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Harris AHS, Finlay AK, Hagedorn HJ, Manfredi L, Jones G, Kamal RN, Sears ED, Hawn M, Eisenberg D, Pershing S, Mudumbai S. Identifying Strategies to Reduce Low-Value Preoperative Testing for Low-Risk Procedures: a Qualitative Study of Facilities with High or Recently Improved Levels of Testing. J Gen Intern Med 2023; 38:3209-3215. [PMID: 37407767 PMCID: PMC10651557 DOI: 10.1007/s11606-023-08287-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 06/14/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Healthcare agencies and perioperative professional organizations recommend avoiding preoperative screening tests for low-risk surgical procedures. However, low-value preoperative tests are still commonly ordered even for generally healthy patients and active strategies to reduce this testing have not been adequately described. OBJECTIVE We sought to learn from hospitals with either high levels of testing or that had recently reduced use of low-value screening tests (aka "delta sites") about reasons for testing and active deimplementation strategies they used to effectively improve practice. DESIGN Qualitative study of semi-structured telephone interviews. PARTICIPANTS We identified facilities in the US Veterans Health Administration (VHA) with high or recently improved burden of potentially low-value preoperative testing for carpal tunnel release and cataract surgery. We recruited perioperative clinicians to participate. APPROACH Questions focused on reasons to order preoperative screening tests for patients undergoing low-risk surgery and, more importantly, what strategies had been successfully used to reduce testing. A framework method was used to identify common improvement strategies and specific care delivery innovations. KEY RESULTS Thirty-five perioperative clinicians (e.g., hand surgeons, ophthalmologists, anesthesiologists, primary care providers, directors of preoperative clinics, nurses) from 29 VHA facilities participated. Facilities that successfully reduced the burden of low-value testing shared many improvement strategies (e.g., building consensus among stakeholders; using evidence/norm-based education and persuasion; clarifying responsibility for ordering tests) to implement different care delivery innovations (e.g., pre-screening to decide if a preop clinic evaluation is necessary; establishing a dedicated preop clinic for low-risk procedures). CONCLUSIONS We identified a menu of common improvement strategies and specific care delivery innovations that might be helpful for institutions trying to design their own quality improvement programs to reduce low-value preoperative testing given their unique structure, resources, and constraints.
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Affiliation(s)
- Alex H S Harris
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA.
- Stanford -Surgical Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - Andrea K Finlay
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
| | - Hildi J Hagedorn
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Luisa Manfredi
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
| | - Gabrielle Jones
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
| | - Robin N Kamal
- Department of Orthopedic Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Erika D Sears
- Center for Clinical Management Research, VA Ann Arbor Health Care System , Ann Arbor, MI, USA
- University of Michigan Department of Surgery, Ann Arbor, MI, USA
| | - Mary Hawn
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
- Stanford -Surgical Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Dan Eisenberg
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
- Stanford -Surgical Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Suzann Pershing
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
- Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Seshadri Mudumbai
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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Hawn M. Lessons learned from Dr. Kirby Bland. Am J Surg 2023; 226:312. [PMID: 37344252 DOI: 10.1016/j.amjsurg.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/02/2023] [Indexed: 06/23/2023]
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Triadafilopoulos G, Mashimo H, Tatum R, O'Clarke J, Hawn M. Mixed Esophageal Disease (MED): A New Concept. Dig Dis Sci 2023; 68:3542-3554. [PMID: 37470896 DOI: 10.1007/s10620-023-08008-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 06/15/2023] [Indexed: 07/21/2023]
Abstract
We define mixed esophageal disease (MED) as a disorder of esophageal structure and/or function that produces variable signs or symptoms, simulating-fully or in part other well-defined esophageal conditions, such as gastroesophageal reflux disease, esophageal motility disorders, or even neoplasia. The central premise of the MED concept is that of an overlap syndrome that incorporates selected clinical, endoscopic, imaging, and functional features that alter the patient's quality of life and affect natural history, prognosis, and management. In this article, we highlight MED scenarios frequently encountered in medico-surgical practices worldwide, posing new diagnostic and therapeutic challenges. These, in turn, emphasize the need for better understanding and management, aiming towards improved outcomes and prognosis. Since MED has variable and sometimes time-evolving clinical phenotypes, it deserves proper recognition, definition, and collaborative, multidisciplinary approach, be it pharmacologic, endoscopic, or surgical, to optimize therapeutic outcomes, while minimizing iatrogenic complications. In this regard, it is best to define MED early in the process, preferably by teams of clinicians with expertise in managing esophageal diseases. MED is complex enough that is increasingly becoming the subject of virtual, multi-disciplinary, multi-institutional meetings.
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Affiliation(s)
- George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, 94305, USA.
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway Street 3rd floor, MC6341, Redwood City, CA, 94063, USA.
| | - Hiroshi Mashimo
- Section of Gastroenterology, Harvard Medical School, VA Boston Healthcare - Roxbury, 1400 VFW Pkwy, West Roxbury, MA, 02132, USA
| | - Roger Tatum
- Department of General Surgery, University of Washington, 1660 S. Columbian Way, Seattle, WA, 98108, USA
| | - John O'Clarke
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Mary Hawn
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, 94305, USA
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Harris AHS, Bowe T, Kamal RN, Sears ED, Hawn M, Eisenberg D, Finlay AK, Hagedorn HJ, Mudumbai S. Frequency and costs of low-value preoperative tests for patients undergoing low-risk procedures in the veterans health administration. Perioper Med (Lond) 2022; 11:33. [PMID: 36096937 PMCID: PMC9469517 DOI: 10.1186/s13741-022-00265-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical practice guidelines discourage routine preoperative screening tests for patients undergoing low-risk procedures. This study sought to determine the frequency and costs of potentially low-value preoperative screening tests in Veterans Health Administration (VA) patients undergoing low-risk procedures. METHODS Using the VA Corporate Data Warehouse, we identified Operative Stress Score class 1 procedures ("very minor") performed without general anesthesia in VA during fiscal year 2019 and calculated the overall national and facility-level rates and costs of nine common tests received in the 30 preoperative days. Patient factors associated with receiving at least one screening test, and the number of tests received, were examined. RESULTS Eighty-six thousand three hundred twenty-seven of 178,775 low-risk procedures (49.3%) were preceded by 321,917 potentially low-value screening tests representing $11,505,170 using Medicare average costs. Complete blood count was the most common (33.2% of procedures), followed by basic metabolic profile (32.0%), urinalysis (26.3%), electrocardiography (18.9%), and pulmonary function test (12.4%). Older age, female sex, Black race, and having more comorbidities were associated with higher odds of low-value testing. Transthoracic echocardiogram occurred prior to only 4.5% of the procedures but accounted for 47.8% of the total costs ($5,499,860). In 129 VA facilities, the facility-level proportion of procedures preceded by at least one test ranged from 0 to 81.2% and facility-level costs ranged from $0 to $388,476. CONCLUSIONS Routine preoperative screening tests for very low-risk procedures are common and costly in some VA facilities. These results highlight a potential target to improve quality and value by reducing unnecessary care. Measures of low-value perioperative care could be integrated into VA's extensive quality monitoring and improvement infrastructure.
