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Official Newspaper of the American College of Surgeons
Liver Candidates Decline Many Organ Offers
Eighty-four percent of candidates on the wait-list for liver transplant who either died or were removed from the list before they were able to undergo transplantation declined at least one offer of a donor liver, Dr. Jennifer Cindy Lai of the University of California, San Francisco, and her colleagues reported in the November issue of Gastroenterology.
Even more surprising, most of these candidates declined "not just one or two but a median of six liver offers during their time on the wait-list."
The "declined" donor organs were then successfully transplanted into lower-priority recipients.
These findings suggest that mortality among wait-listed patients "is not simply a result of not having the opportunity for transplantation, as many of us assume. Rather, wait-list mortality appears to result from opportunities for transplantation that were declined," Dr. Lai and her associates wrote.
The reasons that so many viable donor livers were initially declined are not yet clear. General, somewhat vague reasons were listed but not fully explained in the records the researchers analyzed for this study, which they obtained from the United Network for Organ Sharing/Organ Procurement Transplantation Network database.
The investigators assessed organ offers to 33,389 liver transplant candidates aged 18 years and older who were wait-listed across the United States between 2005 and 2010.
The reasons that proffered organs were declined, as listed in the medical records, fit into six broad categories: unfavorable donor age or quality of organ; unfavorable donor organ size/weight; other unfavorable donor factors, such as ABO blood transfusion incompatibility, "social history," "positive serologic tests," or "organ anatomical damage or defect"; unreadiness of the recipient, usually because he or she was ill, unavailable, refused the organ, or required multiple organ transplants at the same time; problems with the transplant program itself, such as a "heavy workload" or unavailability of a surgeon or operating room at the recipient’s medical center, failure to respond to the offer in a timely way, or excessive distance to ship the organ.
A total of 20% of the study population (6,737 patients) died or were removed from the wait-list because they became too sick before they could undergo transplantation. A total of 5,680 (84%) of those patients had been offered one or more donor livers before they died or were taken off the list.
Offers of donor livers were declined most often (68%) because of "unfavorable donor age or quality of organ," whereas 9% were declined because of unfavorable organ size, 15% because of "other donor factors," 4% because the recipient wasn’t ready, and 4% because of transplant program or miscellaneous other factors.
However, the dominant use of the "donor quality or age" refusal code in the database almost certainly "does not accurately or fully capture the true refusal reason," Dr. Lai and her associates said.
Even livers judged to be of high quality according to standard criteria were declined because of supposed "unfavorable donor age or quality of organ." But the investigators found no difference in the risk of graft failure between such high-quality livers that were declined and other high-quality livers that were accepted on the first offer.
Other reasons must be playing an important role in this high rate refusal, but "the nuances of these refusals cannot be determined" without more individualized data, they said.
Dr. Lai and her colleagues suggested that to cut down on refusals of apparently viable organs, the transplant community should "reduce the stigma associated with non–ideal livers, and set realistic expectations for wait-listed candidates" so that they’re less likely to pass up a suitable donation while assuming that a better offer will come along.
Patients also should be educated about the unpredictability of death or of sudden worsening of liver disease while on the wait-list. They should be advised that there is a survival benefit associated with the transplantation of any graft, compared with continuing on the wait-list.
In addition, the current regulatory environment focuses on transplant centers’ outcomes, which may influence some centers to discourage the acceptance of less than optimal donor organs. "This may be especially relevant for low-volume transplant centers, for whom even a small number of poor outcomes ... may make a relatively large difference in the centers’ perceived performance," the researchers wrote.
Finally, wait-list candidates should be encouraged to complete their transplant work-ups as expeditiously as possible to avoid having to refuse a donor offer simply because they have not yet undergone the necessary cardiac testing or cancer screening.
This study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases and the University of California, San Francisco. No financial conflicts of interest were reported.
Eighty-four percent of candidates on the wait-list for liver transplant who either died or were removed from the list before they were able to undergo transplantation declined at least one offer of a donor liver, Dr. Jennifer Cindy Lai of the University of California, San Francisco, and her colleagues reported in the November issue of Gastroenterology.
Even more surprising, most of these candidates declined "not just one or two but a median of six liver offers during their time on the wait-list."
The "declined" donor organs were then successfully transplanted into lower-priority recipients.
These findings suggest that mortality among wait-listed patients "is not simply a result of not having the opportunity for transplantation, as many of us assume. Rather, wait-list mortality appears to result from opportunities for transplantation that were declined," Dr. Lai and her associates wrote.
The reasons that so many viable donor livers were initially declined are not yet clear. General, somewhat vague reasons were listed but not fully explained in the records the researchers analyzed for this study, which they obtained from the United Network for Organ Sharing/Organ Procurement Transplantation Network database.
The investigators assessed organ offers to 33,389 liver transplant candidates aged 18 years and older who were wait-listed across the United States between 2005 and 2010.
The reasons that proffered organs were declined, as listed in the medical records, fit into six broad categories: unfavorable donor age or quality of organ; unfavorable donor organ size/weight; other unfavorable donor factors, such as ABO blood transfusion incompatibility, "social history," "positive serologic tests," or "organ anatomical damage or defect"; unreadiness of the recipient, usually because he or she was ill, unavailable, refused the organ, or required multiple organ transplants at the same time; problems with the transplant program itself, such as a "heavy workload" or unavailability of a surgeon or operating room at the recipient’s medical center, failure to respond to the offer in a timely way, or excessive distance to ship the organ.
A total of 20% of the study population (6,737 patients) died or were removed from the wait-list because they became too sick before they could undergo transplantation. A total of 5,680 (84%) of those patients had been offered one or more donor livers before they died or were taken off the list.
Offers of donor livers were declined most often (68%) because of "unfavorable donor age or quality of organ," whereas 9% were declined because of unfavorable organ size, 15% because of "other donor factors," 4% because the recipient wasn’t ready, and 4% because of transplant program or miscellaneous other factors.
However, the dominant use of the "donor quality or age" refusal code in the database almost certainly "does not accurately or fully capture the true refusal reason," Dr. Lai and her associates said.
Even livers judged to be of high quality according to standard criteria were declined because of supposed "unfavorable donor age or quality of organ." But the investigators found no difference in the risk of graft failure between such high-quality livers that were declined and other high-quality livers that were accepted on the first offer.
Other reasons must be playing an important role in this high rate refusal, but "the nuances of these refusals cannot be determined" without more individualized data, they said.
Dr. Lai and her colleagues suggested that to cut down on refusals of apparently viable organs, the transplant community should "reduce the stigma associated with non–ideal livers, and set realistic expectations for wait-listed candidates" so that they’re less likely to pass up a suitable donation while assuming that a better offer will come along.
Patients also should be educated about the unpredictability of death or of sudden worsening of liver disease while on the wait-list. They should be advised that there is a survival benefit associated with the transplantation of any graft, compared with continuing on the wait-list.
In addition, the current regulatory environment focuses on transplant centers’ outcomes, which may influence some centers to discourage the acceptance of less than optimal donor organs. "This may be especially relevant for low-volume transplant centers, for whom even a small number of poor outcomes ... may make a relatively large difference in the centers’ perceived performance," the researchers wrote.
Finally, wait-list candidates should be encouraged to complete their transplant work-ups as expeditiously as possible to avoid having to refuse a donor offer simply because they have not yet undergone the necessary cardiac testing or cancer screening.
This study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases and the University of California, San Francisco. No financial conflicts of interest were reported.
Eighty-four percent of candidates on the wait-list for liver transplant who either died or were removed from the list before they were able to undergo transplantation declined at least one offer of a donor liver, Dr. Jennifer Cindy Lai of the University of California, San Francisco, and her colleagues reported in the November issue of Gastroenterology.
Even more surprising, most of these candidates declined "not just one or two but a median of six liver offers during their time on the wait-list."
The "declined" donor organs were then successfully transplanted into lower-priority recipients.
These findings suggest that mortality among wait-listed patients "is not simply a result of not having the opportunity for transplantation, as many of us assume. Rather, wait-list mortality appears to result from opportunities for transplantation that were declined," Dr. Lai and her associates wrote.
The reasons that so many viable donor livers were initially declined are not yet clear. General, somewhat vague reasons were listed but not fully explained in the records the researchers analyzed for this study, which they obtained from the United Network for Organ Sharing/Organ Procurement Transplantation Network database.
The investigators assessed organ offers to 33,389 liver transplant candidates aged 18 years and older who were wait-listed across the United States between 2005 and 2010.
