the surgery clerkship. Am J Surg 2019; 217:169-174. [DOI: 10.1016/j.amjsurg.2018.09.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 09/04/2018] [Accepted: 09/16/2018] [Indexed: 11/27/2022]
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12
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Pugh AM, Giannini CM, Pinney SM, Hanseman DJ, Shaughnessy EA, Lewis JD. Characteristics and diagnosis of pregnancy and lactation associated breast cancer: Analysis of a self-reported regional registry. Am J Surg 2018; 216:809-812. [PMID: 30270029 DOI: 10.1016/j.amjsurg.2018.07.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/25/2018] [Accepted: 07/14/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pregnancy-associated breast cancer (PABC) is the most common malignancy in pregnancy. However due to its infrequent occurrence, PABC continues to be poorly understood. METHODS We performed a retrospective study using self-reported data from 1079 eligible women in a regional breast cancer registry. RESULTS The PABC cases were more likely than non-PABCs to be younger than age 35 and have nodal involvement at diagnosis. Despite diagnosis at a young age, there was not an association between PABC and family history. For method of diagnosis, PABC was found on self-exam, while non-PABCs were found on mammography. CONCLUSION In conclusion, PABC is rarely detected by mammography and diagnosis is highly dependent on detection during self-breast exam. Women who are or recently were pregnant should be encouraged to perform regular self-breast exams to report any changes for further evaluation. Patient and clinician education regarding risk and realities of PABC is essential.
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Affiliation(s)
- Amanda M Pugh
- Department of Surgery Division of Research, University of Cincinnati, College of Medicine, Cincinnati, OH, 45267, United States.
| | - Courtney M Giannini
- University of Cincinnati, College of Medicine, Cincinnati, OH, 45267, United States
| | - Susan M Pinney
- Department of Environmental Health, University of Cincinnati, College of Medicine, Cincinnati, OH, 45267, United States
| | - Dennis J Hanseman
- Department of Surgery Division of Research, University of Cincinnati, College of Medicine, Cincinnati, OH, 45267, United States
| | - Elizabeth A Shaughnessy
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati, College of Medicine, Cincinnati, OH, 45267, United States
| | - Jaime D Lewis
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati, College of Medicine, Cincinnati, OH, 45267, United States
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13
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Midura EF, Jung AD, Hanseman DJ, Dhar V, Shah SA, Rafferty JF, Davis BR, Paquette IM. Combination oral and mechanical bowel preparations decreases complications in both right and left colectomy. Surgery 2018; 163:528-534. [DOI: 10.1016/j.surg.2017.10.023] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 10/09/2017] [Accepted: 10/11/2017] [Indexed: 11/25/2022]
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14
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Dhar VK, Hanseman DJ, Watkins BM, Paquette IM, Shah SA, Thompson JR. What matters after sleeve gastrectomy: patient characteristics or surgical technique? Surgery 2018; 163:571-577. [DOI: 10.1016/j.surg.2017.09.052] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 08/25/2017] [Accepted: 09/12/2017] [Indexed: 11/26/2022]
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15
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Kim Y, Jung AD, Dhar VK, Tadros JS, Schauer DP, Smith EP, Hanseman DJ, Cuffy MC, Alloway RR, Shields AR, Shah SA, Woodle ES, Diwan TS. Laparoscopic sleeve gastrectomy improves renal transplant candidacy and posttransplant outcomes in morbidly obese patients. Am J Transplant 2018; 18:410-416. [PMID: 28805345 DOI: 10.1111/ajt.14463] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [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: 06/05/2017] [Revised: 08/04/2017] [Accepted: 08/04/2017] [Indexed: 01/25/2023]
Abstract
Morbid obesity is a barrier to kidney transplantation due to inferior outcomes, including higher rates of new-onset diabetes after transplantation (NODAT), delayed graft function (DGF), and graft failure. Laparoscopic sleeve gastrectomy (LSG) increases transplant eligibility by reducing BMI in kidney transplant candidates, but the effect of surgical weight loss on posttransplantation outcomes is unknown. Reviewing single-center medical records, we identified all patients who underwent LSG before kidney transplantation from 2011-2016 (n = 20). Post-LSG kidney recipients were compared with similar-BMI recipients who did not undergo LSG, using 2:1 direct matching for patient factors. McNemar's test and signed-rank test were used to compare groups. Among post-LSG patients, mean BMI ± standard deviation (SD) was 41.5 ± 4.4 kg/m2 at initial encounter, which decreased to 32.3 ± 2.9 kg/m2 prior to transplantation (P < .01). No complications, readmissions, or mortality occurred following LSG. After transplantation, one patient (5%) experienced DGF, and no patients experienced NODAT. Allograft and patient survival at 1-year posttransplantation was 100%. Compared with non-LSG patients, post-LSG recipients had lower rates of DGF (5% vs 20%) and renal dysfunction-related readmissions (10% vs 27.5%) (P < .05 each). Perioperative complications, allograft survival, and patient survival were similar between groups. These data suggest that morbidly obese patients with end-stage renal disease who undergo LSG to improve transplant candidacy, achieve excellent posttransplantation outcomes.
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Affiliation(s)
- Y Kim
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - A D Jung
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - V K Dhar
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - J S Tadros
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - D P Schauer
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - E P Smith
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - D J Hanseman
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - M C Cuffy
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - R R Alloway
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - A R Shields
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - S A Shah
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - E S Woodle
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - T S Diwan
- Cincinnati Collaborative for Obesity Research (CCORE), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
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Hoehn RS, Go DE, Hanseman DJ, Shah SA, Paquette IM. Hospital safety-net burden does not predict differences in rectal cancer treatment and outcomes. J Surg Res 2018; 221:204-210. [DOI: 10.1016/j.jss.2017.08.047] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 07/14/2017] [Accepted: 08/30/2017] [Indexed: 01/23/2023]
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17
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Midura EF, Jung AD, Daly MC, Hanseman DJ, Davis BR, Shah SA, Paquette IM. Cancer Center Volume and Type Impact Stage-Specific Utilization of Neoadjuvant Therapy in Rectal Cancer. Dig Dis Sci 2017; 62:1906-1912. [PMID: 28501970 DOI: 10.1007/s10620-017-4610-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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] [Received: 11/16/2016] [Accepted: 05/04/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Neoadjuvant chemoradiation reduces local recurrence in locally advanced rectal cancer, and adherence to national and societal recommendations remains unknown. OBJECTIVE To determine variability in guideline adherence in rectal cancer treatment and investigate whether hospital volume correlated with variability seen. DESIGN We performed a retrospective analysis using the National Cancer Database rectal cancer participant user files from 2005 to 2010. Stage-specific predictors of neoadjuvant chemotherapy and radiation use were determined, and variation in use across hospitals analyzed. Hospitals were ranked based on likelihood of preoperative therapy use by stage, and observed-to-expected ratios for neoadjuvant therapy use calculated. Hospital outliers were identified, and their center characteristics compared. RESULTS A total of 23,488 patients were identified at 1183 hospitals. There was substantial variability in the use of neoadjuvant chemoradiation across hospitals. Patients managed outside clinical guidelines for both stage 1 and stage 3 disease tended to receive treatment at lower-volume, community cancer centers. CONCLUSIONS There is substantial variability in adherence to national guidelines in the use of neoadjuvant chemoradiation for rectal cancer across all stages. Both hospital volume and center type are associated with over-treatment of early-stage tumors and under-treatment of more invasive tumors. These findings identify a clear need for national quality improvement efforts in the treatment of rectal cancer.
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Affiliation(s)
- Emily F Midura
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA.,Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH, USA
| | - Andrew D Jung
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA.,Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH, USA
| | - Meghan C Daly
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA.,Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH, USA
| | - Dennis J Hanseman
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA.,Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH, USA
| | - Bradley R Davis
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Shimul A Shah
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA.,Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH, USA
| | - Ian M Paquette
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA. .,Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH, USA. .,, 2123 Auburn Avenue, #524, Cincinnati, OH, 45219, USA.
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Jernigan PL, Wallace MC, Novak CS, Gerlach TW, Hanseman DJ, Pritts TA, Davis BR. Measuring Intangibles: Defining Predictors of Non-Technical Skills in Critical Care Air Transport Team Trainees. Mil Med 2017; 181:1357-1362. [PMID: 27753575 DOI: 10.7205/milmed-d-15-00493] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Critical Care Air Transport Teams (CCATTs) are integral to the U.S. Air Force aeromedical evacuation paradigm. The current study was conducted to evaluate predictors of nontechnical skills (NOTECHS) in CCATT trainees. METHODS Sixteen CCATTs were studied over a 6-month period. Team members completed a biographical survey and teams were videotaped during a simulated CCATT mission. Teams and individuals were assigned a "red flag score" using a validated assessment tool for NOTECHS. Salivary cortisol levels were measured at baseline and pre- and postsimulation exercises. RESULTS 63% of participants reported regular intensive care unit (ICU) experience and 67% had flown real-world CCATT missions. Sixteen simulated missions were reviewed, with 69 crisis events identified. Task saturation was observed in 42% of crisis events. Average team red flag score correlated with task saturation during the simulated missions (odds ratio = 0.5). Daily ICU experience (p < 0.03) and previous deployment (p < 0.04) correlated with NOTECHS performance. Cortisol levels increased from baseline as the result of the simulation (p < 0.01) but did not correlate with red flag scores or biographical data. CONCLUSIONS Task saturation occurred frequently and correlated with performance of NOTECHS. Previous real-world CCATT experience and daily ICU care correlated with improved performance of NOTECHS.