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Affiliation(s)
- Alex H S Harris
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, USA.
- Stanford -Surgical Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Palo Alto, USA.
| | - Thomas Bowe
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, USA
| | - Robin N Kamal
- Department of Orthopedic Surgery, Stanford University School of Medicine, Palo Alto, USA
| | - Erika D Sears
- Center for Clinical Management Research, VA Ann Arbor Health Care System, Michigan Medicine Department of Surgery, Ann Arbor, USA
| | - Mary Hawn
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, USA
- Stanford -Surgical Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Palo Alto, USA
| | - Dan Eisenberg
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, USA
- Stanford -Surgical Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Palo Alto, USA
| | - Andrea K Finlay
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, USA
| | - Hildi J Hagedorn
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Medical Center, Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, USA
| | - Seshadri Mudumbai
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, USA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, USA
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Branch-Elliman W, Elwy AR, Lamkin RL, Shin M, Engle RL, Colborn K, Rove J, Pendergast J, Hederstedt K, Hawn M, Mull HJ. Assessing the sustainability of compliance with surgical site infection prophylaxis after discontinuation of mandatory active reporting: study protocol. Implement Sci Commun 2022; 3:47. [PMID: 35468871 PMCID: PMC9036843 DOI: 10.1186/s43058-022-00288-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 03/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Surgical site infections are common. Risk can be reduced substantially with appropriate preoperative antimicrobial administration. In 2005, the VA implemented the Surgical Care Improvement Project (SCIP) in the setting of high rates of non-compliance with antimicrobial prophylaxis guidelines. SCIP included public reporting of evidenced-based antimicrobial guideline compliance metrics in high-risk surgeries. SCIP was highly successful and led to high rates of adoption of preoperative antimicrobials and early discontinuation of postoperative antimicrobials (>95%). The program was retired in 2015, as the manual measurement and reporting process was costly with limited expected additional benefit. To our knowledge, no studies have assessed whether the gains achieved by SCIP were sustained since active support for the program was discontinued. Furthermore, there has been no investigation of the spread of antimicrobial prophylaxis guideline adoption beyond the limited set of procedures that were included in the program. METHODS Using a mixed methods sequential exploratory approach, this study will (1) quantitatively measure compliance with SCIP metrics over time and across all procedures in the five major surgical specialties targeted by SCIP and (2) collect qualitative data from stakeholders to identify strategies that were effective for sustaining compliance. Diffusion of Innovation Theory will guide assessment of whether improvements achieved spread to procedures not included under the umbrella of the program. Electronic algorithms to measure SCIP antimicrobial use will be adapted from previously developed methodology. These highly novel data mining algorithms leverage the rich VA electronic health record and capture structured and text data and represent a substantial technological advancement over resource-intensive manual chart review or incomplete electronic surveillance based on pharmacy data. An interrupted time series analysis will be used to assess whether SCIP compliance was sustained following program discontinuation. Generalized linear models will be used to assess whether compliance with appropriate prophylaxis increased in all SCIP targeted and non-targeted procedures by specialty over the duration the program's active reporting. The Dynamic Sustainability Framework will guide the qualitative methods to assess intervention, provider, facility, specialty, and contextual factors associated with sustainability over time. Barriers and facilitators to sustainability will be mapped to implementation strategies and the study will yield an implementation playbook to guide future sustainment efforts. RELEVANCE Sustainability of practice change has been described as one of the most important, but least studied areas of clinical medicine. Learning how practices spread is also a critically important area of investigation. This study will use novel informatics strategies to evaluate factors associated with sustainability following removal of active policy surveillance and advance our understanding about these important, yet understudied, areas.
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Affiliation(s)
- Westyn Branch-Elliman
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, USA.
- Department of Medicine, Infectious Disease Section, VA Boston Healthcare System, Boston, USA.
- Harvard Medical School, Boston, USA.
- Department of Medicine, Section of Infectious Diseases, VA Boston Healthcare System, 1400 VFW Parkway, West Roxbury, MB, 02132, USA.
| | - A Rani Elwy
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, USA
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, USA
| | - Rebecca L Lamkin
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, USA
| | - Marlena Shin
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, USA
| | - Ryann L Engle
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, USA
| | - Kathryn Colborn
- Eastern Colorado VA Healthcare System, Aurora, USA
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Jessica Rove
- Eastern Colorado VA Healthcare System, Aurora, USA
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Jacquelyn Pendergast
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, USA
| | - Kierstin Hederstedt
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, USA
| | - Mary Hawn
- Department of Surgery, Stanford University School of Medicine, Stanford, USA
| | - Hillary J Mull
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, USA
- Department of Surgery, Boston University School of Medicine, Boston, USA
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Abdullah F, Ghomrawi HMK, Hawn M. Board Certification - A Remnant of Days Past or Reflection of a Commitment to Lifelong Learning and Professionalism? Ann Surg 2021; 274:227-228. [PMID: 33856376 DOI: 10.1097/sla.0000000000004881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Fizan Abdullah
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.,Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL.,Center for Health Services and Outcomes Research, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Hassan M K Ghomrawi
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL.,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL.,Center for Health Services and Outcomes Research, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Mary Hawn
- Department of Surgery, Stanford University, Stanford, CA
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Titan A, Doyle A, Pfaff K, Baiu I, Lee A, Graham L, Shelton A, Hawn M. Impact of policy-based and institutional interventions on postoperative opioid prescribing practices. Am J Surg 2021; 222:766-772. [PMID: 33593614 DOI: 10.1016/j.amjsurg.2021.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/26/2021] [Accepted: 02/05/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND We assessed the impact of policy-based and institutional interventions to limit postoperative opioid prescribing. METHODS Retrospective cohort study of patients who underwent laparoscopic/open appendectomies, laparoscopic/open cholecystectomies, and laparoscopic/open inguinal hernia repair during a 6-month interval in 2018 (control), 2019 (post-policy intervention), and 2020 (post-institutional intervention) to assess changes in postoperative opioid prescribing patterns. A survey was collected for the 2020 cohort. RESULTS Comparing the 762 patients identified in 2018, 2019, and 2020 cohorts there was a significant decrease in mean opioid tabs prescribed (23.5 ± 8.9 vs. 16.2 ± 7.0 vs. 12.8 ± 4.9, p < 0.01) and mean OME dosage (148.0 ± 68.0 vs. 108.6 ± 51.8 vs. 95.4 ± 38.0, p < 0.01), without a difference in refill requests. Patient survey (response rate 63%) indicated 91.4% of patients reported sufficient pain control. CONCLUSION Formalized opioid-prescribing guidelines and statewide regulations can significantly decrease postoperative opioid prescribing with good patient satisfaction. Surgeon education may facilitate efforts to minimize narcotic over-prescription without compromising pain management.