The reasons that proffered organs were declined, as listed in the medical records, fit into six broad categories: unfavorable donor age or quality of organ; unfavorable donor organ size/weight; other unfavorable donor factors, such as ABO blood transfusion incompatibility, "social history," "positive serologic tests," or "organ anatomical damage or defect"; unreadiness of the recipient, usually because he or she was ill, unavailable, refused the organ, or required multiple organ transplants at the same time; problems with the transplant program itself, such as a "heavy workload" or unavailability of a surgeon or operating room at the recipient’s medical center, failure to respond to the offer in a timely way, or excessive distance to ship the organ.
A total of 20% of the study population (6,737 patients) died or were removed from the wait-list because they became too sick before they could undergo transplantation. A total of 5,680 (84%) of those patients had been offered one or more donor livers before they died or were taken off the list.
Offers of donor livers were declined most often (68%) because of "unfavorable donor age or quality of organ," whereas 9% were declined because of unfavorable organ size, 15% because of "other donor factors," 4% because the recipient wasn’t ready, and 4% because of transplant program or miscellaneous other factors.
However, the dominant use of the "donor quality or age" refusal code in the database almost certainly "does not accurately or fully capture the true refusal reason," Dr. Lai and her associates said.
Even livers judged to be of high quality according to standard criteria were declined because of supposed "unfavorable donor age or quality of organ." But the investigators found no difference in the risk of graft failure between such high-quality livers that were declined and other high-quality livers that were accepted on the first offer.
Other reasons must be playing an important role in this high rate refusal, but "the nuances of these refusals cannot be determined" without more individualized data, they said.
Dr. Lai and her colleagues suggested that to cut down on refusals of apparently viable organs, the transplant community should "reduce the stigma associated with non–ideal livers, and set realistic expectations for wait-listed candidates" so that they’re less likely to pass up a suitable donation while assuming that a better offer will come along.
Patients also should be educated about the unpredictability of death or of sudden worsening of liver disease while on the wait-list. They should be advised that there is a survival benefit associated with the transplantation of any graft, compared with continuing on the wait-list.
In addition, the current regulatory environment focuses on transplant centers’ outcomes, which may influence some centers to discourage the acceptance of less than optimal donor organs. "This may be especially relevant for low-volume transplant centers, for whom even a small number of poor outcomes ... may make a relatively large difference in the centers’ perceived performance," the researchers wrote.
Finally, wait-list candidates should be encouraged to complete their transplant work-ups as expeditiously as possible to avoid having to refuse a donor offer simply because they have not yet undergone the necessary cardiac testing or cancer screening.
This study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases and the University of California, San Francisco. No financial conflicts of interest were reported.
FROM GASTROENTEROLOGY
Laparoscopic Tops Transabdominal US for Polyp Detection
CHICAGO – Laparoscopic ultrasound was as effective as transabdominal ultrasound for detecting cholelithiasis, and superior at finding gallbladder polyps, based on data from 253 adults undergoing laparoscopic gastric bypass procedures.
Morbidly obese patients are at increased risk for cholelithiasis, with approximately 22%-52% developing the condition, said Dr. Kosisochi M. Obinwanne at the annual clinical congress of the American College of Surgeons.
For surgeons who perform gallbladder surgery separate from the gastric bypass, "it becomes necessary to obtain images of the gallbladder to determine the presence of gallstones," said Dr. Obinwanne of Gundersen Lutheran Health System in La Crosse, Wisc.
"Transabdominal ultrasound is the gold standard for detecting cholelithiasis," he said. However, the increased visceral and subcutaneous fat in patients with morbid obesity can make detection of gallbladder pathology difficult using transabdominal ultrasound (TAU), but laparoscopic ultrasound (LU) has the potential to be as effective as TAU, he noted.
To evaluate the sensitivity and specificity of LU vs. TAU for detecting gallbladder pathology in morbidly obese patients, Dr. Obinwanne and his colleagues conducted a prospective study of 253 patients who underwent laparoscopic gastric bypass over a 6-year period. Their average age was 43 years, average body mass index was 48 kg/m2, and 76% were women.
The patients underwent both TAU and LU during laparoscopic gastric bypass surgery. Certified ultrasonographers performed TAU, and surgeons blinded to the TAU results performed LU, Dr. Obinwanne said.
Overall, LU and TAU identified cholelithiasis in 60 and 61 patients, respectively, said Dr. Obinwanne. The average common bile duct diameter measurement was 3.7 mm with LU and 4.0 mm with TAU.
However, LU found significantly more gallbladder polyps than did TAU (41 vs. 6). The sensitivity and specificity of LU were 90% and 98%, respectively, for gallbladder pathology and 83% and 85%, respectively, for polyps.
"The mean time to complete an LU procedure was 4 minutes," Dr. Obinwanne said.
The study was limited by its small size, but the results suggest that LU is safe, quick, and easy to perform – and thus it’s an alternative to TAU for detecting gallbladder pathology in bariatric surgery patients.
Dr. Obinwanne had no financial conflicts to disclose.
CHICAGO – Laparoscopic ultrasound was as effective as transabdominal ultrasound for detecting cholelithiasis, and superior at finding gallbladder polyps, based on data from 253 adults undergoing laparoscopic gastric bypass procedures.
Morbidly obese patients are at increased risk for cholelithiasis, with approximately 22%-52% developing the condition, said Dr. Kosisochi M. Obinwanne at the annual clinical congress of the American College of Surgeons.
For surgeons who perform gallbladder surgery separate from the gastric bypass, "it becomes necessary to obtain images of the gallbladder to determine the presence of gallstones," said Dr. Obinwanne of Gundersen Lutheran Health System in La Crosse, Wisc.
"Transabdominal ultrasound is the gold standard for detecting cholelithiasis," he said. However, the increased visceral and subcutaneous fat in patients with morbid obesity can make detection of gallbladder pathology difficult using transabdominal ultrasound (TAU), but laparoscopic ultrasound (LU) has the potential to be as effective as TAU, he noted.
To evaluate the sensitivity and specificity of LU vs. TAU for detecting gallbladder pathology in morbidly obese patients, Dr. Obinwanne and his colleagues conducted a prospective study of 253 patients who underwent laparoscopic gastric bypass over a 6-year period. Their average age was 43 years, average body mass index was 48 kg/m2, and 76% were women.
The patients underwent both TAU and LU during laparoscopic gastric bypass surgery. Certified ultrasonographers performed TAU, and surgeons blinded to the TAU results performed LU, Dr. Obinwanne said.
Overall, LU and TAU identified cholelithiasis in 60 and 61 patients, respectively, said Dr. Obinwanne. The average common bile duct diameter measurement was 3.7 mm with LU and 4.0 mm with TAU.
However, LU found significantly more gallbladder polyps than did TAU (41 vs. 6). The sensitivity and specificity of LU were 90% and 98%, respectively, for gallbladder pathology and 83% and 85%, respectively, for polyps.
"The mean time to complete an LU procedure was 4 minutes," Dr. Obinwanne said.
The study was limited by its small size, but the results suggest that LU is safe, quick, and easy to perform – and thus it’s an alternative to TAU for detecting gallbladder pathology in bariatric surgery patients.
Dr. Obinwanne had no financial conflicts to disclose.
CHICAGO – Laparoscopic ultrasound was as effective as transabdominal ultrasound for detecting cholelithiasis, and superior at finding gallbladder polyps, based on data from 253 adults undergoing laparoscopic gastric bypass procedures.
Morbidly obese patients are at increased risk for cholelithiasis, with approximately 22%-52% developing the condition, said Dr. Kosisochi M. Obinwanne at the annual clinical congress of the American College of Surgeons.
For surgeons who perform gallbladder surgery separate from the gastric bypass, "it becomes necessary to obtain images of the gallbladder to determine the presence of gallstones," said Dr. Obinwanne of Gundersen Lutheran Health System in La Crosse, Wisc.
"Transabdominal ultrasound is the gold standard for detecting cholelithiasis," he said. However, the increased visceral and subcutaneous fat in patients with morbid obesity can make detection of gallbladder pathology difficult using transabdominal ultrasound (TAU), but laparoscopic ultrasound (LU) has the potential to be as effective as TAU, he noted.
To evaluate the sensitivity and specificity of LU vs. TAU for detecting gallbladder pathology in morbidly obese patients, Dr. Obinwanne and his colleagues conducted a prospective study of 253 patients who underwent laparoscopic gastric bypass over a 6-year period. Their average age was 43 years, average body mass index was 48 kg/m2, and 76% were women.
The patients underwent both TAU and LU during laparoscopic gastric bypass surgery. Certified ultrasonographers performed TAU, and surgeons blinded to the TAU results performed LU, Dr. Obinwanne said.