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Affiliation(s)
- Peter L Jernigan
- Department of Surgery and Institute for Military Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267
| | - Matthew C Wallace
- Department of Anesthesiology, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267
| | - Christine S Novak
- Department of Anesthesiology, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267
| | - Travis W Gerlach
- Cincinnati Center for Sustainment of Trauma and Readiness Skills, 234 Goodman Street, Cincinnati, OH 45219
| | - Dennis J Hanseman
- Department of Surgery and Institute for Military Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267
| | - Timothy A Pritts
- Department of Surgery and Institute for Military Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267
| | - Bradley R Davis
- Department of Surgery and Institute for Military Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267
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19
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Xia BT, Ahmad SA, Al Humaidi AH, Hanseman DJ, Ethun CG, Maithel SK, Kooby DA, Salem A, Cho CS, Weber SM, Stocker SJ, Talamonti MS, Bentrem DJ, Abbott DE. Time to Initiation of Adjuvant Chemotherapy in Pancreas Cancer: A Multi-Institutional Experience. Ann Surg Oncol 2017; 24:2770-2776. [PMID: 28600732 DOI: 10.1245/s10434-017-5918-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Despite randomized trials addressing adjuvant therapy (AT) for pancreas cancer, the ideal time to initiate therapy remains undefined. Retrospective analyses of the ESPAC-3 trial demonstrated that time to initiation of AT did not impact overall survival (OS). Given the absence of confirmatory data outside of a clinical trial, we sought to determine if AT timing in routine clinical practice is associated with OS differences. METHODS Perioperative data of pancreatectomies for ductal adenocarcinoma from five institutions (2005-2015) were assessed. Delay in AT was defined as initiation >12 weeks after surgery. Multivariate analysis was performed to identify predictors of mortality. RESULTS Of 867 patients, 172 (19.8%) experienced omission of AT. Improved OS was observed in patients who received AT compared with patients who did not (24.8 vs. 19.1 months, p < 0.01). Information on time to initiation of AT was available in 488 patients, of whom 407 (83.4%) and 81 (16.6%) received chemotherapy ≤12 and >12 weeks after surgery, respectively. There were no differences in recurrence-free survival or OS (all p > 0.05) between the timely and delayed AT groups. After controlling for perioperative characteristics and tumor pathology, patients who initiated AT ≤ 12 or > 12 weeks after surgery had a 50% lower odds of mortality than patients who only underwent resection (p < 0.01). CONCLUSIONS In a multi-institutional experience of resected pancreas cancer, delayed initiation of AT was not associated with poorer survival. Patients who do not receive AT within 12 weeks after surgery are still appropriate candidates for multimodal therapy and its associated survival benefit.
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Affiliation(s)
- Brent T Xia
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Syed A Ahmad
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Ali H Al Humaidi
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Dennis J Hanseman
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Cecilia G Ethun
- Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA, USA
| | - David A Kooby
- Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA, USA
| | - Ahmed Salem
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Clifford S Cho
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA.,Division of Surgical Oncology, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Sharon M Weber
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Susan J Stocker
- Department of Surgery, Northwestern University, Chicago, IL, USA.,Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Mark S Talamonti
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - David J Bentrem
- Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Daniel E Abbott
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA.
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20
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Daly MC, Jung AD, Hanseman DJ, Shah SA, Paquette IM. Surviving rectal cancer: examination of racial disparities surrounding access to care. J Surg Res 2017; 211:100-106. [DOI: 10.1016/j.jss.2016.12.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 11/08/2016] [Accepted: 12/09/2016] [Indexed: 10/20/2022]
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21
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Hoehn RS, Hanseman DJ, Dhar VK, Go DE, Edwards MJ, Shah SA. Opportunities to Improve Care of Hepatocellular Carcinoma in Vulnerable Patient Populations. J Am Coll Surg 2017; 224:697-704. [DOI: 10.1016/j.jamcollsurg.2016.12.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 12/15/2016] [Indexed: 12/11/2022]
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22
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Abbott DE, Tzeng CWD, McMillan MT, Callery MP, Kent TS, Christein JD, Behrman SW, Schauer DP, Hanseman DJ, Eckman MH, Vollmer CM. Pancreas fistula risk prediction: implications for hospital costs and payments. HPB (Oxford) 2017; 19:140-146. [PMID: 27884544 DOI: 10.1016/j.hpb.2016.10.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [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] [Received: 08/24/2016] [Revised: 10/13/2016] [Accepted: 10/28/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND As payment models evolve, disease-specific risk stratification may impact patient selection and financial outcomes. This study sought to determine whether a validated clinical risk score for post-operative pancreatic fistula (POPF) could predict hospital costs, payments, and profit margins. METHODS A multi-institutional cohort of 1193 patients undergoing pancreaticoduodenectomy (PD) were matched to an independent hospital where cost, in US$, and payment data existed. An analytic model detailed POPF risk and post-operative sequelae, and their relationship with hospital cost and payment. RESULTS Per-patient hospital cost for negligible-risk patients was $37,855. Low-, moderate-, and high- risk patients had incrementally higher hospital costs of $38,125 ($270; 0.7% above negligible-risk), $41,128 ($3273; +8.6%), and $41,983 ($3858; +10.9%), respectively. Similarly, hospital payment for negligible-risk patients was $42,685/patient, with incrementally higher payments for low-risk ($43,265; +1.4%), moderate-risk ($45,439; +6.5%) and high-risk ($46,564; +9.1%) patients. The lowest 30-day readmission rates - with highest net profit - were found for negligible/low-risk patients (10.5%/11.1%), respectively, compared with readmission rates of moderate/high-risk patients (15%/15.7%). CONCLUSION Financial outcomes following PD can be predicted using the FRS. Such prediction may help hospitals and payers plan for resource allocation and payment matched to patient risk, while providing a benchmark for quality improvement initiatives.
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23
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Xia BT, Fu B, Wang J, Kim Y, Ahmad SA, Dhar VK, Levinsky NC, Hanseman DJ, Habib DA, Wilson GC, Smith M, Olowokure OO, Kharofa J, Al Humaidi AH, Choe KA, Abbott DE, Ahmad SA. Does radiologic response correlate to pathologic response in patients undergoing neoadjuvant therapy for borderline resectable pancreatic malignancy? J Surg Oncol 2017; 115:376-383. [DOI: 10.1002/jso.24538] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Revised: 11/24/2016] [Accepted: 12/04/2016] [Indexed: 12/27/2022]
Affiliation(s)
- Brent T. Xia
- Division of Surgical Oncology, Department of Surgery; University of Cincinnati; Cincinnati Ohio
| | - Baojin Fu
- Department of Pathology; University of Cincinnati; Cincinnati Ohio
| | - Jiang Wang
- Department of Pathology; University of Cincinnati; Cincinnati Ohio
| | - Young Kim
- Division of Surgical Oncology, Department of Surgery; University of Cincinnati; Cincinnati Ohio
| | - S. Ameen Ahmad
- Division of Surgical Oncology, Department of Surgery; University of Cincinnati; Cincinnati Ohio
| | - Vikrom K. Dhar
- Division of Surgical Oncology, Department of Surgery; University of Cincinnati; Cincinnati Ohio
| | - Nick C. Levinsky
- Division of Surgical Oncology, Department of Surgery; University of Cincinnati; Cincinnati Ohio
| | - Dennis J. Hanseman
- Division of Surgical Oncology, Department of Surgery; University of Cincinnati; Cincinnati Ohio
| | - David A. Habib
- Division of Surgical Oncology, Department of Surgery; University of Cincinnati; Cincinnati Ohio
| | - Gregory C. Wilson
- Division of Surgical Oncology, Department of Surgery; University of Cincinnati; Cincinnati Ohio
| | - Milton Smith
- Division of Gastroenterology, Department of Internal Medicine; University of Cincinnati; Cincinnati Ohio
| | - Olugbenga O. Olowokure
- Division of Medical Oncology, Department of Internal Medicine; University of Cincinnati; Cincinnati Ohio
| | - Jordan Kharofa
- Department of Radiation Oncology; University of Cincinnati; Cincinnati Ohio
| | - Ali H. Al Humaidi
- Division of Surgical Oncology, Department of Surgery; University of Cincinnati; Cincinnati Ohio
| | - Kyuran A. Choe
- Department of Radiology; University of Cincinnati; Cincinnati Ohio
| | - Daniel E. Abbott
- Division of Surgical Oncology, Department of Surgery; Univesity of Wisconsin; Madison Wisconsin
| | - Syed A. Ahmad
- Division of Surgical Oncology, Department of Surgery; University of Cincinnati; Cincinnati Ohio
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24
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Hoehn RS, Hanseman DJ, Chang AL, Daly MC, Ertel AE, Abbott DE, Shah SA, Paquette IM. Surgeon Characteristics Supersede Hospital Characteristics in Mortality After Urgent Colectomy. J Gastrointest Surg 2017; 21:23-32. [PMID: 27586190 DOI: 10.1007/s11605-016-3254-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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] [Received: 05/12/2016] [Accepted: 08/11/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Urgent colectomy is a common procedure with a high mortality rate that is performed by a variety of surgeons and hospitals. We investigated patient, surgeon, and hospital characteristics that predicted mortality after urgent colectomy. METHODS The University HealthSystem Consortium was queried for adults undergoing urgent or emergent colectomy between 2009 and 2013 (n = 50,707). Hospitals were grouped into quartiles according to risk-adjusted observed-to-expected (O/E) mortality ratios and compared using the 2013 American Hospital Association Annual Survey. Multiple logistic regression was used to determine patient and provider characteristics associated with in-hospital mortality. RESULTS The overall mortality rate after urgent colectomy was 9 %. Mortality rates were higher for patients with extreme severity of illness (27.6 %), lowest socioeconomic status (10.6 %), weekend admissions (10.7 %), and open (10.5 %) and total (15.8 %) colectomies. Hospitals with the lowest O/E ratios were smaller and had lower volume and less teaching intensity, but there were no significant trends with regard to financial (expenses, payroll, capital expenditures per bed) or personnel characteristics (physicians, nurses, technicians per bed). On multivariate analysis, mortality was associated with patient age (10 years: OR 1.31, p < 0.01), severity of illness (extreme: OR 34.68, p < 0.01), insurance status (Medicaid: OR 1.24, p < 0.01; uninsured: OR 1.40, p < 0.01), and weekend admission (OR 1.09, p = 0.04). Surgeon volume was associated with reduced mortality (per 10 cases: OR 0.99, p < 0.01), but hospital volume was not (per case: OR 1.00, p = 0.84). CONCLUSIONS Mortality is common after urgent colectomy and is associated with patient characteristics. Surgeon volume and practice patterns predicted differences in mortality, whereas hospital factors did not. These data suggest that policies focusing solely on hospital volume ignore other more important predictors of patient outcomes.