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Affiliation(s)
- Ashley Titan
- Department of Surgery, Stanford University Hospital, Stanford, CA, USA
| | - Alexis Doyle
- Department of Surgery, Stanford University Hospital, Stanford, CA, USA
| | - Kayla Pfaff
- Department of Surgery, Stanford University Hospital, Stanford, CA, USA
| | - Ioana Baiu
- Department of Surgery, Stanford University Hospital, Stanford, CA, USA
| | - Angela Lee
- Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Laura Graham
- Department of Surgery, Stanford University Hospital, Stanford, CA, USA
| | - Andrew Shelton
- Department of Surgery, Stanford University Hospital, Stanford, CA, USA
| | - Mary Hawn
- Department of Surgery, Stanford University Hospital, Stanford, CA, USA.
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Shanafelt TD, Wang H, Leonard M, Hawn M, McKenna Q, Majzun R, Minor L, Trockel M. Assessment of the Association of Leadership Behaviors of Supervising Physicians With Personal-Organizational Values Alignment Among Staff Physicians. JAMA Netw Open 2021; 4:e2035622. [PMID: 33560424 PMCID: PMC7873777 DOI: 10.1001/jamanetworkopen.2020.35622] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Although misalignment of values between physicians and their organization is associated with increased risk of burnout, actionable organizational factors that contribute to perceived values alignment are poorly understood. OBJECTIVE To evaluate the association between the leadership behaviors of immediate supervisors and physicians' perception of personal-organizational values alignment. DESIGN, SETTING, AND PARTICIPANTS This survey study of faculty physicians and physician leaders at Stanford University School of Medicine was conducted from April 1 to May 13, 2019. The survey included assessments of perceived personal-organizational values alignment, professional fulfillment, and burnout. Physicians also evaluated the leadership behaviors of their immediate supervisor (eg, division chief) using a standardized assessment. Data analysis was performed from May to December 2020. MAIN OUTCOMES AND MEASURES Association between mean leadership behavior score (range, 0-10) of each supervisor and the mean personal-organizational values alignment scores (range, 0-12) for the physicians in their work unit. RESULTS Of 1924 physicians eligible to participate, 1285 (67%) returned surveys. Among these, 651 (51%) were women and 729 (57%) were aged 40 years or older. Among the 117 physician leaders evaluated, 66 (56%) had their leadership behavior independently evaluated by at least 5 physicians and were included in analyses. The mean (SD) personal-organizational values alignment score on the 0 to 12 scale was 6.19 (3.21). As the proportion of work effort devoted to clinical care increased, values alignment scores decreased. Personal-organizational values alignment scores demonstrated an inverse correlation with burnout (r = -0.39; P < .001) and a positive correlation with professional fulfillment (r = 0.52; P < .001). The aggregate leader behavior score of the 66 leaders evaluated correlated with the mean values alignment score for physicians in their work unit (r = 0.53; P < .001). Aggregate leader behavior score was associated with 21.6% of the variation in personal-organizational values alignment scores between work units. After adjusting for age, gender, academic rank, work hours, physician-leader gender concordance, and time devoted to clinical care, each 1-point increase in leadership score of immediate supervisor was associated with a 0.56-point (95% CI, 0.46-0.66; P < .001) increase in personal-organizational values alignment score. CONCLUSIONS AND RELEVANCE This survey study's results suggest that physicians experience their organization through the prism of their work unit leader. Organizational efforts to improve values alignment should attend to the development of first-line physician leaders.
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Affiliation(s)
- Tait D. Shanafelt
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Hanhan Wang
- WellMD Center, Stanford University School of Medicine, Stanford, California
| | - Mary Leonard
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Mary Hawn
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Quinn McKenna
- Stanford Health Care, Stanford Medicine, Stanford, California
| | - Rick Majzun
- Stanford Children's Health/Lucile Packard Children's Hospital, Stanford Medicine, Stanford, California
| | - Lloyd Minor
- Department of Otolaryngology, Stanford University School of Medicine, Stanford, California
| | - Mickey Trockel
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
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Frush K, Lee G, Wald SH, Hawn M, Krna C, Holubar M, Beatty D, Chawla A, Pinsky BA, Schilling L, Maldonado Y. Navigating the Covid-19 Pandemic by Caring for Our Health Care Workforce as They Care for Our Patients. NEJM Catalyst 2021. [PMCID: PMC7743894 DOI: 10.1056/cat.20.0378] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Leaders at Stanford Medicine, located in one of the first U.S. communities to be affected by Covid-19, quickly realized that they were not prepared to meet the escalating needs of their clinical and operational workforce. The pandemic would require existing care-delivery structures across the academic medical system to be expanded and aligned to prioritize workforce protection. Leaders identified an approach driven by connection, collaboration, and caring. They created specialized teams to develop a systemwide Occupational Health service with practices and procedures to assess health care workers and begin robust Covid-19 polymerase chain reaction testing; to centralize operations to maximize utilization of essential clinical and nonclinical staffing resources; to make visible and address psychological safety concerns and basic needs for faculty and staff; to aggressively address personal protective equipment supply chain issues and effectively assess infection risk; and to plan for a safe return of elective procedures and visits.