Overall, LU and TAU identified cholelithiasis in 60 and 61 patients, respectively, said Dr. Obinwanne. The average common bile duct diameter measurement was 3.7 mm with LU and 4.0 mm with TAU.
However, LU found significantly more gallbladder polyps than did TAU (41 vs. 6). The sensitivity and specificity of LU were 90% and 98%, respectively, for gallbladder pathology and 83% and 85%, respectively, for polyps.
"The mean time to complete an LU procedure was 4 minutes," Dr. Obinwanne said.
The study was limited by its small size, but the results suggest that LU is safe, quick, and easy to perform – and thus it’s an alternative to TAU for detecting gallbladder pathology in bariatric surgery patients.
Dr. Obinwanne had no financial conflicts to disclose.
AT THE ANNUAL CLINICAL CONGRESS OF THE AMERICAN COLLEGE OF SURGEONS
Major Finding: Laparoscopic ultrasound and transabdominal ultrasound detected gallbladder pathology in similar numbers of patients (60 vs. 61, respectively), but significantly more gallbladder polyps were found via laparoscopic ultrasound (41 vs. 6).
Data Source: The data come from a prospective study of 253 adults who underwent gastric bypass surgery at a single center.
Disclosures: Dr. Obinwanne had no financial conflicts to disclose.
Most Kids' Readmissions Stem From Initial Surgeries
CHICAGO – A majority of unplanned 30-day readmissions of general surgery patients to a pediatric hospital resulted from the initial surgery or procedure for which the child was hospitalized, according to data on more than 300 patients. The findings were presented at the annual clinical congress of the American College of Surgeons.
Hospital readmission within 30 days has become an important quality measure, but data on the frequency and epidemiology of pediatric surgery readmissions are limited, said Dr. Andre Marshall of Vanderbilt University, Nashville, Tenn.
"In order to decrease readmissions, pediatric surgeons must know where to focus efforts," he said.
To determine the proportion of readmissions associated with each surgical service, Dr. Marshall and colleagues reviewed data from 12,438 surgical admissions at a single center between January 2007 and December 2010. Data were taken from the Pediatric Health Information System database and electronic medical records.
A 30-day readmission was defined as any readmission within 30 days of an index hospitalization. Surgical services included general surgery, thoracic surgery, neurosurgery, cardiac surgery, orthopedics, otolaryngology, urologic surgery, ophthalmology, plastic surgery, and kidney and liver transplants.
In all, 1,178 patients were readmitted during the study period, for a readmission rate of 10%. Of these, 318 (27%) were general surgery readmissions. The next highest readmission rates by specialty were neurosurgery (26%), cardiac surgery (18%), and orthopedics (10%). The average age of the readmitted patients was 3 years, and 58% were male.
Of the 318 general surgery readmissions, 295 were unplanned, Dr. Marshall said. Of these, 174 (59%) were related to the index surgery or procedure, and 121 (41%) were related to a new illness, new trauma, or other reason not related to the initial procedure.
Among general surgery patients, infection complications were the most common reason for 30-day readmission (38%), followed by gastrointestinal issues (28%), respiratory complications (9%), planned readmissions (7%), postoperative pain (5%), and other (13%).
The most common preoperative diagnoses associated with 30-day readmission were acute appendicitis (18%), congenital malformations (17%), and gastroesophageal reflux disease (14%).
"Improving processes to anticipate which patients and diagnoses are at the greatest risk of 30-day readmission will potentially allow for early interventions by providers," Dr. Marshall said. Early intervention will allow clinicians to implement strategies to help reduce overall readmission rates and improve the quality of patient care, he added.
Dr. Marshall had no financial conflicts to disclose.
CHICAGO – A majority of unplanned 30-day readmissions of general surgery patients to a pediatric hospital resulted from the initial surgery or procedure for which the child was hospitalized, according to data on more than 300 patients. The findings were presented at the annual clinical congress of the American College of Surgeons.
Hospital readmission within 30 days has become an important quality measure, but data on the frequency and epidemiology of pediatric surgery readmissions are limited, said Dr. Andre Marshall of Vanderbilt University, Nashville, Tenn.
"In order to decrease readmissions, pediatric surgeons must know where to focus efforts," he said.
To determine the proportion of readmissions associated with each surgical service, Dr. Marshall and colleagues reviewed data from 12,438 surgical admissions at a single center between January 2007 and December 2010. Data were taken from the Pediatric Health Information System database and electronic medical records.
A 30-day readmission was defined as any readmission within 30 days of an index hospitalization. Surgical services included general surgery, thoracic surgery, neurosurgery, cardiac surgery, orthopedics, otolaryngology, urologic surgery, ophthalmology, plastic surgery, and kidney and liver transplants.
In all, 1,178 patients were readmitted during the study period, for a readmission rate of 10%. Of these, 318 (27%) were general surgery readmissions. The next highest readmission rates by specialty were neurosurgery (26%), cardiac surgery (18%), and orthopedics (10%). The average age of the readmitted patients was 3 years, and 58% were male.
Of the 318 general surgery readmissions, 295 were unplanned, Dr. Marshall said. Of these, 174 (59%) were related to the index surgery or procedure, and 121 (41%) were related to a new illness, new trauma, or other reason not related to the initial procedure.
Among general surgery patients, infection complications were the most common reason for 30-day readmission (38%), followed by gastrointestinal issues (28%), respiratory complications (9%), planned readmissions (7%), postoperative pain (5%), and other (13%).
The most common preoperative diagnoses associated with 30-day readmission were acute appendicitis (18%), congenital malformations (17%), and gastroesophageal reflux disease (14%).
"Improving processes to anticipate which patients and diagnoses are at the greatest risk of 30-day readmission will potentially allow for early interventions by providers," Dr. Marshall said. Early intervention will allow clinicians to implement strategies to help reduce overall readmission rates and improve the quality of patient care, he added.
Dr. Marshall had no financial conflicts to disclose.
CHICAGO – A majority of unplanned 30-day readmissions of general surgery patients to a pediatric hospital resulted from the initial surgery or procedure for which the child was hospitalized, according to data on more than 300 patients. The findings were presented at the annual clinical congress of the American College of Surgeons.
Hospital readmission within 30 days has become an important quality measure, but data on the frequency and epidemiology of pediatric surgery readmissions are limited, said Dr. Andre Marshall of Vanderbilt University, Nashville, Tenn.
"In order to decrease readmissions, pediatric surgeons must know where to focus efforts," he said.
To determine the proportion of readmissions associated with each surgical service, Dr. Marshall and colleagues reviewed data from 12,438 surgical admissions at a single center between January 2007 and December 2010. Data were taken from the Pediatric Health Information System database and electronic medical records.
A 30-day readmission was defined as any readmission within 30 days of an index hospitalization. Surgical services included general surgery, thoracic surgery, neurosurgery, cardiac surgery, orthopedics, otolaryngology, urologic surgery, ophthalmology, plastic surgery, and kidney and liver transplants.
In all, 1,178 patients were readmitted during the study period, for a readmission rate of 10%. Of these, 318 (27%) were general surgery readmissions. The next highest readmission rates by specialty were neurosurgery (26%), cardiac surgery (18%), and orthopedics (10%). The average age of the readmitted patients was 3 years, and 58% were male.
Of the 318 general surgery readmissions, 295 were unplanned, Dr. Marshall said. Of these, 174 (59%) were related to the index surgery or procedure, and 121 (41%) were related to a new illness, new trauma, or other reason not related to the initial procedure.
Among general surgery patients, infection complications were the most common reason for 30-day readmission (38%), followed by gastrointestinal issues (28%), respiratory complications (9%), planned readmissions (7%), postoperative pain (5%), and other (13%).
The most common preoperative diagnoses associated with 30-day readmission were acute appendicitis (18%), congenital malformations (17%), and gastroesophageal reflux disease (14%).
"Improving processes to anticipate which patients and diagnoses are at the greatest risk of 30-day readmission will potentially allow for early interventions by providers," Dr. Marshall said. Early intervention will allow clinicians to implement strategies to help reduce overall readmission rates and improve the quality of patient care, he added.
Dr. Marshall had no financial conflicts to disclose.
AT THE ANNUAL CLINICAL CONGRESS OF THE AMERICAN COLLEGE OF SURGEONS
Major Finding: More than half (59%) of 30-day readmissions for pediatric general surgery patients were related to their initial surgeries or procedures.
Data Source: The data come from 12,438 surgical admissions at a single center between January 2007 and December 2010.
Disclosures: Dr. Marshall had no financial conflicts to disclose.