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Affiliation(s)
- Richard S Hoehn
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Dennis J Hanseman
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Alex L Chang
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Megan C Daly
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Audrey E Ertel
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Daniel E Abbott
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ian M Paquette
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA. .,Division of Colorectal Surgery, University of Cincinnati School of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267-0558, USA.
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Ertel AE, McHenry ZD, Venkatesan VK, Hanseman DJ, Wima K, Hoehn RS, Shah SA, Abbott DE. Surgeon, not technique, defines outcomes after central venous port insertion. J Surg Res 2016; 209:220-226. [PMID: 28032563 DOI: 10.1016/j.jss.2016.10.030] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 09/21/2016] [Accepted: 10/27/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Although central venous access for port placement is common and relatively safe, complications and poor resource utilization occur. We hypothesized that despite the simplicity of port placement, surgeon and/or resident performance-rather than technique-is associated with clinical outcomes and operating room efficiency. MATERIALS AND METHODS Medical records of 1200 patients who underwent port placement between 2012 and 2015 at our institution were retrospectively reviewed. Insertion route (subclavian, internal jugular, cephalic cutdown), individual surgeon (A-G), surgeon volume, body mass index, patient age, and resident presence were evaluated to determine their association with operating room time, complications, and need for alternate insertion route. RESULTS On univariate analysis, operating room times were significantly different among individual surgeons, with surgeons E and F having the longest operating room times (50 and 63 versus 31-40 min; P < 0.01) and switching to an alternate method more frequently (13.5% and 21.3%, versus 0%-10.3%, P < 0.01). On multivariate analyses, operating time was increased with elevated body mass index, resident presence, and switching to an alternate method. Individual surgeons had varied effects on operating time with two surgeons found to be the predominant drivers (OR 19 and 27; P < 0.01). With residents excluded, these two surgeons continued to increase operating times (OR 15 and 29; P < 0.01) and procedural complications (OR 3.2 and 5.9; P < 0.05). CONCLUSIONS Although port placement is ostensibly simple, individual surgeon performance is the primary driver of patient outcome and operative efficiency. In an era requiring optimized resource utilization and outcomes, these data demonstrate potential for enhanced programmatic organization and case distribution.
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Affiliation(s)
- Audrey E Ertel
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Zachary D McHenry
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Vijay K Venkatesan
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati School of Medicine, Cincinnati, Ohio; Department of Surgery, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Dennis J Hanseman
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Koffi Wima
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Richard S Hoehn
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Shimul A Shah
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
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Go DE, Abbott DE, Wima K, Hanseman DJ, Ertel AE, Chang AL, Shah SA, Hoehn RS. Addressing the High Costs of Pancreaticoduodenectomy at Safety-Net Hospitals. JAMA Surg 2016; 151:908-914. [DOI: 10.1001/jamasurg.2016.1776] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Derek E. Go
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Daniel E. Abbott
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Koffi Wima
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Dennis J. Hanseman
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Audrey E. Ertel
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Alex L. Chang
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Shimul A. Shah
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Richard S. Hoehn
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
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Walther AE, Falcone RA, Pritts TA, Hanseman DJ, Robinson BR. Pediatric and adult trauma centers differ in evaluation, treatment, and outcomes for severely injured adolescents. J Pediatr Surg 2016; 51:1346-50. [PMID: 27132539 PMCID: PMC5558261 DOI: 10.1016/j.jpedsurg.2016.03.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [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] [Received: 10/15/2015] [Revised: 03/06/2016] [Accepted: 03/29/2016] [Indexed: 10/24/2022]
Abstract
BACKGROUND/PURPOSE This study aims to investigate differences in imaging, procedure utilization, and clinical outcomes of severely injured adolescents treated at adult versus pediatric trauma centers. METHODS The National Trauma Data Bank was queried retrospectively for adolescents, 15-19years old, with a length of stay (LOS) >1day and Injury Severity Score (ISS) >25 treated at adult (ATC) or pediatric (PTC) Level 1 trauma centers from 2007 to 2011. Patient demographics and utilization of imaging and procedures were analyzed. Univariate and multivariate regression analysis was used to compare outcomes. RESULTS Of 12,861 adolescents, 51% were treated at ATC. Older age and more nonwhites were seen at ATC (p<0.01). Imaging and invasive procedures were more common at ATC (p<0.01). Shorter LOS (p=0.03) and higher home discharge rates (p<0.01) were seen at PTC. ISS and mortality did not differ. Age, race, ATC care (all p<0.01), and admission systolic blood pressure (SBP) (p=0.03) were predictors of CT utilization. ISS, SBP, and race (p<0.01) were risk factors for overall mortality; SBP (p=0.03) and ISS (p<0.01) predicted death from penetrating injury. CONCLUSIONS Severely injured adolescents experience improved outcomes and decreased imaging and invasive procedures without additional mortality risk when treated at PTC. PTC is an appropriate destination for severely injured adolescents.
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Affiliation(s)
- Ashley E. Walther
- Division of Trauma and Critical Care, Department of Surgery, University of Cincinnati College of Medicine, USA
| | - Richard A. Falcone
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Department of Surgery, University of Cincinnati College of Medicine, USA
| | - Timothy A. Pritts
- Division of Trauma and Critical Care, Department of Surgery, University of Cincinnati College of Medicine, USA
| | - Dennis J. Hanseman
- Division of Trauma and Critical Care, Department of Surgery, University of Cincinnati College of Medicine, USA
| | - Bryce R.H. Robinson
- Division of Trauma, Critical Care, and Burns, Department of Surgery, University of Washington, USA,Corresponding author at: Department of Surgery, Box 359796, Harborview Medical Center, 325 Ninth Avenue, Seattle, WA, 98104-2499, USA. Tel.: +1 206 744 8485; fax: +1 206 744 3656
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Xia BT, Habib DA, Dhar VK, Levinsky NC, Kim Y, Hanseman DJ, Sutton JM, Wilson GC, Smith M, Choe KA, Sussman JJ, Ahmad SA, Abbott DE. Early Recurrence and Omission of Adjuvant Therapy after Pancreaticoduodenectomy Argue against a Surgery-First Approach. Ann Surg Oncol 2016; 23:4156-4164. [PMID: 27459987 DOI: 10.1245/s10434-016-5457-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Sequencing therapy for patients with periampullary malignancy is controversial. Clinical trial data report high rates of adjuvant therapy completion, though contemporary, real-world rates remain incomplete. We sought to identify patients who failed to receive adjuvant therapy and those at risk for early recurrence (ER) who might benefit most from neoadjuvant therapy (NT). METHODS We retrospectively reviewed medical records of 201 patients who underwent pancreaticoduodenectomy for periampullary malignancies between 1999 and 2015; patients receiving NT were excluded. Univariate and multivariate analyses were performed to identify predictors of failure to receive adjuvant therapy and ER (within 6 months) as the primary end points. RESULTS The median age at the time of surgery was 65.5 years (interquartile range 57-74 years). The majority of tumors were pancreatic ductal adenocarcinoma (76.6 %), and 71.6 % of patients received adjuvant therapy after resection. Univariate predictors of failure to undergo adjuvant therapy were advanced age, age-adjusted Charlson comorbidity index, operative transfusion, reoperation, length of stay, and 30- to 90-day readmissions (all p < 0.05). Advanced age, specifically among patients >70 years, persisted as a significant preoperative predictor on multivariate analysis (p < 0.01). Patients who failed to receive adjuvant therapy and/or developed ER had significantly worse overall survival rates compared to all other patients (27.8 vs. 9.7 months; p < 0.01). CONCLUSIONS Approximately one-third of surgery-first patients undergoing pancreaticoduodenectomy at our institution did not receive adjuvant therapy and/or demonstrated ER. This substantial subset of patients may particularly benefit from NT, ensuring completion of multimodal therapy and/or avoiding futile surgical intervention.