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Affiliation(s)
- Karen Frush
- Chief Quality Officer, Stanford Health Care, Stanford, California, USA
- Clinical Professor of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Grace Lee
- Associate Chief Medical Officer for Practice Innovation, Stanford Children’s Health, Stanford, California, USA
- Professor of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Samuel H. Wald
- Associate Chief Medical Officer and Vice President, Perioperative Services, Stanford Health Care, Stanford, California, USA
- Clinical Professor, Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Mary Hawn
- Emile Holman Professor and Chair, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Catherine Krna
- President and CEO, University HealthCare Alliance, Newark, California, USA
- Associate Dean, Ambulatory Care, Stanford University School of Medicine, Stanford, California, USA
| | - Marisa Holubar
- Associate Medical Director, Infection Prevention, Stanford Hospital and Clinics, Stanford, California, USA
- Clinical Associate Professor of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Dale Beatty
- Chief Nursing Officer, Stanford Health Care, Stanford, California, USA
| | - Amanda Chawla
- Vice President, Supply Chain, Stanford Health Care, Stanford, California, USA
| | - Benjamin A. Pinsky
- Associate Medical Director of Clinical Pathology for Covid-19 Testing, Stanford Health Care, Stanford, California, USA
- Medical Director, Clinical Virology Laboratory, Stanford Health Care, Stanford, California, USA
- Associate Professor of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Lisa Schilling
- Vice President, Quality, Safety, and Clinical Effectiveness, Stanford Health Care, Stanford, California, USA
| | - Yvonne Maldonado
- Medical Director, Infection Control, Lucile Packard Children’s Hospital, Palo Alto, California, USA
- Professor, Pediatrics – Infectious Diseases, and Professor, Epidemiology and Population Health, Stanford University, Stanford, California, USA
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Harris AHS, Meerwijk EL, Kamal RN, Sears ED, Hawn M, Eisenberg D, Finlay AK, Hagedorn H, Marshall N, Mudumbai SC. Variation in Surgeons' Requests for General Anesthesia When Scheduling Carpal Tunnel Release. Hand (N Y) 2020; 15:608-614. [PMID: 30789047 PMCID: PMC6703973 DOI: 10.1177/1558944719828006] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background: Carpal tunnel release (CTR) can be performed with a variety of anesthesia techniques. General anesthesia is associated with higher risk profile and increased resource utilization, suggesting it should not be routinely used for CTR. The purpose of this study was to examine the patient factors associated with surgeons' requests for general anesthesia for CTR and the frequency of routine use of general anesthesia by Veterans Health Administration (VHA) surgeons and facilities. Methods: National VHA data for fiscal years 2015 and 2017 were used to identify patients receiving CTR. Mixed-effects logistic regression was used to evaluate patient, procedure, and surgeon factors associated with requests by the surgeon for general anesthesia versus other anesthesia techniques. Results: In all, 18 145 patients underwent CTR performed by 780 surgeons in 113 VHA facilities. Overall, there were 2218 (12.2%) requests for general anesthesia. Although some patient (eg, older age, obesity), procedure (eg, open vs endoscopic), and surgeon (eg, higher volume) factors were associated with lower odds of requests for general anesthesia, there was substantial facility- and surgeon-level variability. The percentage of patients with general anesthesia requested ranged from 0% to 100% across surgeons. Three facilities and 28 surgeons who performed at least 5 CTRs requested general anesthesia for more than 75% of patients. Conclusions: Where CTR is performed and by whom appear to influence requests for general anesthesia more than patient factors in this study. Avoidance of routine use of general anesthesia for CTR should be considered in future clinical practice guidelines and quality measures.
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Affiliation(s)
- Alex H. S. Harris
- VA Palo Alto Health Care System, Menlo Park, CA, USA,Stanford University School of Medicine, CA, USA,Alex H. S. Harris, Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA.
| | | | | | | | - Mary Hawn
- VA Palo Alto Health Care System, Menlo Park, CA, USA,Stanford University School of Medicine, CA, USA
| | - Dan Eisenberg
- VA Palo Alto Health Care System, Menlo Park, CA, USA,Stanford University School of Medicine, CA, USA
| | | | - Hildi Hagedorn
- Minneapolis Veterans Affairs Medical Center, MN, USA,University of Minnesota School of Medicine, Minneapolis, USA
| | - Nell Marshall
- VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Seshadri C. Mudumbai
- VA Palo Alto Health Care System, Menlo Park, CA, USA,Stanford University School of Medicine, CA, USA
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11
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Affiliation(s)
- Sue J Fu
- Department of Surgery, Division of General Surgery, Stanford University, Stanford, CA
- Center for Innovation to Implementation, Veteran Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Elizabeth L George
- Center for Innovation to Implementation, Veteran Affairs Palo Alto Health Care System, Palo Alto, CA
- Department of Surgery, Division of Vascular Surgery, Stanford University, Stanford, CA
| | - Paul M Maggio
- Department of Surgery, Division of General Surgery, Stanford University, Stanford, CA
| | - Mary Hawn
- Department of Surgery, Division of General Surgery, Stanford University, Stanford, CA
| | - Rahim Nazerali
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University, Stanford, CA
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12
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Baker S, Malone E, Graham L, Dasinger E, Wahl T, Titan A, Richman J, Copeland L, Burns E, Whittle J, Hawn M, Morris M. Patient-reported health literacy scores are associated with readmissions following surgery. Am J Surg 2020; 220:1138-1144. [PMID: 32682501 DOI: 10.1016/j.amjsurg.2020.06.071] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 05/05/2020] [Accepted: 06/26/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Health literacy (HL) impacts medical care. We hypothesized that patients with low HL would have higher readmission rates following surgery. METHODS We conducted a prospective, multi-institutional study from 8/2015-6/2017 within the Veterans Affairs (VA) System including veterans who underwent general, vascular, or thoracic surgery. HL was assessed by Brief Health Literacy Screener and stratified into adequate vs. low. Patients were followed for 30 days post-discharge. Multivariable analyses examined correlations and logistic regression models adjusted for covariates. RESULTS 736 patients were enrolled in the study; 98% (n = 722) completed the HL survey. At discharge, 33.2% of patients had low HL. The overall 30-day readmission rate was 16.3%, with a significant difference by HL (Adequate HL: 13.3% vs. Low HL: 22.5%, p < 0.01). After adjusting for clinical and demographic covariates, patients with low HL were 59% more likely to be readmitted (OR = 1.59, 95% CI = 1.02-2.50). CONCLUSION Low HL is common among VA surgery patients and is associated with readmission. Future studies should be focused on interventions to target this vulnerable patient population.
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Affiliation(s)
- Samantha Baker
- University of Alabama at Birmingham, Birmingham, AL, USA; VA Birmingham Healthcare System, Birmingham, AL, USA.
| | - Emily Malone
- University of Alabama at Birmingham, Birmingham, AL, USA; VA Birmingham Healthcare System, Birmingham, AL, USA
| | - Laura Graham
- VA Palo Alto Healthcare Systems, Palo Alto, CA, USA; Stanford University, Stanford, CA, USA
| | - Elise Dasinger
- University of Alabama at Birmingham, Birmingham, AL, USA; VA Birmingham Healthcare System, Birmingham, AL, USA
| | - Tyler Wahl
- University of Alabama at Birmingham, Birmingham, AL, USA; VA Birmingham Healthcare System, Birmingham, AL, USA
| | - Ashley Titan
- VA Palo Alto Healthcare Systems, Palo Alto, CA, USA; Stanford University, Stanford, CA, USA
| | - Joshua Richman
- University of Alabama at Birmingham, Birmingham, AL, USA; VA Birmingham Healthcare System, Birmingham, AL, USA
| | - Laurel Copeland
- VA Central Western Massachusetts Healthcare System, Leeds, MA, USA
| | - Edith Burns
- Milwaukee VA Medical Center, Milwaukee, WI, USA
| | | | - Mary Hawn
- VA Palo Alto Healthcare Systems, Palo Alto, CA, USA; Stanford University, Stanford, CA, USA
| | - Melanie Morris
- University of Alabama at Birmingham, Birmingham, AL, USA; VA Birmingham Healthcare System, Birmingham, AL, USA
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Kent TS, Freischlag J, Minter R, Hawn M, Al-Refaie W, James BC, Eskander M, Chu D. Overcoming a Hostile Work and Learning Environment in Academic Surgery-Tools for Change at Every Level. J Surg Res 2020; 252:281-284. [PMID: 32439143 DOI: 10.1016/j.jss.2019.12.055] [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] [Received: 08/14/2019] [Revised: 11/24/2019] [Accepted: 12/11/2019] [Indexed: 11/16/2022]
Abstract
Mistreatment has been documented as a negative factor in the learning environment for the past 30 y but little progress has been made to determine an effective way to significantly improve these interactions. Faculty may also be victims of a hostile work environment as well, although frequency has not been well-measured or reported. In fact, it may be difficult to identify and address mistreatment and hostility in the work place within the commonly established surgical culture. Thus, efforts to define, identify, and address workplace mistreatment or hostility are crucial to the success of the academic surgical environment. This article summarizes presentations and panel discussion that took place at the 2019 Academic Surgical Congress organized by the Association for Academic Surgery and the Society of University Surgeons. Definitions of mistreatment and hostility were provided, as well as information regarding occurrence. Tools for addressing mistreatment in the work environment and tips for creating a positive environment were presented and discussed.