Sternal SSIs, Mediastinitis Plummet Under Preop Decolonization Program
SAN DIEGO – Conducting preoperative nasal screening and decolonization of Staphylococcus aureus in patients undergoing cardiothoracic surgery led to a significant reduction in the rate of all sternal surgical site infections, including those attributable to S. aureus, results from a large single-center study showed.
"Staphylococcus aureus sternal surgical site infections [SSIs] are associated with significant morbidity and mortality," lead researcher Jennifer Madigan said in an interview following IDWeek 2012, the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. "Multiple studies in the past have shown that screening and decolonization of S. aureus carriers are associated with a reduction in sternal SSIs."
One recent intervention that identified S. aureus nasal carriers concluded that S. aureus SSIs can be reduced by rapid screening and decolonization of nares on hospital admission (N. Engl. J. Med. 2010;362:9-17). "This study used [polymerase chain reaction testing] for identification of S. aureus nasal carriers, followed by treatment with mupirocin nasal ointment and chlorhexidine soap," said Ms. Madigan of the department of infection prevention and control at St. John Hospital and Medical Center, Detroit. "The results showed more than a 50% reduction in S. aureus infections."
Ms. Madigan and her associates compared the SSI rates 57 months before and 24 months after initiation of an S. aureus decolonization program for cardiothoracic surgery patients. For this program S. aureus nasal carriers were decolonized with mupirocin nasal ointment daily for 5 days and were asked to bathe with chlorhexidine gluconate rinse for 5 days immediately before surgery. The researchers reported results from 580 patients who were screened from April 2010 through March 2012. Of these patients, 118 (20%) tested positive for S. aureus colonization, including 34 (6%) who tested positive for methicillin-resistant S. aureus.
After the S. aureus decolonization program was initiated, the rate of postoperative sternal SSIs following coronary artery bypass grafting (CABG) decreased by 65% (from 76 infections per 1,416 cases before screening to 8 infections per 427 cases after screening; P = .0019), with a 75% drop in the number of mediastinitis cases (from 39 infections per 1,416 cases before screening to 3 infections per 427 cases after screening; P = .0106).
The researchers also found that sternal SSIs attributable to S. aureus dropped by 82% (from 39 infections per 1,416 cases before screening to 2 infections per 427 cases after screening; P = .0044), with S. aureus mediastinitis dropping by 87% (from 21 infections per 1,416 cases before screening to 1 infection per 427 cases after screening; P = .0337).
"We encourage hospitals that perform CABG surgeries to incorporate this [decolonization program] into their process," Ms. Madigan said. "The program is associated with significant reductions in infection, morbidity, and mortality. It provides a great tool to reduce the risk of patient harm. In addition, this may have a positive financial impact on hospitals as mediastinitis is no longer a reimbursable condition."
Ms. Madigan said that she had no relevant financial conflicts.
SAN DIEGO – Conducting preoperative nasal screening and decolonization of Staphylococcus aureus in patients undergoing cardiothoracic surgery led to a significant reduction in the rate of all sternal surgical site infections, including those attributable to S. aureus, results from a large single-center study showed.
"Staphylococcus aureus sternal surgical site infections [SSIs] are associated with significant morbidity and mortality," lead researcher Jennifer Madigan said in an interview following IDWeek 2012, the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. "Multiple studies in the past have shown that screening and decolonization of S. aureus carriers are associated with a reduction in sternal SSIs."
One recent intervention that identified S. aureus nasal carriers concluded that S. aureus SSIs can be reduced by rapid screening and decolonization of nares on hospital admission (N. Engl. J. Med. 2010;362:9-17). "This study used [polymerase chain reaction testing] for identification of S. aureus nasal carriers, followed by treatment with mupirocin nasal ointment and chlorhexidine soap," said Ms. Madigan of the department of infection prevention and control at St. John Hospital and Medical Center, Detroit. "The results showed more than a 50% reduction in S. aureus infections."
Ms. Madigan and her associates compared the SSI rates 57 months before and 24 months after initiation of an S. aureus decolonization program for cardiothoracic surgery patients. For this program S. aureus nasal carriers were decolonized with mupirocin nasal ointment daily for 5 days and were asked to bathe with chlorhexidine gluconate rinse for 5 days immediately before surgery. The researchers reported results from 580 patients who were screened from April 2010 through March 2012. Of these patients, 118 (20%) tested positive for S. aureus colonization, including 34 (6%) who tested positive for methicillin-resistant S. aureus.
After the S. aureus decolonization program was initiated, the rate of postoperative sternal SSIs following coronary artery bypass grafting (CABG) decreased by 65% (from 76 infections per 1,416 cases before screening to 8 infections per 427 cases after screening; P = .0019), with a 75% drop in the number of mediastinitis cases (from 39 infections per 1,416 cases before screening to 3 infections per 427 cases after screening; P = .0106).
The researchers also found that sternal SSIs attributable to S. aureus dropped by 82% (from 39 infections per 1,416 cases before screening to 2 infections per 427 cases after screening; P = .0044), with S. aureus mediastinitis dropping by 87% (from 21 infections per 1,416 cases before screening to 1 infection per 427 cases after screening; P = .0337).
"We encourage hospitals that perform CABG surgeries to incorporate this [decolonization program] into their process," Ms. Madigan said. "The program is associated with significant reductions in infection, morbidity, and mortality. It provides a great tool to reduce the risk of patient harm. In addition, this may have a positive financial impact on hospitals as mediastinitis is no longer a reimbursable condition."
Ms. Madigan said that she had no relevant financial conflicts.
SAN DIEGO – Conducting preoperative nasal screening and decolonization of Staphylococcus aureus in patients undergoing cardiothoracic surgery led to a significant reduction in the rate of all sternal surgical site infections, including those attributable to S. aureus, results from a large single-center study showed.
"Staphylococcus aureus sternal surgical site infections [SSIs] are associated with significant morbidity and mortality," lead researcher Jennifer Madigan said in an interview following IDWeek 2012, the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. "Multiple studies in the past have shown that screening and decolonization of S. aureus carriers are associated with a reduction in sternal SSIs."
One recent intervention that identified S. aureus nasal carriers concluded that S. aureus SSIs can be reduced by rapid screening and decolonization of nares on hospital admission (N. Engl. J. Med. 2010;362:9-17). "This study used [polymerase chain reaction testing] for identification of S. aureus nasal carriers, followed by treatment with mupirocin nasal ointment and chlorhexidine soap," said Ms. Madigan of the department of infection prevention and control at St. John Hospital and Medical Center, Detroit. "The results showed more than a 50% reduction in S. aureus infections."
Ms. Madigan and her associates compared the SSI rates 57 months before and 24 months after initiation of an S. aureus decolonization program for cardiothoracic surgery patients. For this program S. aureus nasal carriers were decolonized with mupirocin nasal ointment daily for 5 days and were asked to bathe with chlorhexidine gluconate rinse for 5 days immediately before surgery. The researchers reported results from 580 patients who were screened from April 2010 through March 2012. Of these patients, 118 (20%) tested positive for S. aureus colonization, including 34 (6%) who tested positive for methicillin-resistant S. aureus.
After the S. aureus decolonization program was initiated, the rate of postoperative sternal SSIs following coronary artery bypass grafting (CABG) decreased by 65% (from 76 infections per 1,416 cases before screening to 8 infections per 427 cases after screening; P = .0019), with a 75% drop in the number of mediastinitis cases (from 39 infections per 1,416 cases before screening to 3 infections per 427 cases after screening; P = .0106).
The researchers also found that sternal SSIs attributable to S. aureus dropped by 82% (from 39 infections per 1,416 cases before screening to 2 infections per 427 cases after screening; P = .0044), with S. aureus mediastinitis dropping by 87% (from 21 infections per 1,416 cases before screening to 1 infection per 427 cases after screening; P = .0337).
"We encourage hospitals that perform CABG surgeries to incorporate this [decolonization program] into their process," Ms. Madigan said. "The program is associated with significant reductions in infection, morbidity, and mortality. It provides a great tool to reduce the risk of patient harm. In addition, this may have a positive financial impact on hospitals as mediastinitis is no longer a reimbursable condition."
Ms. Madigan said that she had no relevant financial conflicts.
AT IDWEEK 2012
Major Finding: Following initiation of a preoperative S. aureus decolonization program, the rate of postoperative sternal SSIs following coronary artery bypass grafting dropped by 65%, and the rate of mediastinitis cases dropped by 75%.
Data Source: A single-center study of 580 cardiothoracic surgery patients who were screened from April 2010 through March 2012.
Disclosures: The researchers reported having no relevant financial conflicts.