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Affiliation(s)
- Brent T Xia
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - David A Habib
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Vikrom K Dhar
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Nick C Levinsky
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Young Kim
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Dennis J Hanseman
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Jeffrey M Sutton
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Gregory C Wilson
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Milton Smith
- Department of Medicine, Division of Gastroenterology, University of Cincinnati, Cincinnati, OH, USA
| | - Kyuran Ann Choe
- Department of Radiology, University of Cincinnati, Cincinnati, OH, USA
| | - Jeffrey J Sussman
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Syed A Ahmad
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Daniel E Abbott
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, WI, USA.
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Dhar VK, Levinsky NC, Xia BT, Abbott DE, Wilson GC, Sussman JJ, Smith MT, Poreddy S, Choe K, Hanseman DJ, Edwards MJ, Ahmad SA. The natural history of chronic pancreatitis after operative intervention: The need for revisional operation. Surgery 2016; 160:977-986. [PMID: 27450713 DOI: 10.1016/j.surg.2016.05.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 05/09/2016] [Accepted: 05/24/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND For patients with chronic pancreatitis, duodenum-sparing head resections and pancreaticoduodenectomy are effective operations to relieve abdominal pain. For patients who develop recurrent symptoms after their index operation, the long-term management remains controversial. METHODS Between 2002 and 2014, patients undergoing operative intervention for chronic pancreatitis were identified retrospectively. Patients requiring reoperation after their index operation were reviewed. RESULTS A total of 121 patients with chronic pancreatitis underwent an index operation. At a median time of 33 months, 85 patients underwent no further operative intervention, while 36 patients underwent reoperation. A reoperative procedure was completed with acceptable perioperative morbidity and blood loss. After a revision operation, 25% of patients became narcotic independent. Narcotic requirements decreased from 143 morphine equivalent milligrams per day (MEQ/d) to 80 MEQ/d, and 58% of patients required less than 50 MEQ/d. Insulin requirements were not increased from preoperative levels. Multivariate analysis demonstrated only narcotic requirement and exocrine insufficiency after the index operation to be predictive for the need for a revision operation. CONCLUSION Our data demonstrate the following: (1) A significant number of patients undergoing duodenum-sparing head resections (26%) or pancreaticoduodenectomy (29%) required reoperation for recurrent abdominal pain; and (2) a revisional operation can be effective in relieving recurrent abdominal symptoms. Patients with recurrent symptoms should be considered for additional operative intervention.
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Affiliation(s)
- Vikrom K Dhar
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Nick C Levinsky
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Brent T Xia
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Daniel E Abbott
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Gregory C Wilson
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Jeffrey J Sussman
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Milton T Smith
- Department of Gastroenterology, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Sampath Poreddy
- Department of Gastroenterology, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Kyuran Choe
- Department of Radiology, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Dennis J Hanseman
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Michael J Edwards
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH.
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Quillin RC, Cortez AR, Pritts TA, Hanseman DJ, Edwards MJ, Davis BR. Operative Variability Among Residents Has Increased Since Implementation of the 80-Hour Workweek. J Am Coll Surg 2016; 222:1201-10. [PMID: 27068844 DOI: 10.1016/j.jamcollsurg.2016.03.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 03/02/2016] [Accepted: 03/03/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND The ACGME instituted duty hour restrictions in 2003. This presents a challenge for surgical residents who must acquire a medical and technical knowledge base during their training. Although the effect of work hour limitations on operative volume has been examined, no study has examined whether duty hour reform has had an effect on operative volume variability. STUDY DESIGN The ACGME operative log data of graduating general surgery residents from 1992 to 2015 were examined. Residents with the most and fewest total major cases were identified and case logs, learning styles, and evaluations were analyzed. Statistical analysis was performed using linear regression analysis, chi-square test, Student's t-test, and Wilcoxon rank sum test. Significance was defined as p < 0.05. RESULTS One hundred and thirty-five residents graduated from 1992 to 2015. No change in overall operative volume was seen after the 2003 duty hour reform, however, there was an increase in operative variability. In addition, there was an increase in the variability of total major cases between the resident completing the most and fewest cases per class (183.3; p = 0.02) after the start of work hour restrictions. The residents who graduated with the highest operative volume were more likely to be action-based learners (odds ratio = 6.81; 95% CI, 2.84-16.34; p < 0.001) and received superior evaluation scores. CONCLUSIONS After the implementation of the 80-hour workweek, we found a significant increase in operative variability. This might suggest a growing disparity in the operative experience among surgical residents and, consequently, a varying quality of graduating residents. Programs should therefore consider using learning styles and developing competency-based training curricula to ensure equitable training among all trainees.
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Affiliation(s)
- Ralph C Quillin
- Department of Surgery, University of Cincinnati, Cincinnati, OH.
| | | | | | | | | | - Bradley R Davis
- Department of Surgery, University of Cincinnati, Cincinnati, OH
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Serrone JC, Tackla RD, Gozal YM, Hanseman DJ, Gogela SL, Vuong SM, Kosty JA, Steiner CA, Krueger BM, Grossman AW, Ringer AJ. Aneurysm growth and de novo aneurysms during aneurysm surveillance. J Neurosurg 2016; 125:1374-1382. [PMID: 26967775 DOI: 10.3171/2015.12.jns151552] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Many low-risk unruptured intracranial aneurysms (UIAs) are followed for growth with surveillance imaging. Growth of UIAs likely increases the risk of rupture. The incidence and risk factors of UIA growth or de novo aneurysm formation require further research. The authors retrospectively identify risk factors and annual risk for UIA growth or de novo aneurysm formation in an aneurysm surveillance protocol. METHODS Over an 11.5-year period, the authors recommended surveillance imaging to 192 patients with 234 UIAs. The incidence of UIA growth and de novo aneurysm formation was assessed. With logistic regression, risk factors for UIA growth or de novo aneurysm formation and patient compliance with the surveillance protocol was assessed. RESULTS During 621 patient-years of follow-up, the incidence of aneurysm growth or de novo aneurysm formation was 5.0%/patient-year. At the 6-month examination, 5.2% of patients had aneurysm growth and 4.3% of aneurysms had grown. Four de novo aneurysms formed (0.64%/patient-year). Over 793 aneurysm-years of follow-up, the annual risk of aneurysm growth was 3.7%. Only initial aneurysm size predicted aneurysm growth (UIA < 5 mm = 1.6% vs UIA ≥ 5 mm = 8.7%, p = 0.002). Patients with growing UIAs were more likely to also have de novo aneurysms (p = 0.01). Patient compliance with this protocol was 65%, with younger age predictive of better compliance (p = 0.01). CONCLUSIONS Observation of low-risk UIAs with surveillance imaging can be implemented safely with good adherence. Aneurysm size is the only predictor of future growth. More frequent (semiannual) surveillance imaging for newly diagnosed UIAs and UIAs ≥ 5 mm is warranted.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Andrew J Ringer
- Department of Neurosurgery.,Department of Radiology, University of Cincinnati College of Medicine.,Comprehensive Stroke Center at the University of Cincinnati Neuroscience Institute; and.,Mayfield Clinic, Cincinnati, Ohio
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Hoehn RS, Wima K, Vestal MA, Weilage DJ, Hanseman DJ, Abbott DE, Shah SA. Effect of Hospital Safety-Net Burden on Cost and Outcomes After Surgery. JAMA Surg 2016; 151:120-8. [DOI: 10.1001/jamasurg.2015.3209] [Citation(s) in RCA: 121] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Richard S. Hoehn
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Koffi Wima
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | | | | | - Dennis J. Hanseman
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Daniel E. Abbott
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Shimul A. Shah
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
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Sutton JM, Hoehn RS, Ertel AE, Wilson GC, Hanseman DJ, Wima K, Sussman JJ, Ahmad SA, Shah SA, Abbott DE. Cost-Effectiveness in Hepatic Lobectomy: the Effect of Case Volume on Mortality, Readmission, and Cost of Care. J Gastrointest Surg 2016; 20:253-61. [PMID: 26427373 DOI: 10.1007/s11605-015-2964-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 09/21/2015] [Indexed: 01/31/2023]
Abstract
OBJECTIVE(S) Higher-volume centers demonstrate better perioperative outcomes for complex surgical interventions, though resource utilization implications of this hospital-level variation are unclear. We hypothesized that for hepatic lobectomy, higher operative volume correlates with better outcomes and lower costs. METHODS From 2009 to 2011, 4163 patients undergoing hepatic lobectomy were identified from the University HealthSystems Consortium database. Univariate, multivariate logistic regression, and decision analytic models were constructed to identify differences in hospital utilization and cost. Cost included both index and readmission hospitalizations, when applicable. RESULTS The annual number of hepatic lobectomies performed by the institutions within the study ranged from 1 to 86. The median age of the 4163 patients was 58 years with a roughly equal gender split (M/F 49 %:51 %) and a racial breakdown which reflected that of the general US population. For all patients, the overall perioperative mortality rate was 2.3 % and the 30-day readmission rate was 13.4 %. Hospitals performing >30 hepatic lobectomies per year had significantly lower mortality and readmission rates than those hospitals performing ≤15 lobectomies annually (both p < 0.05). On multivariate analysis, higher severity of illness (odd ratio (OR) 2.13, 95 % confidence interval (CI) [1.48-3.07], p < 0.001), discharge to rehab (OR 1.84, [1.28-2.64], p < 0.001), home with home health care (OR 1.38, [1.08-1.76], p = 0.01), and surgery at a low-volume hospital (OR 1.49, [1.18-1.88], p < 0.001) were significant predictors of readmission. Conversely, surgical intervention at high-volume centers was associated with decreased risk of readmission (OR 0.67, [0.53-0.85], p < 0.001). When both index and readmission costs were considered, per-patient cost at low-volume centers was 21.9 % higher than at high-volume centers ($19,669 vs. $16,137). Sensitivity analyses adjusting for perioperative mortality and readmission at all centers did not significantly change the analysis. CONCLUSIONS These data, for the first time, demonstrate that hospital volume in hepatic lobectomy is an important, modifiable risk factor for readmission and cost. To optimize resource utilization, patients undergoing complex hepatic surgery should be directed to higher-volume surgical institutions.