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Affiliation(s)
- Tara S Kent
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
| | - Julie Freischlag
- Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Rebecca Minter
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Mary Hawn
- Department of Surgery, Stanford University, Stanford, California
| | | | - Benjamin C James
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Mariam Eskander
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Danny Chu
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Choi J, Hawn M. Meckel's Diverticulum Fistulization: Another Complication to Consider. J Gastrointest Surg 2020; 24:913-915. [PMID: 31468335 DOI: 10.1007/s11605-019-04378-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 08/18/2019] [Indexed: 01/31/2023]
Affiliation(s)
- Jeff Choi
- Department of Surgery, Stanford University, Stanford, CA, 94305, USA.
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15
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Podboy AJ, Hwang JH, Rivas H, Azagury D, Hawn M, Lau J, Kamal A, Friedland S, Triadafilopoulos G, Zikos T, Clarke JO. Long-term outcomes of per-oral endoscopic myotomy compared to laparoscopic Heller myotomy for achalasia: a single-center experience. Surg Endosc 2020; 35:792-801. [DOI: 10.1007/s00464-020-07450-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 02/11/2020] [Indexed: 02/07/2023]
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16
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Harris AHS, Meerwijk EL, Kamal RN, Sears ED, Hawn M, Eisenberg D, Finlay AK, Hagedorn H, Mudumbai S. Variability and Costs of Low-Value Preoperative Testing for Carpal Tunnel Release Surgery. Anesth Analg 2019; 129:804-811. [PMID: 31425223 PMCID: PMC6760302 DOI: 10.1213/ane.0000000000004291] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The American Society of Anesthesiologists (ASA) Choosing Wisely Top-5 list of activities to avoid includes "Don't obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery - specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal." Accordingly, we define low-value preoperative tests (LVTs) as those performed before minor surgery in patients without significant systemic disease. The objective of the current study was to examine the extent, variability, drivers, and costs of LVTs before carpal tunnel release (CTR) surgeries in the US Veterans Health Administration (VHA). METHODS Using fiscal year (FY) 2015-2017 data derived from the VHA Corporate Data Warehouse (CDW), we determined the overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days before CTR in ASA physical status (PS) I-II patients. We also examined the patient, procedure, and facility factors associated with receiving ≥1 LVT with mixed-effects logistic regression and the number of tests received with mixed-effects negative binomial regression. RESULTS From FY15-17, 10,000 ASA class I-II patients received a CTR by 699 surgeons in 125 VHA facilities. Overall, 47.0% of patients had a CTR that was preceded by ≥1 LVT, with substantial variability between facilities (range = 0%-100%; interquartile range = 36.3%), representing $339,717 in costs. Older age and female sex were associated with higher odds of receiving ≥1 LVT. Local versus other modes of anesthesia were associated with lower odds of receiving ≥1 LVT. Several facilities experienced large (>25%) increases or decreases from FY15 to FY17 in the proportion of patients receiving ≥1 LVT. CONCLUSIONS Counter to guidance from the ASA, we found that almost half of CTRs performed on ASA class I-II VHA patients were preceded by ≥1 LVT. Although the total cost of these tests is relatively modest, CTR is just one of many low-risk procedures (eg, trigger finger release, cataract surgery) that may involve similar preoperative testing practices. These results will inform site selection for qualitative investigation of the drivers of low-value testing and the development of interventions to improve preoperative testing practice, especially in locations where rates of LVT are high.
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Affiliation(s)
- Alex H S Harris
- From the Center for Innovation to Implementation, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
- Department of Surgery, Stanford-Surgical Policy Improvement Research and Education Center, Stanford University School of Medicine, Stanford, California
| | - Esther L Meerwijk
- From the Center for Innovation to Implementation, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Robin N Kamal
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, California
| | - Erika D Sears
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan
- Department of Surgery, Michigan Medicine
| | - Mary Hawn
- From the Center for Innovation to Implementation, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
- Department of Surgery, Stanford-Surgical Policy Improvement Research and Education Center, Stanford University School of Medicine, Stanford, California
| | - Dan Eisenberg
- From the Center for Innovation to Implementation, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
- Department of Surgery, Stanford-Surgical Policy Improvement Research and Education Center, Stanford University School of Medicine, Stanford, California
| | - Andrea K Finlay
- From the Center for Innovation to Implementation, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Hildi Hagedorn
- Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota
| | - Seshadri Mudumbai
- From the Center for Innovation to Implementation, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
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Gyawali CP, Sifrim D, Carlson DA, Hawn M, Katzka DA, Pandolfino JE, Penagini R, Roman S, Savarino E, Tatum R, Vaezi M, Clarke JO, Triadafilopoulos G. Ineffective esophageal motility: Concepts, future directions, and conclusions from the Stanford 2018 symposium. Neurogastroenterol Motil 2019; 31:e13584. [PMID: 30974032 PMCID: PMC9380027 DOI: 10.1111/nmo.13584] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/11/2019] [Accepted: 03/05/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Ineffective esophageal motility (IEM) is a heterogenous minor motility disorder diagnosed when ≥50% ineffective peristaltic sequences (distal contractile integral <450 mm Hg cm s) coexist with normal lower esophageal sphincter relaxation (integrated relaxation pressure < upper limit of normal) on esophageal high-resolution manometry (HRM). Ineffective esophageal motility is not consistently related to disease states or symptoms and may be seen in asymptomatic healthy individuals. PURPOSE A 1-day symposium of esophageal experts reviewed existing literature on IEM, and this review represents the conclusions from the symposium. Severe IEM (>70% ineffective sequences) is associated with higher esophageal reflux burden, particularly while supine, but milder variants do not progress over time or consistently impact quality of life. Ineffective esophageal motility can be further characterized using provocative maneuvers during HRM, especially multiple rapid swallows, where augmentation of smooth muscle contraction defines contraction reserve. The presence of contraction reserve may predict better prognosis, lesser reflux burden and confidence in a standard fundoplication for surgical management of reflux. Other provocative maneuvers (solid swallows, standardized test meal, rapid drink challenge) are useful to characterize bolus transit in IEM. No effective pharmacotherapy exists, and current managements target symptoms and concurrent reflux. Novel testing modalities (baseline and mucosal impedance, functional lumen imaging probe) show promise in elucidating pathophysiology and stratifying IEM phenotypes. Specific prokinetic agents targeting esophageal smooth muscle need to be developed for precision management.