Early Oral Feeding Benefits Bowel Surgery Patients
CHICAGO – A total of 80% of bowel resection patients tolerated early fluids one day after surgery, based on data from 100 patients.
"Early oral feeding is an important part of fast-track surgery, which enhances recovery after surgery," but feeding in patients undergoing emergency bowel resection is often delayed until the resolution of ileus, Dr. Mohamed E. Shams of Suez Canal University in Ismailia, Egypt, said at the annual clinical congress of the American College of Surgeons.
Dr. Shams and colleagues randomized 100 adults who underwent small or large bowel resection into two groups. The early group comprised 50 patients who received fluid oral feedings on the first day after surgery. The late group comprised 50 patients who received oral feedings after the resolution of ileus.
Overall, 80% of patients in the early group tolerated the early oral feeding. In addition, patients in the early group averaged a significantly shorter time than did the late group to the passage of flatus (3.2 days vs. 0.8 days, respectively), and stool (4.4 days vs. 1.2 days, respectively).
Postoperative monitoring showed that the chest infections occurred in four patients in the early feeding group compared with 10 patients in the late feeding group, while wound infections occurred in 12 patients in the early group and 15 patients in the late group, Dr. Shams said. No incidents of a burst abdomen occurred in the early group, and three incidents occurred in the late group.
"Early oral feeding after emergency intestinal surgery is safe and well tolerated by the majority of patients, without an increase in mortality and morbidity risk," said Dr. Shams. "It also has a positive impact on reduction in hospital stay," he said.
The findings were limited by the small number of patients, but the results suggest that a majority of patients undergoing emergency intestinal surgery can benefit from early feeding, Dr. Shams noted.
Dr. Shams had no financial conflicts to disclose.
CHICAGO – A total of 80% of bowel resection patients tolerated early fluids one day after surgery, based on data from 100 patients.
"Early oral feeding is an important part of fast-track surgery, which enhances recovery after surgery," but feeding in patients undergoing emergency bowel resection is often delayed until the resolution of ileus, Dr. Mohamed E. Shams of Suez Canal University in Ismailia, Egypt, said at the annual clinical congress of the American College of Surgeons.
Dr. Shams and colleagues randomized 100 adults who underwent small or large bowel resection into two groups. The early group comprised 50 patients who received fluid oral feedings on the first day after surgery. The late group comprised 50 patients who received oral feedings after the resolution of ileus.
Overall, 80% of patients in the early group tolerated the early oral feeding. In addition, patients in the early group averaged a significantly shorter time than did the late group to the passage of flatus (3.2 days vs. 0.8 days, respectively), and stool (4.4 days vs. 1.2 days, respectively).
Postoperative monitoring showed that the chest infections occurred in four patients in the early feeding group compared with 10 patients in the late feeding group, while wound infections occurred in 12 patients in the early group and 15 patients in the late group, Dr. Shams said. No incidents of a burst abdomen occurred in the early group, and three incidents occurred in the late group.
"Early oral feeding after emergency intestinal surgery is safe and well tolerated by the majority of patients, without an increase in mortality and morbidity risk," said Dr. Shams. "It also has a positive impact on reduction in hospital stay," he said.
The findings were limited by the small number of patients, but the results suggest that a majority of patients undergoing emergency intestinal surgery can benefit from early feeding, Dr. Shams noted.
Dr. Shams had no financial conflicts to disclose.
CHICAGO – A total of 80% of bowel resection patients tolerated early fluids one day after surgery, based on data from 100 patients.
"Early oral feeding is an important part of fast-track surgery, which enhances recovery after surgery," but feeding in patients undergoing emergency bowel resection is often delayed until the resolution of ileus, Dr. Mohamed E. Shams of Suez Canal University in Ismailia, Egypt, said at the annual clinical congress of the American College of Surgeons.
Dr. Shams and colleagues randomized 100 adults who underwent small or large bowel resection into two groups. The early group comprised 50 patients who received fluid oral feedings on the first day after surgery. The late group comprised 50 patients who received oral feedings after the resolution of ileus.
Overall, 80% of patients in the early group tolerated the early oral feeding. In addition, patients in the early group averaged a significantly shorter time than did the late group to the passage of flatus (3.2 days vs. 0.8 days, respectively), and stool (4.4 days vs. 1.2 days, respectively).
Postoperative monitoring showed that the chest infections occurred in four patients in the early feeding group compared with 10 patients in the late feeding group, while wound infections occurred in 12 patients in the early group and 15 patients in the late group, Dr. Shams said. No incidents of a burst abdomen occurred in the early group, and three incidents occurred in the late group.
"Early oral feeding after emergency intestinal surgery is safe and well tolerated by the majority of patients, without an increase in mortality and morbidity risk," said Dr. Shams. "It also has a positive impact on reduction in hospital stay," he said.
The findings were limited by the small number of patients, but the results suggest that a majority of patients undergoing emergency intestinal surgery can benefit from early feeding, Dr. Shams noted.
Dr. Shams had no financial conflicts to disclose.
FROM THE ANNUAL CLINICAL CONGRESS OF THE AMERICAN COLLEGE OF SURGEONS
Major Finding: Eighty percent of patients who received oral fluids on the first day after surgery vs. delayed feeding had significantly shorter time to the passage of flatus (3.2 days vs. 0.8 days, respectively), and stool (4.4 days vs. 1.2 days, respectively).
Data Source: The data come from a randomized trial of 100 adults who underwent bowel resection.
Disclosures: Dr. Shams reported having no financial conflicts.
Blood Cultures Can Miss Invasive Candidiasis
SAN FRANCISCO – Every patient should get antifungal therapy following surgical treatment of intra-abdominal candidiasis, according to researchers at the University of Pittsburgh.
Not all do; 38% of 199 patients there (76) who had surgical drainage received no antifungals, at least initially; infections persisted in half (38) and 20% (15) died.
"Clinicians could not reliably identify patients who were cured with surgical drainage alone, showing that all patients require antifungal therapy in addition to drainage. A lot of people don’t get treatment, and it’s a problem," said lead investigator Dr. M. Hong Nguyen, director of both the transplant infectious diseases and the antimicrobial management programs at the university.
An overreliance on blood cultures to screen for invasive candidiasis – either before or after surgery – could be to blame; blood cultures aren’t that good at picking it up, she said at the meeting, which was sponsored by the American Society for Microbiology
Even so, they are the go-to screening option in many places because blood stream infections (candidemia) are thought to be the most common manifestations of invasive candidiasis.
That wasn’t true in Pittsburgh. Among the 199 invasive candidiasis patients Dr. Nguyen and her team investigated, intra-abdominal candidiasis (IAC) – mostly abscesses and peritonitis without candidemia – accounted for 53% (105) of cases, and candidemia just 28% (56). Intra-abdominal candidiasis "is much more of a problem than candidemia," Dr. Nguyen said.
Other cases were a blend of both, or infections at another site. Candida albicans was the most implicated organism.
Dr. Nguyen and her colleagues concluded that blood cultures aren’t the right screening tool for invasive candidiasis because they can be negative even when patients have serious disease. "We need some kind of blood diagnostic to help us," she said.
They’ve found that Candida polymerase chain reaction and Fungitell 1,3-Beta-D-glucan (BDG) blood tests seem to be better options, especially helpful when used with blood cultures (Clin. Infect. Dis. 2012;54:1240-8).
The team also concluded that "IAC is more common than recognized ... more common than candidemia, [and] associated with significant morbidity and mortality," she said.
Dr. Nguyen reported having no disclosures.
SAN FRANCISCO – Every patient should get antifungal therapy following surgical treatment of intra-abdominal candidiasis, according to researchers at the University of Pittsburgh.
Not all do; 38% of 199 patients there (76) who had surgical drainage received no antifungals, at least initially; infections persisted in half (38) and 20% (15) died.
"Clinicians could not reliably identify patients who were cured with surgical drainage alone, showing that all patients require antifungal therapy in addition to drainage. A lot of people don’t get treatment, and it’s a problem," said lead investigator Dr. M. Hong Nguyen, director of both the transplant infectious diseases and the antimicrobial management programs at the university.
An overreliance on blood cultures to screen for invasive candidiasis – either before or after surgery – could be to blame; blood cultures aren’t that good at picking it up, she said at the meeting, which was sponsored by the American Society for Microbiology
Even so, they are the go-to screening option in many places because blood stream infections (candidemia) are thought to be the most common manifestations of invasive candidiasis.