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Affiliation(s)
- Jeffrey M Sutton
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH, USA
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati Medical Center, 234 Goodman Street, ML 0772, Cincinnati, OH, 45219, USA
| | - Richard S Hoehn
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Audrey E Ertel
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Gregory C Wilson
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH, USA
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati Medical Center, 234 Goodman Street, ML 0772, Cincinnati, OH, 45219, USA
| | - Dennis J Hanseman
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Koffi Wima
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Jeffrey J Sussman
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH, USA
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati Medical Center, 234 Goodman Street, ML 0772, Cincinnati, OH, 45219, USA
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH, USA
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati Medical Center, 234 Goodman Street, ML 0772, Cincinnati, OH, 45219, USA
| | - Shimul A Shah
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Daniel E Abbott
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH, USA.
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati Medical Center, 234 Goodman Street, ML 0772, Cincinnati, OH, 45219, USA.
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Jernigan PL, Wima K, Hanseman DJ, Hoehn RS, Ahmad SA, Shah SA, Abbott DE. Natural history and treatment trends in hepatocellular carcinoma subtypes: Insights from a national cancer registry. J Surg Oncol 2015; 112:872-6. [DOI: 10.1002/jso.24083] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 10/17/2015] [Indexed: 01/02/2023]
Affiliation(s)
- Peter L. Jernigan
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS); Department of Surgery; University of Cincinnati School of Medicine; Cincinnati Ohio
| | - Koffi Wima
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS); Department of Surgery; University of Cincinnati School of Medicine; Cincinnati Ohio
| | - Dennis J. Hanseman
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS); Department of Surgery; University of Cincinnati School of Medicine; Cincinnati Ohio
| | - Richard S. Hoehn
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS); Department of Surgery; University of Cincinnati School of Medicine; Cincinnati Ohio
| | - Syed A. Ahmad
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS); Department of Surgery; University of Cincinnati School of Medicine; Cincinnati Ohio
| | - Shimul A. Shah
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS); Department of Surgery; University of Cincinnati School of Medicine; Cincinnati Ohio
| | - Daniel E. Abbott
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS); Department of Surgery; University of Cincinnati School of Medicine; Cincinnati Ohio
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Sutton JM, Wilson GC, Wima K, Hoehn RS, Cutler Quillin R, Hanseman DJ, Paquette IM, Sussman JJ, Ahmad SA, Shah SA, Abbott DE. Readmission After Pancreaticoduodenectomy: The Influence of the Volume Effect Beyond Mortality. Ann Surg Oncol 2015; 22:3785-3792. [DOI: 10.1245/s10434-015-4451-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Indexed: 08/30/2023]
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Hoehn RS, Hanseman DJ, Jernigan PL, Wima K, Ertel AE, Abbott DE, Shah SA. Disparities in care for patients with curable hepatocellular carcinoma. HPB (Oxford) 2015; 17:747-52. [PMID: 26278321 PMCID: PMC4557647 DOI: 10.1111/hpb.12427] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 04/13/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND The incidence of hepatocellular carcinoma (HCC) is increasing, but surgical management continues to be underutilized. This retrospective review investigates treatment decisions and survival for early stage HCC. METHODS The National Cancer Database (NCDB) was queried for all patients with curable HCC (Stage I/II) from 1998 to 2011 (n = 43 859). Patient and tumour characteristics were analysed to determine predictors of having surgery and of long-term survival. RESULTS Only 39.7% of patients received surgery for early stage HCC. Surgical therapies included resection (34.6%), transplant (28.7%), radiofrequency ablation (27.1%) and other therapies. Surgery correlated with improved median survival (48.3 versus 8.4 months), but was only performed on 42% of stage I patients and 50% of tumours smaller than 2 cm. Patients were more likely to receive surgery if they were Asian or white race, had private insurance, higher income, better education, or treatment at an academic centre (P < 0.05). However, private insurance and treatment at an academic centre were the only variables associated with improved survival (P < 0.05). CONCLUSION Fewer than half of patients with curable HCC receive surgery, possibly as a result of multiple socioeconomic variables. Past these barriers to care, survival is related to adequate and reliable treatment. Further efforts should address these disparities in treatment decisions.
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Affiliation(s)
- Richard S Hoehn
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Dennis J Hanseman
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Peter L Jernigan
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Koffi Wima
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Audrey E Ertel
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Daniel E Abbott
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Shimul A Shah
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
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Atkinson SJ, Swenson BR, Hanseman DJ, Midura EF, Davis BR, Rafferty JF, Abbott DE, Shah SA, Paquette IM. In the Absence of a Mechanical Bowel Prep, Does the Addition of Pre-Operative Oral Antibiotics to Parental Antibiotics Decrease the Incidence of Surgical Site Infection after Elective Segmental Colectomy? Surg Infect (Larchmt) 2015; 16:728-32. [PMID: 26230616 DOI: 10.1089/sur.2014.215] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Pre-operative oral antibiotics administered the day prior to elective colectomy have been shown to decrease the incidence of surgical site infections (SSI) if a mechanical bowel prep (MBP) is used. Recently, the role for mechanical bowel prep has been challenged as being unnecessary and potentially harmful. We hypothesize that if MBP is omitted, oral antibiotics do not alter the incidence of SSI following colectomy. METHODS We selected patients who underwent an elective segmental colectomy from the 2012 and 2013 National Surgical Quality Improvement Program colectomy procedure targeted database. Indications for surgery included colon cancer, diverticulitis, inflammatory bowel disease, or benign polyp. Patients who received mechanical bowel prep were excluded. The primary outcome measured was surgical site infection, defined as the presence of superficial, deep or, organ space infection within 30 d from surgery. RESULTS A total of 6,399 patients underwent elective segmental colectomy without MBP. The incidence of SSI differed substantially between patients who received oral antibiotics, versus those who did not (9.7% vs. 13.7%, p=0.01). Multivariate analysis indicated that age, smoking status, operative time, perioperative transfusions, oral antibiotics, and surgical approach were associated with post-operative SSI. When controlling for confounding factors, the use of pre-operative oral antibiotics decreased the incidence of surgical site infection (odds ratio=0.66, 95% confidence interval=0.48-0.90, p=0.01). CONCLUSION Even in the absence of mechanical bowel prep, pre-operative oral antibiotics appear to reduce the incidence of surgical site infection following elective colectomy.