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Affiliation(s)
- C. Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel Sifrim
- Barts and The London School of Medicine and Dentistry Queen Mary, University of London, London, UK
| | - Dustin A. Carlson
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Mary Hawn
- Department of Surgery, Stanford University, Stanford, California
| | - David A. Katzka
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - John E. Pandolfino
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Roberto Penagini
- Università degli Studi di Milano, Milan, Italy,Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Sabine Roman
- Digestive Physiology, Hopital E Herriot, Hospices Civils de Lyon, Université de Lyon, Lyon, France,Digestive Physiology, Lyon I University, Université de Lyon, Lyon, France,Université de Lyon, Inserm U1032, LabTAU, Université de Lyon, Lyon, France
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Roger Tatum
- Department of Surgery, University of Washington, Seattle, Washington
| | - Michel Vaezi
- Division of Gastroenterology, Vanderbilt University, Nashville, Tennessee
| | - John O. Clarke
- Division of Gastroenterology, Stanford University, Stanford, California
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18
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Bidwell SS, Miller MO, Lee EW, Yelorda K, Koshy S, Hawn M, Morris AM. Development and Implementation of a Hands-on Surgical Pipeline Program for Low-Income High School Students. JAMA Netw Open 2019; 2:e199991. [PMID: 31441933 PMCID: PMC6714018 DOI: 10.1001/jamanetworkopen.2019.9991] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This qualitative study describes the development and implementation of a hands-on surgical pipeline program for low-income high school students.
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Affiliation(s)
- Serena S. Bidwell
- S-SPIRE Center, Department of Surgery, Stanford University, Stanford, California
| | - Miquell O. Miller
- S-SPIRE Center, Department of Surgery, Stanford University, Stanford, California
| | - Edmund W. Lee
- S-SPIRE Center, Department of Surgery, Stanford University, Stanford, California
| | - Kirbi Yelorda
- S-SPIRE Center, Department of Surgery, Stanford University, Stanford, California
| | | | - Mary Hawn
- S-SPIRE Center, Department of Surgery, Stanford University, Stanford, California
| | - Arden M. Morris
- S-SPIRE Center, Department of Surgery, Stanford University, Stanford, California
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19
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Triadafilopoulos G, Clarke J, Hawn M. Whole greater than the parts: integrated esophageal centers (IEC) and advanced training in esophageal diseases. Dis Esophagus 2017; 30:1-9. [PMID: 28859396 DOI: 10.1093/dote/dox084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 05/30/2017] [Indexed: 02/06/2023]
Abstract
An integrated esophageal center (IEC) is a multidisciplinary team with expertise, skill, range, and facilities necessary to achieve optimal outcomes in patients with esophageal diseases efficiently and expeditiously. Within IEC, patients presenting with esophageal symptoms undergo a detailed clinical, functional and structural evaluation of their esophagus prior to implementation of tailored medical, endoscopic or surgical therapy. Serving as a core, the IEC clinical practice also supports research and innovation in esophageal diseases as well as public and physician education. Referrals to the unit may be primary, either from primary care or self-initiated, or secondary from other specialty practices, to reassess patients who have previously failed therapies and to manage complex or complicated cases. The fundamental goals of the IEC are to provide value for patients with esophageal diseases, streamlining complex diagnostic investigations and expediting therapies aiming at reducing costs while improving clinical outcomes, and to accelerate knowledge generation through robust interaction and cross-training across disciplines. The organization of the IEC goes beyond traditional academic and clinical silos and involves a director and administrative team coordinating faculty and fellows from both medical and surgical disciplines and supported by other clinical lines, such as radiology, pathology, etc., while it interfaces with physicians, the public, basic, translational and clinical research groups, and related industry partners.
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Abstract
The highly heterogeneous nature of gastroesophageal reflux disease (GERD), together with the multiplicity of available diagnostic and therapeutic options (lifestyle, pharmacologic, endoscopic and surgical) available today call for a new approach that funnels the multidimensionality of the disease into precise and effective algorithms - reviewed herein- aimed at improving clinical outcomes.
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Affiliation(s)
- G Triadafilopoulos
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology and Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - J O Clarke
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology and Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - M Hawn
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology and Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
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Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is the most common gastrointestinal disorder of the esophagus. It is a chronic, progressive disorder that presents most typically with heartburn and regurgitation and atypically with chest pain, dysphagia, chronic cough, globus, or sore throat. The mainstay for diagnosis and characterization of the disorder is esophagoduodenoscopy (EGD), high-resolution esophageal manometry, and symptom-associated ambulatory esophageal pH impedance monitoring. Additional studies that can be useful in certain clinical presentations include gastric scintigraphy and oral contrast upper gastrointestinal radiographic series. DISCUSSION Refractory GERD can be surgically managed with various techniques. In obese individuals, laparoscopic Roux-en-Y gastric bypass should be considered due to significant symptom improvement and lower incidence of recurrent symptoms with weight loss. Otherwise, laparoscopic Nissen fundoplication is the preferred surgical technique for treatment of this disease with concomitant hiatal hernia repair when present for either procedure. The short-term risks associated with these procedures include esophageal or gastric injury, pneumothorax, wound infection, and dysphagia. Emerging techniques for treatment of this disease include the Linx Reflux Management System, EndoStim LES Stimulation System, Esophyx® and MUSE™ endoscopic fundoplication devices, and the Stretta endoscopic ablation system. Outcomes after surgical management of refractory GERD are highly dependent on adherence to strict surgical indications and appropriate patient-specific procedure selection.
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Affiliation(s)
- William Kethman
- Department of Surgery, Stanford University, Alway Building, Room M121, 300 Pasteur Drive, MC 5115, Stanford, CA, 94305, USA
| | - Mary Hawn
- Department of Surgery, Stanford University, Alway Building, Room M121, 300 Pasteur Drive, MC 5115, Stanford, CA, 94305, USA.