That wasn’t true in Pittsburgh. Among the 199 invasive candidiasis patients Dr. Nguyen and her team investigated, intra-abdominal candidiasis (IAC) – mostly abscesses and peritonitis without candidemia – accounted for 53% (105) of cases, and candidemia just 28% (56). Intra-abdominal candidiasis "is much more of a problem than candidemia," Dr. Nguyen said.
Other cases were a blend of both, or infections at another site. Candida albicans was the most implicated organism.
Dr. Nguyen and her colleagues concluded that blood cultures aren’t the right screening tool for invasive candidiasis because they can be negative even when patients have serious disease. "We need some kind of blood diagnostic to help us," she said.
They’ve found that Candida polymerase chain reaction and Fungitell 1,3-Beta-D-glucan (BDG) blood tests seem to be better options, especially helpful when used with blood cultures (Clin. Infect. Dis. 2012;54:1240-8).
The team also concluded that "IAC is more common than recognized ... more common than candidemia, [and] associated with significant morbidity and mortality," she said.
Dr. Nguyen reported having no disclosures.
SAN FRANCISCO – Every patient should get antifungal therapy following surgical treatment of intra-abdominal candidiasis, according to researchers at the University of Pittsburgh.
Not all do; 38% of 199 patients there (76) who had surgical drainage received no antifungals, at least initially; infections persisted in half (38) and 20% (15) died.
"Clinicians could not reliably identify patients who were cured with surgical drainage alone, showing that all patients require antifungal therapy in addition to drainage. A lot of people don’t get treatment, and it’s a problem," said lead investigator Dr. M. Hong Nguyen, director of both the transplant infectious diseases and the antimicrobial management programs at the university.
An overreliance on blood cultures to screen for invasive candidiasis – either before or after surgery – could be to blame; blood cultures aren’t that good at picking it up, she said at the meeting, which was sponsored by the American Society for Microbiology
Even so, they are the go-to screening option in many places because blood stream infections (candidemia) are thought to be the most common manifestations of invasive candidiasis.
That wasn’t true in Pittsburgh. Among the 199 invasive candidiasis patients Dr. Nguyen and her team investigated, intra-abdominal candidiasis (IAC) – mostly abscesses and peritonitis without candidemia – accounted for 53% (105) of cases, and candidemia just 28% (56). Intra-abdominal candidiasis "is much more of a problem than candidemia," Dr. Nguyen said.
Other cases were a blend of both, or infections at another site. Candida albicans was the most implicated organism.
Dr. Nguyen and her colleagues concluded that blood cultures aren’t the right screening tool for invasive candidiasis because they can be negative even when patients have serious disease. "We need some kind of blood diagnostic to help us," she said.
They’ve found that Candida polymerase chain reaction and Fungitell 1,3-Beta-D-glucan (BDG) blood tests seem to be better options, especially helpful when used with blood cultures (Clin. Infect. Dis. 2012;54:1240-8).
The team also concluded that "IAC is more common than recognized ... more common than candidemia, [and] associated with significant morbidity and mortality," she said.
Dr. Nguyen reported having no disclosures.
AT THE ANNUAL INTERSCIENCE CONFERENCE ON ANTIMICROBIAL AGENTS AND CHEMOTHERAPY
Major Finding: Based on blood culture results, 38% of patients who had surgical drainage received no antifungals, at least initially; infections persisted in half, and 20% died.
Data Source: Observational study of 199 patients with invasive candidiasis.
Disclosures: The investigator reported having no relevant disclosures.
Kids' Outcomes Equal Across Pediatric, Adult Trauma Centers
CHICAGO – Outcomes for children seen at pediatric trauma centers were not significantly different than for children seen at adult trauma centers, according to a review of more than 45,000 pediatric injuries.
The finding "has significant policy implications because it means that emergency medical services do not have to triage patients according to specialty care centers," and it informs discussions about pediatric access to trauma care, said researcher Dr. Cassandra Villegas of the University of Arizona in Tucson.
Trauma accounts for approximately one-third of all pediatric mortality, but there are only 170 pediatric-specific trauma centers in the United States, which "means that the vast majority of pediatric patients that are injured are actually managed and evaluated at adult trauma centers," Dr. Villegas said at the annual clinical congress of the American College of Surgeons.
Nonetheless, data on pediatric outcomes for children treated at pediatric vs. adult trauma centers have not been conclusive, and most previous studies have focused on metropolitan or state pediatric centers, she said.
Dr. Villegas and her colleagues reviewed data from the National Trauma Database for 2007-2008 that included 27 pediatric trauma centers and 30 adult (mixed care) centers that had pediatric beds. Most (90%) of the 30 mixed care centers provided all acute pediatric services, while 10% shared these services with another medical center. All of the pediatric centers and 90% of the mixed care centers had pediatric intensive care units. The pediatric centers were significantly more likely to be university hospitals than were the mixed centers (85% vs. 53%).
The researchers analyzed outcomes for children aged 0-14 years, including 33,327 patients treated at pediatric centers and 12,605 patients treated at mixed centers.
After controlling for multiple variables including injury characteristics, Dr. Villegas and her associates found that in-hospital mortality – the primary outcome – was twice as high at mixed centers as at pediatric centers (2% vs. 1%), but this difference was not significant. The median length of stay was 2 days at all centers, although ICU admission rates were higher at mixed centers vs. pediatric centers (26% vs. 14%).
Approximately one-third of the patients seen at either type of center had an Injury Severity Score (ISS) in the 9-15 range, said Dr. Villegas. Falls were the most common type of injury, accounting for 49% of cases at pediatric centers and 37% of cases at mixed centers.
The patients at mixed centers were more likely than those at pediatric centers to be hypotensive (18% vs. 10%).
The study was limited by several factors, including the low incidence of pediatric mortality, the lack of uniform coding for death on arrival, and differences in ICU admission practices, said Dr. Villegas.
However, the findings suggest that there are no differences in outcomes for children treated at pediatric vs. mixed care centers, she said.
Dr. Villegas reported having no financial conflicts of interest.
CHICAGO – Outcomes for children seen at pediatric trauma centers were not significantly different than for children seen at adult trauma centers, according to a review of more than 45,000 pediatric injuries.
The finding "has significant policy implications because it means that emergency medical services do not have to triage patients according to specialty care centers," and it informs discussions about pediatric access to trauma care, said researcher Dr. Cassandra Villegas of the University of Arizona in Tucson.
Trauma accounts for approximately one-third of all pediatric mortality, but there are only 170 pediatric-specific trauma centers in the United States, which "means that the vast majority of pediatric patients that are injured are actually managed and evaluated at adult trauma centers," Dr. Villegas said at the annual clinical congress of the American College of Surgeons.
Nonetheless, data on pediatric outcomes for children treated at pediatric vs. adult trauma centers have not been conclusive, and most previous studies have focused on metropolitan or state pediatric centers, she said.
Dr. Villegas and her colleagues reviewed data from the National Trauma Database for 2007-2008 that included 27 pediatric trauma centers and 30 adult (mixed care) centers that had pediatric beds. Most (90%) of the 30 mixed care centers provided all acute pediatric services, while 10% shared these services with another medical center. All of the pediatric centers and 90% of the mixed care centers had pediatric intensive care units. The pediatric centers were significantly more likely to be university hospitals than were the mixed centers (85% vs. 53%).
The researchers analyzed outcomes for children aged 0-14 years, including 33,327 patients treated at pediatric centers and 12,605 patients treated at mixed centers.
After controlling for multiple variables including injury characteristics, Dr. Villegas and her associates found that in-hospital mortality – the primary outcome – was twice as high at mixed centers as at pediatric centers (2% vs. 1%), but this difference was not significant. The median length of stay was 2 days at all centers, although ICU admission rates were higher at mixed centers vs. pediatric centers (26% vs. 14%).
Approximately one-third of the patients seen at either type of center had an Injury Severity Score (ISS) in the 9-15 range, said Dr. Villegas. Falls were the most common type of injury, accounting for 49% of cases at pediatric centers and 37% of cases at mixed centers.
The patients at mixed centers were more likely than those at pediatric centers to be hypotensive (18% vs. 10%).
The study was limited by several factors, including the low incidence of pediatric mortality, the lack of uniform coding for death on arrival, and differences in ICU admission practices, said Dr. Villegas.
However, the findings suggest that there are no differences in outcomes for children treated at pediatric vs. mixed care centers, she said.
Dr. Villegas reported having no financial conflicts of interest.
CHICAGO – Outcomes for children seen at pediatric trauma centers were not significantly different than for children seen at adult trauma centers, according to a review of more than 45,000 pediatric injuries.
The finding "has significant policy implications because it means that emergency medical services do not have to triage patients according to specialty care centers," and it informs discussions about pediatric access to trauma care, said researcher Dr. Cassandra Villegas of the University of Arizona in Tucson.