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Affiliation(s)
- Sarah J Atkinson
- 1 Department of Surgery, University of Cincinnati College of Medicine , Cincinnati, Ohio.,2 Cincinnati Research on Outcomes and Safety in Surgery (CROSS) , Cincinnati, Ohio
| | - Brian R Swenson
- 3 Mercy Clinic Colon and Rectal Surgery, Springfield, Missouri
| | - Dennis J Hanseman
- 1 Department of Surgery, University of Cincinnati College of Medicine , Cincinnati, Ohio.,2 Cincinnati Research on Outcomes and Safety in Surgery (CROSS) , Cincinnati, Ohio
| | - Emily F Midura
- 1 Department of Surgery, University of Cincinnati College of Medicine , Cincinnati, Ohio.,2 Cincinnati Research on Outcomes and Safety in Surgery (CROSS) , Cincinnati, Ohio
| | - Bradley R Davis
- 1 Department of Surgery, University of Cincinnati College of Medicine , Cincinnati, Ohio.,2 Cincinnati Research on Outcomes and Safety in Surgery (CROSS) , Cincinnati, Ohio
| | - Janice F Rafferty
- 1 Department of Surgery, University of Cincinnati College of Medicine , Cincinnati, Ohio.,2 Cincinnati Research on Outcomes and Safety in Surgery (CROSS) , Cincinnati, Ohio
| | - Daniel E Abbott
- 1 Department of Surgery, University of Cincinnati College of Medicine , Cincinnati, Ohio.,2 Cincinnati Research on Outcomes and Safety in Surgery (CROSS) , Cincinnati, Ohio
| | - Shimul A Shah
- 1 Department of Surgery, University of Cincinnati College of Medicine , Cincinnati, Ohio.,2 Cincinnati Research on Outcomes and Safety in Surgery (CROSS) , Cincinnati, Ohio
| | - Ian M Paquette
- 1 Department of Surgery, University of Cincinnati College of Medicine , Cincinnati, Ohio.,2 Cincinnati Research on Outcomes and Safety in Surgery (CROSS) , Cincinnati, Ohio
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Gaitonde SG, Hanseman DJ, Wima K, Sutton JM, Wilson GC, Sussman JJ, Ahmad SA, Shah SA, Abbott DE. Resource utilization in esophagectomy: When higher costs are associated with worse outcomes. J Surg Oncol 2015; 112:51-5. [DOI: 10.1002/jso.23958] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 06/05/2015] [Indexed: 12/25/2022]
Affiliation(s)
- Shrawan G. Gaitonde
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS); University of Cincinnati; Cincinnati Ohio
| | - Dennis J. Hanseman
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS); University of Cincinnati; Cincinnati Ohio
| | - Koffi Wima
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS); University of Cincinnati; Cincinnati Ohio
| | - Jeffrey M. Sutton
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS); University of Cincinnati; Cincinnati Ohio
| | - Gregory C. Wilson
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS); University of Cincinnati; Cincinnati Ohio
| | - Jeffrey J. Sussman
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS); University of Cincinnati; Cincinnati Ohio
| | - Syed A. Ahmad
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS); University of Cincinnati; Cincinnati Ohio
| | - Shimul A. Shah
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS); University of Cincinnati; Cincinnati Ohio
| | - Daniel E. Abbott
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS); University of Cincinnati; Cincinnati Ohio
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Stahl CC, Wima K, Hanseman DJ, Hoehn RS, Ertel A, Midura EF, Hohmann SF, Paquette IM, Shah SA, Abbott DE. Organ quality metrics are a poor predictor of costs and resource utilization in deceased donor kidney transplantation. Surgery 2015; 158:1635-41. [PMID: 26096564 DOI: 10.1016/j.surg.2015.05.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 05/03/2015] [Accepted: 05/20/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND The desire to provide cost-effective care has lead to an investigation of the costs of therapy for end-stage renal disease. Organ quality metrics are one way to attempt to stratify kidney transplants, although the ability of these metrics to predict costs and resource use is undetermined. METHODS The Scientific Registry of Transplant Recipients database was linked to the University HealthSystem Consortium Database to identify adult deceased donor kidney transplant recipients from 2009 to 2012. Patients were divided into cohorts by kidney criteria (standard vs expanded) or kidney donor profile index (KDPI) score (<85 vs 85+). Length of stay, 30-day readmission, discharge disposition, and delayed graft function were used as indicators of resource use. Cost was defined as reimbursement based on Medicare cost/charge ratios and included the costs of readmission when applicable. RESULTS More than 19,500 patients populated the final dataset. Lower-quality kidneys (expanded criteria donor or KDPI 85+) were more likely to be transplanted in older (both P < .001) and diabetic recipients (both P < .001). After multivariable analysis controlling for recipient characteristics, we found that expanded criteria donor transplants were not associated with increased costs compared with standard criteria donor transplants (risk ratio [RR] 0.97, 95% confidence interval [CI] 0.93-1.00, P = .07). KDPI 85+ was associated with slightly lower costs than KDPI <85 transplants (RR 0.95, 95% CI 0.91-0.99, P = .02). When KDPI was considered as a continuous variable, the association was maintained (RR 0.9993, 95% CI 0.999-0.9998, P = .01). CONCLUSION Organ quality metrics are less influential predictors of short-term costs than recipient factors. Future studies should focus on recipient characteristics as a way to discern high versus low cost transplantation procedures.
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Affiliation(s)
- Christopher C Stahl
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Koffi Wima
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Dennis J Hanseman
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Richard S Hoehn
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Audrey Ertel
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Emily F Midura
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH
| | | | - Ian M Paquette
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Daniel E Abbott
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH.
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Midura EF, Hanseman DJ, Hoehn RS, Davis BR, Abbott DE, Shah SA, Paquette IM. The effect of surgical approach on short-term oncologic outcomes in rectal cancer surgery. Surgery 2015; 158:453-9. [PMID: 25999253 DOI: 10.1016/j.surg.2015.02.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 01/28/2015] [Accepted: 02/15/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although evidence to support the use of laparoscopic and robotic approaches for the treatment of rectal cancer is limited, these approaches are being adopted broadly. We sought to investigate national practice patterns and compare short-term oncologic outcomes of different approaches for rectal cancer resections. METHODS The 2010 National Cancer Database was queried for operative cases of rectal cancer. Approach was classified as open, laparoscopic, or robotic. Patient, tumor, and hospital characteristics and surgical margin status were evaluated. Propensity score matching was used to compare outcomes across approaches. RESULTS We identified 8,712 patients. Laparoscopic and robotic approaches were more common in privately insured and wealthier patients at high-volume centers (P < .001). Open approaches were used for tumors with higher histologic grade and pathologic stage (P < .001). A minimally invasive approach was associated with fewer positive margins and shorter hospital stays. After propensity score matching, the laparoscopic approach was associated with a 2.0% lesser (P = .01) and robotic surgery with a 3.8% lesser (P = .004) incidence of positive margins compared with open surgery. CONCLUSION An open approach is often used in rectal cancers with higher pathologic stages. Matched patient analysis suggests minimally invasive approaches are associated with improved R0 resections.
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Affiliation(s)
- Emily F Midura
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH; Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH
| | - Dennis J Hanseman
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH; Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH
| | - Richard S Hoehn
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH; Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH
| | - Bradley R Davis
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Daniel E Abbott
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH; Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH
| | - Shimul A Shah
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH; Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH
| | - Ian M Paquette
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH; Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH.
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Hoehn RS, Hanseman DJ, Wima K, Ertel AE, Paquette IM, Abbott DE, Shah SA. Does race affect management and survival in hepatocellular carcinoma in the United States? Surgery 2015; 158:1244-51. [PMID: 25958069 DOI: 10.1016/j.surg.2015.03.026] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 03/17/2015] [Accepted: 03/30/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death, and its incidence is increasing in the United States. This analysis describes the association between race, treatment decisions, operative outcomes, and survival for patients with HCC. METHODS The National Cancer Database was queried for all patients diagnosed with HCC from 1998 to 2011 (n = 143,692) who were white (76.9%), black (14.7%), or Asian (8.4%). Multivariate logistic regression was performed to determine factors that affected the likelihood of having surgery and postoperative mortality, and a Cox regression was performed to evaluate the effect of these factors on survival. RESULTS The proportion of black patients with HCC increased in the United States during the 13-year period. There were no substantial differences among races in tumor size, grade, or overall clinical stage at the time of presentation; however, black patients were less likely to have surgery (odds ratio 0.69, 95% confidence interval 0.67-0.72). Of patients who had surgery, there were no significant differences in pathologic stage, margin negative resection rate, or 30-day mortality; however, black patients had the longest interval between diagnosis and surgery, as well as the worst overall adjusted survival (hazard ratio 1.14, 95% confidence interval 1.05-1.25). These findings were independent of HCC stage, insurance provider, and socioeconomic status. CONCLUSION Despite similar clinical presentation of HCC, substantial racial differences exist with regard to management and outcomes. Black patients are less likely to receive surgery for HCC and have worse long-term survival, despite similar perioperative quality metrics. This difference in long-term survival may highlight neighborhood, cultural, or biological differences between races.
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Affiliation(s)
- Richard S Hoehn
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Dennis J Hanseman
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Koffi Wima
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Audrey E Ertel
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Ian M Paquette
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Daniel E Abbott
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH.
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Gozal YM, Farley CW, Hanseman DJ, Harwell D, Magner M, Andaluz N, Shutter L. Ventriculostomy-associated infection: a new, standardized reporting definition and institutional experience. Neurocrit Care 2015; 21:147-51. [PMID: 24343563 DOI: 10.1007/s12028-013-9936-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Shortcomings created by the lack of both a uniform definition of ventriculostomy-associated infection (VAI) and reporting standards have led to widely ranging infections rates (2-24%) whose significance is uncertain. We propose a standardized definition of VAI and a consistent reporting format compliant with Centers for Disease Control and Prevention (CDC) for device-related infections. Using those parameters to establish an infection-control surveillance program, we report our 4-year institutional VAI rates. METHODS In this prospective study covering ventriculostomy utilization (October 2006-December 2010), 498 patients had a total of 4,673 ventriculostomy days. By review of the literature and our institutional analysis, we defined VAI as a positive CSF culture in a patient with ventriculostomy catheter, plus one or more of the following (1) fever recorded >101.5 °F or (2) cerebrospinal fluid (CSF) glucose level, either <50 mg/dL or <50% of a serum glucose level drawn within 24 h of the CSF glucose. In a report format that is CDC compliant, rates of VAI are reported. RESULTS Among our patients, the CDC-compliant infection rate was 2.14 per 1,000 ventriculostomy days. Of the 10 VAIs occurring in 498 patients during 4,673 ventriculostomy days, this 2.0% infection rate was lower than the previously reported 8.8% composite rates of VAI. Average duration of ventriculostomy was 9.4 days. Neither antibiotic-impregnated catheters nor periprocedural or prophylactic antibiotics were used. CONCLUSIONS Our standardized VAI definition and CDC format seems promising toward facilitating future study and guideline development. Given our strict protocol of sterile catheter placement and care, and our institution's low 2.0% infection rates, we propose an infection-rate target of ≤5 per 1,000 device days. Our results suggest that the use of antibiotics or antibiotic-impregnated catheters is unwarranted--a positive given concerns of evolving anti-microbial resistance.