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22
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Gehring M, Burns E, Telford G, Whittle J, Copeland L, Morris M, Hawn M. COGNITIVE STATUS, CO-MORBID CONDITIONS, AND UNPLANNED READMISSIONS IN OLDER SURGICAL PATIENTS. Innov Aging 2017. [DOI: 10.1093/geroni/igx004.1566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- M. Gehring
- Medical College of Wisconsin, Milwaukee, Wisconsin,
| | - E.A. Burns
- Medical College of Wisconsin, Milwaukee, Wisconsin,
| | - G. Telford
- Medical College of Wisconsin, Milwaukee, Wisconsin,
| | - J. Whittle
- Medical College of Wisconsin, Milwaukee, Wisconsin,
| | - L. Copeland
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts,
| | - M. Morris
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - M. Hawn
- Stanford University School of Medicine, Stanford, California,
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Ponce B, Raines BT, Reed RD, Vick C, Richman J, Hawn M. Surgical Site Infection After Arthroplasty: Comparative Effectiveness of Prophylactic Antibiotics: Do Surgical Care Improvement Project Guidelines Need to Be Updated? J Bone Joint Surg Am 2014; 96:970-977. [PMID: 24951731 DOI: 10.2106/jbjs.m.00663] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Prophylactic antibiotics decrease surgical site infection (SSI) rates, and their timing, choice, and discontinuation are measured and reported as part of the Surgical Care Improvement Project (SCIP). The aim of this study was to assess the comparative effectiveness of the SCIP-approved antibiotics for SSI prevention. METHODS This retrospective cohort study utilized national Veterans Affairs (VA) data on patients undergoing elective hip or knee arthroplasty from 2005 to 2009. Data on prophylactic antibiotics were merged with VA Surgical Quality Improvement Program data to identify patient and procedure-related risk factors for SSI. Patients were stratified by documented penicillin allergy. Chi-square and Wilcoxon rank-sum tests were used to compare SSI rates among patients receiving SCIP-approved prophylactic antibiotics. RESULTS A total of 18,830 elective primary arthroplasties (12,823 knee and 6007 hip) were included. Most patients received prophylactic cefazolin as the sole agent (81.9%), followed by vancomycin as the sole agent (8.0%), vancomycin plus cefazolin (5.6%), and clindamycin (4.5%). Documented penicillin allergy accounted for 54.1% of cases involving vancomycin administration compared with 94.6% of cases involving clindamycin. The overall thirty-day SSI rate was 1.4%, and the unadjusted rate was 2.3% with vancomycin only, 1.5% with vancomycin plus cefazolin, 1.3% with cefazolin only, and 1.1% with clindamycin. Unadjusted analysis of penicillin-allergic patients revealed an SSI rate of 2.0% with vancomycin only compared with 1.0% with clindamycin (p = 0.18). For patients without penicillin allergy, the SSI rate was 2.6% with vancomycin only compared with 1.6% with vancomycin plus cefazolin (p = 0.17) and 1.3% with cefazolin only (p < 0.01). CONCLUSIONS Current SCIP guidelines address antibiotic timing but not antibiotic dosage. (The generally accepted recommendation for vancomycin is 15 mg/kg.) Although vancomycin is a narrower-spectrum antibiotic than either cefazolin or clindamycin, our finding of higher SSI rates following prophylaxis with vancomycin only may suggest a failure to use an appropriate dosage rather than an inequality of antibiotic effectiveness. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Brent Ponce
- Division of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13th Street South, Suite 203, Birmingham, AL 35205-5327. E-mail address:
| | - Benjamin Todd Raines
- Center for Surgical, Medical Acute Care Research and Transitions, Birmingham Alabama VA Medical Center, 700 South 19th Street, Birmingham, AL 35233. E-mail address for B.T. Raines: . E-mail address for R.D. Reed: . E-mail address for J. Richman: . E-mail address for M. Hawn:
| | - Rhiannon D Reed
- Center for Surgical, Medical Acute Care Research and Transitions, Birmingham Alabama VA Medical Center, 700 South 19th Street, Birmingham, AL 35233. E-mail address for B.T. Raines: . E-mail address for R.D. Reed: . E-mail address for J. Richman: . E-mail address for M. Hawn:
| | | | - Joshua Richman
- Center for Surgical, Medical Acute Care Research and Transitions, Birmingham Alabama VA Medical Center, 700 South 19th Street, Birmingham, AL 35233. E-mail address for B.T. Raines: . E-mail address for R.D. Reed: . E-mail address for J. Richman: . E-mail address for M. Hawn:
| | - Mary Hawn
- Center for Surgical, Medical Acute Care Research and Transitions, Birmingham Alabama VA Medical Center, 700 South 19th Street, Birmingham, AL 35233. E-mail address for B.T. Raines: . E-mail address for R.D. Reed: . E-mail address for J. Richman: . E-mail address for M. Hawn:
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Singh JA, Hawn M, Campagna EJ, Henderson WG, Richman J, Houston TK. Mediation of smoking-associated postoperative mortality by perioperative complications in veterans undergoing elective surgery: data from Veterans Affairs Surgical Quality Improvement Program (VASQIP)--a cohort study. BMJ Open 2013; 3:bmjopen-2012-002157. [PMID: 23604347 PMCID: PMC3641431 DOI: 10.1136/bmjopen-2012-002157] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To assess the mediation of smoking-associated postoperative mortality by postoperative complications. DESIGN Observational cohort study. SETTING Using data from the Veterans Affairs (VA) Surgical Quality Improvement Programme, a quality assurance programme for major surgical procedures in the VA healthcare system, we assessed the association of current smoking at the time of the surgery with 6-month and 1-year mortality. PRIMARY AND SECONDARY OUTCOME MEASURES Using mediation analyses, we calculated the relative contribution of each smoking-associated complication to smoking-associated postoperative mortality, both unadjusted and adjusted for age, race/ethnicity, work relative value unit of the operation, surgeon specialty, American Society of Anesthesiologists class and year of surgery. Smoking-associated complications included surgical site infection (SSI), cardiovascular complications (myocardial infarction, cardiac arrest and/or stroke) and pulmonary complications (pneumonia, failure to wean and/or reintubation). RESULTS There were 186 632 never smokers and 135 741 current smokers. The association of smoking and mortality was mediated by smoking-related complications with varying effects. In unadjusted analyses, the proportions of mediation of smoking to 6-month mortality explained by the complications were as follows: SSIs 22%, cardiovascular complications 12% and pulmonary complications 89%. In adjusted analyses, the per cents mediated by each complication were as follows: SSIs 2%, cardiovascular complications 4% and pulmonary complications 22%. In adjusted analyses for 1-year mortality, respective per cents mediated were 2%, 3% and 16%. CONCLUSIONS Pulmonary complications, followed by cardiovascular complications and SSIs were mediators of smoking-associated 6-month and 1-year mortality. Interventions targeting smoking cessation and prevention and early treatment of pulmonary complications has the likelihood of reducing postoperative mortality after elective surgery.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service, Birmingham VA Medical Center and Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Center for Surgical Medical Acute Care Research and Transitions, Birmingham VA Medical Center, Birmingham, Alabama, USA
- Division of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Mary Hawn
- Medicine Service, Birmingham VA Medical Center and Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Center for Surgical Medical Acute Care Research and Transitions, Birmingham VA Medical Center, Birmingham, Alabama, USA
| | - Elizabeth J Campagna
- Colorado Health Outcomes Program, University of Colorado Denver, Aurora, Colorado, USA
- VA Medical Center, Denver, Colorado, USA
| | - William G Henderson
- Colorado Health Outcomes Program, University of Colorado Denver, Aurora, Colorado, USA
| | - Joshua Richman
- Medicine Service, Birmingham VA Medical Center and Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Thomas K Houston
- Center for Health Quality Outcomes and Economic Research, Bedford VA Medical Center, Bedford, Massachusetts, USA
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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Finan KR, Vick C, Arguedas M, Hawn M. Open suture versus mesh repair of primary ventral hernias: a cost utility analysis. J Am Coll Surg 2005. [DOI: 10.1016/j.jamcollsurg.2005.06.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
OBJECTIVE/HYPOTHESIS A duplicate publication duplicates other published work by the same author(s). The purpose of the study was to define the extent of this problem within the otolaryngology literature. STUDY DESIGN Retrospective review of the literature. METHODS Original articles published in Archives of Otolaryngology-Head and Neck Surgery and Laryngoscope in 1999 were reviewed using the OVID search engine. Titles and abstracts from English articles written by the same first, second, or last author were analyzed, and suspected publications were evaluated. Duplicate publications were classified as dual (identical data set and conclusions) or suspected dual (nearly identical data set and conclusions) publications. RESULTS Of the 492 articles evaluated, 40 index articles were identified. These led to a total of 42 (8.5%) duplicate articles of which 27 were classified as dual and 15 as suspected dual publications. Approximately half of the duplicate publications were published by authors in the United States (55%). Duplicate articles usually appeared within 12 months of the each other (74%) and failed to cross-reference the earlier publication (83%). CONCLUSIONS Journal editors have become aware of an increase in the number of duplicate publications in the medical literature. The incidence of duplicate publications in the otolaryngology literature appears to be similar to that in other specialties.