Trauma accounts for approximately one-third of all pediatric mortality, but there are only 170 pediatric-specific trauma centers in the United States, which "means that the vast majority of pediatric patients that are injured are actually managed and evaluated at adult trauma centers," Dr. Villegas said at the annual clinical congress of the American College of Surgeons.
Nonetheless, data on pediatric outcomes for children treated at pediatric vs. adult trauma centers have not been conclusive, and most previous studies have focused on metropolitan or state pediatric centers, she said.
Dr. Villegas and her colleagues reviewed data from the National Trauma Database for 2007-2008 that included 27 pediatric trauma centers and 30 adult (mixed care) centers that had pediatric beds. Most (90%) of the 30 mixed care centers provided all acute pediatric services, while 10% shared these services with another medical center. All of the pediatric centers and 90% of the mixed care centers had pediatric intensive care units. The pediatric centers were significantly more likely to be university hospitals than were the mixed centers (85% vs. 53%).
The researchers analyzed outcomes for children aged 0-14 years, including 33,327 patients treated at pediatric centers and 12,605 patients treated at mixed centers.
After controlling for multiple variables including injury characteristics, Dr. Villegas and her associates found that in-hospital mortality – the primary outcome – was twice as high at mixed centers as at pediatric centers (2% vs. 1%), but this difference was not significant. The median length of stay was 2 days at all centers, although ICU admission rates were higher at mixed centers vs. pediatric centers (26% vs. 14%).
Approximately one-third of the patients seen at either type of center had an Injury Severity Score (ISS) in the 9-15 range, said Dr. Villegas. Falls were the most common type of injury, accounting for 49% of cases at pediatric centers and 37% of cases at mixed centers.
The patients at mixed centers were more likely than those at pediatric centers to be hypotensive (18% vs. 10%).
The study was limited by several factors, including the low incidence of pediatric mortality, the lack of uniform coding for death on arrival, and differences in ICU admission practices, said Dr. Villegas.
However, the findings suggest that there are no differences in outcomes for children treated at pediatric vs. mixed care centers, she said.
Dr. Villegas reported having no financial conflicts of interest.
FROM THE ANNUAL CLINICAL CONGRESS OF THE AMERICAN COLLEGE OF SURGEONS
Major Finding: In-hospital mortality for children aged 0-14 years was twice as high for those treated at mixed centers as for those treated at pediatric centers (2% vs. 1%), but this difference was not significant.
Data Source: The data come from the National Trauma Database for 2007-2008, and included 33,327 patients treated at pediatric centers and 12,605 patients treated at mixed centers.
Disclosures: Dr. Villegas reported having no financial conflicts of interest.
Postop Radiation Slows Prostate Cancer Progression
Delivering radiation therapy immediately after radical prostatectomy resulted in fewer cases of biochemical progression of prostate cancer, compared with a "wait-and-see" approach, according to long-term data from a randomized phase III trial.
However, no such effect on overall survival was seen, with a possible detrimental effect in patients older than 70 years, investigators reported online Oct. 19 in the Lancet (doi: 10.1016/S0140-6736(12)61253-7).
Dr. Michel Bolla, of the Centre Hospitalier Universitaire A Michallon in Grenoble, France, and his colleagues looked at 1,005 men enrolled in the European Organisation for Research and Treatment of Cancer (EORTC) 22911 trial, who were followed for a median of 10.6 years.
The cohort (median age 65 years) included patients with untreated adenocarcinoma of the prostate and at least one of the following: capsular perforation, positive surgical margins, or seminal vesicle invasion.
All patients underwent radical prostatectomy, and were then randomly assigned either to receive immediate postoperative external irradiation (within 16 weeks of surgery) or to a "wait-and-see" policy, whereby subsequent treatment was delayed until biochemical or clinical relapse.
Overall, Dr. Bolla and his coauthors found that 198 patients (39.4%) in the postoperative radiation group had biochemical progression (defined as an increase in prostate-specific antigen concentration to more than 0.2 mcg/L measured on two occasions at least 2 weeks apart), clinical progression, or died.
In contrast, the "wait-and-see" group recorded 311 patients (61.8%) who either progressed or died, for a hazard ratio of 0.49 for the radiation approach (P less than .0001).
Stratifying the results by age showed that patients under 70 years old had improved biochemical progression-free survival (hazard ratio, 0.44; P less than .0001) and clinical progression-free survival (HR, 0.67; P = .0013) in the radiation cohort compared with wait-and-see patients.
However, "excess mortality was seen in patients aged 70 years or older who had received immediate radiation compared with those aged 70 years or older who were on the wait-and-see policy," they wrote, with 40 deaths out of 94 older patients in the radiation group versus 20 deaths out of 102 patients in the wait-and-see group (HR, 2.94; P less than .0001).
Finally, looking at the entire cohort, the authors found that overall all-cause 10-year survival did not differ substantially, at 76.9% for the postoperative radiation patients and 80.7% for the wait-and-see group.
"Prostate cancer mortality did not differ significantly between groups either," added the authors.
Dr. Bolla and his colleagues said they had no conflicts of interest related to this study, which was funded by the Ligue Nationale contre le Cancer and the EORTC Charitable Trust.
In a comment accompanying the article, Dr. Jason A. Efstathiou wrote that "the decision to treat [prostate cancer] needs multidisciplinary input" from the entire uro-oncology team, including surgical, radiation, and medical specialists (Lancet 2012 Oct. 19 [doi: 10.1016/S0140-6736(12)61253-7]).
"When surgery has probably not cured a patient, prospective data still support postoperative radiation. The onus is on the uro-oncology team (surgical, radiation, and medical) to discuss postoperative radiation with the patient, address optimal timing of initiation when it is used, and provide justification when it is not," he wrote.
Looking to the future, "novel imaging modalities, such as lymphotropic nanoparticle and multiparametric MRI and PET (18F-sodium fluoride, 18F-acetate, 11C-acetate, 18F-choline, 11C-choline, and others), are being explored extensively, and provide further promise," he added.
"Such advances might help discern which patients are most likely to benefit from postoperative radiation."
DR. EFSTATHIOU is with the department of radiation oncology at Massachusetts General Hospital in Boston. He declared that he had no conflicts of interest.
In a comment accompanying the article, Dr. Jason A. Efstathiou wrote that "the decision to treat [prostate cancer] needs multidisciplinary input" from the entire uro-oncology team, including surgical, radiation, and medical specialists (Lancet 2012 Oct. 19 [doi: 10.1016/S0140-6736(12)61253-7]).
"When surgery has probably not cured a patient, prospective data still support postoperative radiation. The onus is on the uro-oncology team (surgical, radiation, and medical) to discuss postoperative radiation with the patient, address optimal timing of initiation when it is used, and provide justification when it is not," he wrote.
Looking to the future, "novel imaging modalities, such as lymphotropic nanoparticle and multiparametric MRI and PET (18F-sodium fluoride, 18F-acetate, 11C-acetate, 18F-choline, 11C-choline, and others), are being explored extensively, and provide further promise," he added.
"Such advances might help discern which patients are most likely to benefit from postoperative radiation."
DR. EFSTATHIOU is with the department of radiation oncology at Massachusetts General Hospital in Boston. He declared that he had no conflicts of interest.
In a comment accompanying the article, Dr. Jason A. Efstathiou wrote that "the decision to treat [prostate cancer] needs multidisciplinary input" from the entire uro-oncology team, including surgical, radiation, and medical specialists (Lancet 2012 Oct. 19 [doi: 10.1016/S0140-6736(12)61253-7]).
"When surgery has probably not cured a patient, prospective data still support postoperative radiation. The onus is on the uro-oncology team (surgical, radiation, and medical) to discuss postoperative radiation with the patient, address optimal timing of initiation when it is used, and provide justification when it is not," he wrote.
Looking to the future, "novel imaging modalities, such as lymphotropic nanoparticle and multiparametric MRI and PET (18F-sodium fluoride, 18F-acetate, 11C-acetate, 18F-choline, 11C-choline, and others), are being explored extensively, and provide further promise," he added.
"Such advances might help discern which patients are most likely to benefit from postoperative radiation."
DR. EFSTATHIOU is with the department of radiation oncology at Massachusetts General Hospital in Boston. He declared that he had no conflicts of interest.
Delivering radiation therapy immediately after radical prostatectomy resulted in fewer cases of biochemical progression of prostate cancer, compared with a "wait-and-see" approach, according to long-term data from a randomized phase III trial.