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Affiliation(s)
- Yair M Gozal
- Department of Neurosurgery, University of Cincinnati College of Medicine, ML 0515, Cincinnati, OH, 45267-0515, USA
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Wilson GC, Quillin RC, Wima K, Sutton JM, Hoehn RS, Hanseman DJ, Paquette IM, Paterno F, Woodle ES, Abbott DE, Shah SA. Is liver transplantation safe and effective in elderly (≥70 years) recipients? A case-controlled analysis. HPB (Oxford) 2014; 16:1088-94. [PMID: 25099347 PMCID: PMC4253332 DOI: 10.1111/hpb.12312] [Citation(s) in RCA: 44] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 06/02/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Elderly patients are evaluated for liver transplantation (LT) with increasing frequency, but outcomes in this group have not been well defined. METHODS A linkage of the Scientific Registry of Transplant Recipients (SRTR) and the University HealthSystem Consortium (UHC) databases identified 12,445 patients who underwent LT during 2007-2011. Two cohorts were created consisting of, respectively, elderly recipients aged ≥70 years (n = 323) and recipients aged 18-69 years (n = 12,122). A 1:1 case-matched analysis was performed based on propensity scores. RESULTS Elderly recipients had lower Model for End-stage Liver Disease (MELD) scores at LT (median 15 versus 19; P < 0.0001), more often underwent transplantation at high-volume centres (46% versus 33%; P < 0.0001) and more often received grafts from donors aged >60 years (24% versus 15%; P < 0.0001). The two cohorts had similar hospital lengths of stay, in-hospital mortality, hospital costs and 30-day readmission rates. There were no differences in graft survival between the two cohorts (P = 0.10), but elderly recipients had worse longterm overall survival (P = 0.009). However, a case-controlled analysis confirmed similar perioperative hospital outcomes, graft survival and longterm patient survival in the two matched cohorts. CONCLUSIONS Elderly LT recipients accounted for <3% of all LTs performed during 2007-2011. Selected elderly recipients have perioperative outcomes and survival similar to those in younger adults.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Shimul A Shah
- Correspondence Shimul A. Shah, Division of Transplant Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, MSB 2006C, Cincinnati, OH 45267-0558, USA. Tel: + 1 513 558 3993. Fax: + 1 513 558 8689. E-mail:
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Sutton JM, Wilson GC, Paquette IM, Wima K, Hanseman DJ, Quillin RC, Sussman JJ, Edwards MJ, Ahmad SA, Shah SA, Abbott DE. Cost effectiveness after a pancreaticoduodenectomy: bolstering the volume argument. HPB (Oxford) 2014; 16:1056-61. [PMID: 25041104 PMCID: PMC4253327 DOI: 10.1111/hpb.12309] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [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] [Received: 03/05/2014] [Accepted: 06/02/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND The cost implication of variability in pancreatic surgery is not well described. It was hypothesized that for a pancreaticoduodenectomy (PD), lower volume centres demonstrate worse peri-operative outcomes at higher costs. METHODS From 2009-2011, 9883 patients undergoing a PD were identified from the University HealthSystems Consortium (UHC) database and stratified into quintiles by annual hospital case volume. A decision analytic model was constructed to assess cost effectiveness. Total direct cost data were based on Medicare cost/charge ratios and included readmission costs when applicable. RESULTS The lowest volume centres demonstrated a higher peri-operative mortality rate (3.5% versus 1.3%, P < 0.001) compared with the highest volume centres. When both index and readmission costs were considered, the per-patient total direct cost at the lowest volume centres was $23,005, or 10.9% (i.e. $2263 per case) more than at the highest volume centres. One-way sensitivity analyses adjusting for peri-operative mortality (1.3% at all centres) did not materially change the cost effectiveness analysis. Differences in cost were largely recognized in the index admission; readmission costs were similar across quintiles. CONCLUSIONS For PD, low volume centres have higher peri-operative mortality rates and 10.9% higher cost per patient. Performance of PD at higher volume centres can lead to both better outcomes and substantial cost savings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Daniel E Abbott
- Correspondence Daniel E. Abbott, Division of Surgical Oncology, Department of Surgery, University of Cincinnati Medical Center, 234 Goodman Street, ML 0772, Cincinnati, OH 45219, USA. Tel: +1 513 584 8900. Fax: +1 513 584 0459. E-mail:
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Fisher AV, Sutton JM, Wilson GC, Hanseman DJ, Abbott DE, Smith MT, Schmulewitz N, Choe KA, Wang J, Sussman JJ, Ahmad SA. High readmission rates after surgery for chronic pancreatitis. Surgery 2014; 156:787-94. [PMID: 25239319 DOI: 10.1016/j.surg.2014.06.068] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 06/26/2014] [Indexed: 01/02/2023]
Abstract
BACKGROUND Readmission after complex gastrointestinal surgery is a frequent occurrence that burdens the health care system and leads to increased cost. Recent studies have demonstrated 30- and 90-day readmission rates of 15% and 19%, respectively, following pancreaticoduodenectomy. Given the psychosocial issues often associated with chronic pancreatitis, we hypothesized that readmission rates following surgery for chronic pancreatitis would be higher than previously reported for pancreaticoduodenectomy. METHODS We retrospectively reviewed patients undergoing surgery for chronic pancreatitis at a single institution between 2001 and 2013. Patients in this cohort underwent pancreaticoduodenectomy, Berne, Beger, or Frey procedures. Readmission to a primary or secondary hospital was evaluated at both 30 and 90 days after discharge. Multivariate logistic regression analysis was performed to identify factors associated with readmission. RESULTS The records of 111 patients were evaluated, of which 69 (62%) underwent duodenal-preserving pancreatic head resection (Berne, Beger, or Frey), while the remaining 42 (38%) underwent pancreaticoduodenectomy. Within the duodenal-preserving pancreatic head resection arm, readmission rates at 30 and 90 days were 30.4% and 43.5%, respectively. Readmission rates following pancreaticoduodenectomy were similar with 33.3% at 30 days and 40.5% at 90 days. The most common reasons for readmission were pain control, infectious complications, and recurrent pancreatitis. On multivariate analysis, wound infection during the initial hospital stay was a predictor of readmission at both 30 and 90 days (P = .02). CONCLUSION To our knowledge, our data represent the first report demonstrating very high readmission rates after surgery for chronic pancreatitis, more than double the previous rates reported for pancreaticoduodenectomy. This cohort of patients requires extensive discharge planning focused on pain control, nutritional optimization, and close postoperative monitoring.
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Affiliation(s)
- Alexander V Fisher
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Jeffrey M Sutton
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Gregory C Wilson
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Dennis J Hanseman
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Daniel E Abbott
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Milton T Smith
- Department of Gastroenterology, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Nathan Schmulewitz
- Department of Gastroenterology, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Kyran A Choe
- Department of Radiology, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Jiang Wang
- Department of Pathology, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Jeffrey J Sussman
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH.
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Robinson BRH, Pritts TA, Hanseman DJ, Wilson GC, Abbott DE. Cost discrepancies for common acute care surgery diagnoses in Ohio: influences of hospital characteristics on charge and payment differences. Surgery 2014; 156:814-22. [PMID: 25239325 DOI: 10.1016/j.surg.2014.06.071] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 06/27/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Charge and payment discrepancies exist between hospitals, although such variation is understood incompletely. We hypothesized that hospital characteristics may account for such differences. METHODS The 2011 Medicare Inpatient Prospective Payment System for Ohio hospitals was queried for discharge diagnoses of gastrointestinal bleed (GIB), GI obstruction (GIO), and laparoscopic cholecystectomy (LC). Analyses were performed to assess the association of hospital variables with charges and payments. RESULTS For all three diagnoses, urban hospitals had greater median charges than rural hospitals; payments were not significantly different. Consequently, urban centers had lesser cost to charge ratios than rural centers for GIB, GIO, and LC: 0.29 versus 0.32 (P = .004), 0.27 versus 0.47 (P = .0007), and 0.26 versus 0.40 (P = .04), respectively. Centers with the greatest bed size had higher median charges and payments. Other discrepancies for all three diagnoses were greater payments at verified Level 1 centers and major teaching institutions (P value range <.0001 to .03). On multivariate analysis, excess charges were greater at urban centers for both GIB ($4,482, P = .02) and GIO ($5,700, P < .01). CONCLUSION Hospital characteristics are associated with differences in charges and payments for acute care surgery diagnoses. Further study should investigate whether these cost discrepancies are associated with outcomes.