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Affiliation(s)
- Eben L Rosenthal
- Department of Surgery, University of Alabama at Birmingham, 35249, USA.
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Rosenbaum E, Gautier H, Fobair P, Andrews A, Hawn M, Kurshner R, Festa B, Kramer P, Manuel F, Hirschberger N, Selim S, Spiegel D. Developing a free supportive care program for cancer patients within an integrative medicine clinic. Support Care Cancer 2003; 11:263-9. [PMID: 12690540 DOI: 10.1007/s00520-003-0439-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [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: 09/16/2002] [Accepted: 12/19/2002] [Indexed: 11/26/2022]
Abstract
The cancer patient's journey not only includes a threat to one's life, but the need to face many medical and emotional challenges. The free Cancer Supportive Care Program (CSCP) within the Center for Integrative Medicine Clinic at Stanford University Hospital and Clinics has been identified as a successful model for helping patients to deal with these challenges. Its programs include informational lectures, support groups, chair massages, exercise, alternative modality classes, a Life Tapes Project, an informational website, and a bimonthly newsletter available free to anybody touched by cancer. Now in its third year, this program benefits from a blending of leadership resources, availability of space, institutional agreement on patient need and funds from private and corporate donations. By presenting the basic premises of the Cancer Supportive Care program and outlining specifics about the program, institutions in various national and international demographic regions may implement similar programs according to their resources and the needs of patients. It is our hope that the CSCP can become a model for the development of similar programs in various parts of the United States and abroad.
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Affiliation(s)
- E Rosenbaum
- Medical Plaza, Suite 6, 1101 Welch Rd. Bldg. A, Palo Alto, CA 94304, USA.
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Hawn M, Minderler K, Baldwin D. Patients can be pain-free while undergoing implanted port assessment. Oncol Nurs Forum 1997; 24:801-2. [PMID: 9201734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Luce MC, Marra G, Chauhan DP, Laghi L, Carethers JM, Cherian SP, Hawn M, Binnie CG, Kam-Morgan LN, Cayouette MC. In vitro transcription/translation assay for the screening of hMLH1 and hMSH2 mutations in familial colon cancer. Gastroenterology 1995; 109:1368-74. [PMID: 7557107 DOI: 10.1016/0016-5085(95)90600-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND & AIMS Hereditary nonpolyposis colorectal cancer (HNPCC) has been linked recently to a defect in repairing mismatched nucleotides in DNA. The aim of this study was to screen for germline mutations that result in prematurely truncated proteins in two of the mismatch repair genes identified at this time, hMLH1 and hMSH2, in a consecutive series of patients belonging to familial aggregations of colorectal cancer. METHODS Nineteen individuals with colorectal cancer from 19 families were consecutively referred because of a strong positive family history of colorectal cancer. Premature truncation mutations in hMLH1 and hMSH2 were sought from lymphocyte RNA by using an in vitro transcription/translation (IVTT) assay. RESULTS Protein truncating mutations in the hMLH1 or hMSH2 genes were found in 50% of families with HNPCC (6 of 12) but were not observed in any of the remaining familial aggregations that did not fulfill the standard criteria for HNPCC. In some of the IVTT-positive samples, the mutations were characterized by genomic sequencing. CONCLUSIONS IVTT may be a practical method to accomplish primary screening of germline mutations in DNA mismatch pair genes in HNPCC; however, a broader approach is necessary to obtain a more complete picture of the mutational spectrum in HNPCC and other familial aggregations of colorectal cancer.
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Affiliation(s)
- M C Luce
- Roche Biomedical Laboratories, Research Triangle Park, North Carolina, USA
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Abstract
The participation of carbonic anhydrase (CA II) in the gastric acid secretory process has been the subject of considerable controversy. We utilized a cDNA probe for CA II to measure CA II gene expression in canine gastric parietal cells that had been stimulated with the three principal acid secretagogues, carbachol, gastrin, and histamine. Hybridization to dot blots of total parietal cell RNA showed a significant increase in specific CA II mRNA content within minutes of secretagogue addition: carbachol stimulation led to an increase of 52 +/- 8.9%, reaching a maximum within 20 min; gastrin stimulation led to an increase within 60 min of 104 +/- 10.6%; stimulation with histamine was followed within 20 min by an increase of 30 +/- 7.2%. We also measured transcription rates for the CA II gene in cells stimulated by each agent and found an increase within 15 min. Our results show that CA II gene expression is regulated by agents that stimulate the parietal cell to secrete acid and that the accumulation of CA II mRNA subsequent to the initial interaction of stimulant appears to result from new transcription of the CA II gene. These data suggest the participation of CA II in the acid secretory response of the parietal cell to secretagogues.
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Affiliation(s)
- V W Campbell
- Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor 48109-0682
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Eller T, Hawn M, McGowan S. A pharmacy computer system on a remote network. Top Hosp Pharm Manage 1984; 4:70-4. [PMID: 10314073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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