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Affiliation(s)
- Bryce R H Robinson
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.
| | - Timothy A Pritts
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Dennis J Hanseman
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Gregory C Wilson
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Daniel E Abbott
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
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Quillin RC, Wilson GC, Sutton JM, Hanseman DJ, Paterno F, Cuffy MC, Paquette IM, Diwan TS, Woodle ES, Abbott DE, Shah SA. Increasing prevalence of nonalcoholic steatohepatitis as an indication for liver transplantation. Surgery 2014; 156:1049-56. [PMID: 25239365 DOI: 10.1016/j.surg.2014.06.075] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 06/27/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND In Ohio, the obesity rate has increased from 21.5% in 2000 to 30.1% in 2012. Nonalcoholic steatohepatitis is believed to be increasing as an indication for orthotopic liver transplantation. METHODS We evaluated the diagnosis of nonalcoholic steatohepatitis as an indication for orthotopic liver transplantation and ensuing outcomes relative to other common hepatic diseases requiring orthotopic liver transplantation in Ohio. We queried 2,356 patients with nonalcoholic steatohepatitis, alcoholic cirrhosis (ETOH), and hepatitis C cirrhosis from the Ohio Solid Organ Transplantation Consortium who were listed for and/or received an orthotopic liver transplant from 2000 to 2012. RESULTS The proportion of listed patients with nonalcoholic steatohepatitis increased from 0% to 26% and the proportion of transplanted patients increased from 0% to 23.4%. Compared with patients with hepatitis C and ETOH, patients with nonalcoholic steatohepatitis were older, and more likely to be white, and have private insurance (P < .05 for each). There was no difference in median waiting time among patients with nonalcoholic steatohepatitis, hepatitis C, and ETOH (P = .18) and Model for End-Stage Liver Disease scores at orthotopic liver transplantation among patients with nonalcoholic steatohepatitis, hepatitis C (P = .48), and ETOH (P = .27). Patient and graft survival after orthotopic liver transplantation was comparable between patients with nonalcoholic steatohepatitis and ETOH (P = .79 and P = .86, respectively); however, patients with nonalcoholic steatohepatitis had better patient and graft survival compared with patients with hepatitis C after orthotopic liver transplantation (P < .01 and P = .02, respectively). Additionally, body mass index had no influence on overall or graft survival for patients with nonalcoholic steatohepatitis undergoing orthotopic liver transplantation. CONCLUSION This study reflects the growing potential for transplantation in patients with fatty liver disease and suggests the outcomes are equivalent or superior to other common indications for orthotopic liver transplantation.
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Affiliation(s)
- R Cutler Quillin
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Gregory C Wilson
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Jeffrey M Sutton
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Dennis J Hanseman
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Flavio Paterno
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Madison C Cuffy
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Ian M Paquette
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Tayyab S Diwan
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - E Steve Woodle
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Daniel E Abbott
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH.
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Stahl CC, Hanseman DJ, Wima K, Sutton JM, Wilson GC, Hohmann SF, Shah SA, Abbott DE. Increasing age is a predictor of short-term outcomes in esophagectomy: a propensity score adjusted analysis. J Gastrointest Surg 2014; 18:1423-8. [PMID: 24866369 PMCID: PMC7065666 DOI: 10.1007/s11605-014-2544-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [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] [Received: 04/07/2014] [Accepted: 05/13/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Esophagectomy is a high-risk surgical procedure. As the population ages, more elderly candidates are being evaluated for esophagectomy. The effects of patient age on outcomes after esophagectomy need to be evaluated. STUDY DESIGN We identified all nonemergent esophagectomies in patients at least 18 years of age within the University HealthSystems Consortium Clinical Database/Resource Manager from 2009 to 2012. Using univariate and multivariate methods, the impact of increasing age on outcomes was analyzed. Additionally, propensity scoring was used to match patients to further investigate the effect of age on the stated outcomes. RESULTS Increasing age is associated with increased mortality (p < 0.001), length of stay (p < 0.001), discharge to rehabilitative care (p < 0.001), and cost (p < 0.001). The effects of age on mortality (8.0 vs 4.2 %, p = 0.03) and discharge to rehabilitative care (44.1 vs 23.4 %, p < 0.01) were confirmed using propensity scoring, comparing patients above 80 with those age 70-79. CONCLUSIONS Increasing age has a significant impact on outcomes following esophagectomy, particularly mortality and discharge disposition. Compared to patients under age 80, patients at least 80 years of age considering esophagectomy should be recognized as a high-risk cohort, and these patients must be carefully risk-stratified, counseled, and selected for surgical intervention to prevent unnecessary hospitalization and mortality.
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Affiliation(s)
- Christopher C. Stahl
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, 234 Goodman St, ML 0772, Cincinnati, OH 45219, USA
| | - Dennis J. Hanseman
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, 234 Goodman St, ML 0772, Cincinnati, OH 45219, USA
| | - Koffi Wima
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, 234 Goodman St, ML 0772, Cincinnati, OH 45219, USA
| | - Jeffrey M. Sutton
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, 234 Goodman St, ML 0772, Cincinnati, OH 45219, USA
| | - Gregory C. Wilson
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, 234 Goodman St, ML 0772, Cincinnati, OH 45219, USA
| | | | - Shimul A. Shah
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, 234 Goodman St, ML 0772, Cincinnati, OH 45219, USA
| | - Daniel E. Abbott
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, 234 Goodman St, ML 0772, Cincinnati, OH 45219, USA
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Serrone JC, Jimenez L, Hanseman DJ, Carroll CP, Grossman AW, Wang L, Vagal A, Choutka O, Andaluz N, Ringer AJ, Abruzzo T, Zuccarello M. Changes in computed tomography perfusion parameters after superficial temporal artery to middle cerebral artery bypass: an analysis of 29 cases. J Neurol Surg B Skull Base 2014; 75:371-7. [PMID: 25452893 DOI: 10.1055/s-0034-1373658] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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: 12/31/2013] [Accepted: 02/23/2014] [Indexed: 10/25/2022] Open
Abstract
Introduction Analysis of computed tomography perfusion (CTP) studies before and after superficial temporal artery to middle cerebral artery (STA-MCA) bypass is warranted to better understand cerebral steno-occlusive pathology. Methods Retrospective review was performed of STA-MCA bypass patients with steno-occlusive disease with CTP before and after surgery. CTP parameters were evaluated for change after STA-MCA bypass. Results A total of 29 hemispheres were bypassed in 23 patients. After STA-MCA bypass, mean transit time (MTT) and time to peak (TTP) improved. When analyzed as a ratio to the contralateral hemisphere, MTT, TTP, and cerebral blood flow (CBF) improved. There was no effect of gender, double vessel versus single vessel bypass, or time until postoperative CTP study to changes in CTP parameters after bypass. Conclusions Blood flow augmentation after STA-MCA bypass may best be assessed by CTP using baseline MTT or TTP and ratios of MTT, TTP, or CBF to the contralateral hemisphere. The failure of cerebrovascular reserve to improve after cerebral bypass may indicate irreversible loss of autoregulation with chronic cerebral vasodilation or the inability of CTP to detect these improvements.
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Affiliation(s)
- Joseph C Serrone
- Departments of Neurosurgery, UC College of Medicine, Cincinnati, Ohio, United States
| | - Lincoln Jimenez
- Departments of Neurosurgery, UC College of Medicine, Cincinnati, Ohio, United States
| | - Dennis J Hanseman
- Department of Surgery, Division of Trauma/Critical Care, University of Cincinnati, Cincinnati, Ohio, United States
| | - Christopher P Carroll
- Departments of Neurosurgery, UC College of Medicine, Cincinnati, Ohio, United States
| | - Aaron W Grossman
- Departments of Neurosurgery, UC College of Medicine, Cincinnati, Ohio, United States ; Comprehensive Stroke Center at the UC Neuroscience Institute, Cincinnati, Ohio, United States
| | - Lily Wang
- Department Radiology, University of Cincinnati, Ohio, United States
| | - Achala Vagal
- Department Radiology, University of Cincinnati, Ohio, United States
| | - Ondrej Choutka
- Departments of Neurosurgery, UC College of Medicine, Cincinnati, Ohio, United States
| | - Norberto Andaluz
- Departments of Neurosurgery, UC College of Medicine, Cincinnati, Ohio, United States ; Comprehensive Stroke Center at the UC Neuroscience Institute, Cincinnati, Ohio, United States ; Mayfield Clinic, Cincinnati, Ohio, United States
| | - Andrew J Ringer
- Departments of Neurosurgery, UC College of Medicine, Cincinnati, Ohio, United States ; Comprehensive Stroke Center at the UC Neuroscience Institute, Cincinnati, Ohio, United States ; Mayfield Clinic, Cincinnati, Ohio, United States
| | - Todd Abruzzo
- Departments of Neurosurgery, UC College of Medicine, Cincinnati, Ohio, United States ; Comprehensive Stroke Center at the UC Neuroscience Institute, Cincinnati, Ohio, United States ; Department Radiology, University of Cincinnati, Ohio, United States ; Mayfield Clinic, Cincinnati, Ohio, United States
| | - Mario Zuccarello
- Departments of Neurosurgery, UC College of Medicine, Cincinnati, Ohio, United States ; Comprehensive Stroke Center at the UC Neuroscience Institute, Cincinnati, Ohio, United States ; Mayfield Clinic, Cincinnati, Ohio, United States
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