However, no such effect on overall survival was seen, with a possible detrimental effect in patients older than 70 years, investigators reported online Oct. 19 in the Lancet (doi: 10.1016/S0140-6736(12)61253-7).
Dr. Michel Bolla, of the Centre Hospitalier Universitaire A Michallon in Grenoble, France, and his colleagues looked at 1,005 men enrolled in the European Organisation for Research and Treatment of Cancer (EORTC) 22911 trial, who were followed for a median of 10.6 years.
The cohort (median age 65 years) included patients with untreated adenocarcinoma of the prostate and at least one of the following: capsular perforation, positive surgical margins, or seminal vesicle invasion.
All patients underwent radical prostatectomy, and were then randomly assigned either to receive immediate postoperative external irradiation (within 16 weeks of surgery) or to a "wait-and-see" policy, whereby subsequent treatment was delayed until biochemical or clinical relapse.
Overall, Dr. Bolla and his coauthors found that 198 patients (39.4%) in the postoperative radiation group had biochemical progression (defined as an increase in prostate-specific antigen concentration to more than 0.2 mcg/L measured on two occasions at least 2 weeks apart), clinical progression, or died.
In contrast, the "wait-and-see" group recorded 311 patients (61.8%) who either progressed or died, for a hazard ratio of 0.49 for the radiation approach (P less than .0001).
Stratifying the results by age showed that patients under 70 years old had improved biochemical progression-free survival (hazard ratio, 0.44; P less than .0001) and clinical progression-free survival (HR, 0.67; P = .0013) in the radiation cohort compared with wait-and-see patients.
However, "excess mortality was seen in patients aged 70 years or older who had received immediate radiation compared with those aged 70 years or older who were on the wait-and-see policy," they wrote, with 40 deaths out of 94 older patients in the radiation group versus 20 deaths out of 102 patients in the wait-and-see group (HR, 2.94; P less than .0001).
Finally, looking at the entire cohort, the authors found that overall all-cause 10-year survival did not differ substantially, at 76.9% for the postoperative radiation patients and 80.7% for the wait-and-see group.
"Prostate cancer mortality did not differ significantly between groups either," added the authors.
Dr. Bolla and his colleagues said they had no conflicts of interest related to this study, which was funded by the Ligue Nationale contre le Cancer and the EORTC Charitable Trust.
Delivering radiation therapy immediately after radical prostatectomy resulted in fewer cases of biochemical progression of prostate cancer, compared with a "wait-and-see" approach, according to long-term data from a randomized phase III trial.
However, no such effect on overall survival was seen, with a possible detrimental effect in patients older than 70 years, investigators reported online Oct. 19 in the Lancet (doi: 10.1016/S0140-6736(12)61253-7).
Dr. Michel Bolla, of the Centre Hospitalier Universitaire A Michallon in Grenoble, France, and his colleagues looked at 1,005 men enrolled in the European Organisation for Research and Treatment of Cancer (EORTC) 22911 trial, who were followed for a median of 10.6 years.
The cohort (median age 65 years) included patients with untreated adenocarcinoma of the prostate and at least one of the following: capsular perforation, positive surgical margins, or seminal vesicle invasion.
All patients underwent radical prostatectomy, and were then randomly assigned either to receive immediate postoperative external irradiation (within 16 weeks of surgery) or to a "wait-and-see" policy, whereby subsequent treatment was delayed until biochemical or clinical relapse.
Overall, Dr. Bolla and his coauthors found that 198 patients (39.4%) in the postoperative radiation group had biochemical progression (defined as an increase in prostate-specific antigen concentration to more than 0.2 mcg/L measured on two occasions at least 2 weeks apart), clinical progression, or died.
In contrast, the "wait-and-see" group recorded 311 patients (61.8%) who either progressed or died, for a hazard ratio of 0.49 for the radiation approach (P less than .0001).
Stratifying the results by age showed that patients under 70 years old had improved biochemical progression-free survival (hazard ratio, 0.44; P less than .0001) and clinical progression-free survival (HR, 0.67; P = .0013) in the radiation cohort compared with wait-and-see patients.
However, "excess mortality was seen in patients aged 70 years or older who had received immediate radiation compared with those aged 70 years or older who were on the wait-and-see policy," they wrote, with 40 deaths out of 94 older patients in the radiation group versus 20 deaths out of 102 patients in the wait-and-see group (HR, 2.94; P less than .0001).
Finally, looking at the entire cohort, the authors found that overall all-cause 10-year survival did not differ substantially, at 76.9% for the postoperative radiation patients and 80.7% for the wait-and-see group.
"Prostate cancer mortality did not differ significantly between groups either," added the authors.
Dr. Bolla and his colleagues said they had no conflicts of interest related to this study, which was funded by the Ligue Nationale contre le Cancer and the EORTC Charitable Trust.
FROM THE LANCET
Major Finding: Among postprostatectomy patients, 39.4% of patients who underwent immediate radiation had biochemical progression, versus 61.8% of patients who took a "wait-and-see" approach.
Data Source: This was a randomized trial of 1,005 patients in the European Organisation for Research and Treatment of Cancer 22911 study.
Disclosures: Dr. Bolla and his colleagues said they had no conflicts of interest related to this study, which was funded by the Ligue Nationale contre le Cancer and the EORTC Charitable Trust.
Analysis: Surgical Practice Changes Warrant Residency Reforms
Surgical residency programs have not kept up with radical changes in the practice of surgery over the past two decades, but innovations ranging from curriculum reform to increasing the length of residency could help to improve the overall performance of recent surgical residency graduates, according to an analysis in Annals of Surgery.
"The changes that have occurred have been disruptive to residency training, and to date there has been minimal compensation for these," Dr. Frank Lewis and Dr. Mary Klingensmith wrote. "Evidence is now emerging of significant issues in the overall performance of recent graduates from at least three sources – the evaluation of external agents who incorporate these graduates into their practice or group, the opinions of the residents themselves, and the performance of graduates on the oral examination of the American Board of Surgery during the last 8 years" (Ann. Surg. 2012;256:553-59).
The changes include not only the 80-hour workweek for surgical residents, but also clinical areas, according to Dr. Lewis, executive director of the American Board of Surgery, and Dr. Klingensmith, residency program director at Washington University in St. Louis.
The effect of the 80-hour workweek has been a reduction by 6 months to a year of in-hospital experience during 5 years of residency. Most of that reduced time corresponds to night and weekend experience, when residents would be more likely to see urgent and emergent conditions, and to have a greater degree of independent functioning, autonomy, and indirect supervision, they said.
The most significant clinical change has been the development of laparoscopic surgery for intra-abdominal surgical management, which is replacing open surgery and the abdominal incision. Because surgeons in academic settings have been slower to adopt laparoscopy, resident training in the use of this technology has proceeded slowly, they explained.
"While the Residency Review Committee (RRC) for Surgery has been steadily increasing the requirements for surgical resident training, it is still the rule that the most complex laparoscopic surgery is reserved for fellows in postresidency fellowships and not for residents during surgical training, although there is no reason this should be the case," they noted.
In addition, operations performed by general surgeons, and the way in which they are done, have changed significantly in the past 20 years, according to the analysis. For example, the advent of better medical management for benign peptic ulcer disease – along with flexible endoscopy and endoscopic retrograde cholangiopancreatography – means that fewer surgical interventions for peptic ulcer complications and biliary tree stone disease are necessary.
Furthermore, technological innovations have allowed vascular surgeons, rather than general surgeons, to perform most abdominal vascular surgery. Finally, the two surgeons reported, abdominal trauma injuries – which require surgical intervention in 80%-90% of cases – have declined dramatically since 1992.
These types of changes "will undoubtedly continue, and the directions in which surgery will evolve in the future are not predictable," Dr. Lewis and Dr. Klingensmith wrote.
They laid out seven potential ways in which surgical residency programs can address the changes:
• There should be a continuous process to define and continually update the surgical residency curriculum, which needs to keep pace with the fast-changing surgical practice landscape, and to "prune" information related to diseases that no longer are seen frequently in practice.
"The starting point for making changes in residency is to recognize that much of what is being taught is obsolete, and addresses diseases that are no longer a significant problem, or those for which surgical treatment is rarely needed," they said.
• Residency programs should improve the efficacy of resident learning by reducing clerical functions for residents, using physician extenders where appropriate, and utilizing mobile computing technology to deliver "a more defined and comprehensive curriculum to residents at an individual level."
• Educators could make better use of simulators in certain areas, such as laparoscopic surgery and endoscopic surgery.
• There should be an earlier specialty focus in residency training for those surgical residents who already know which specialty they would like to pursue.
• Surgical residency should include expanded laparoscopic surgery training.
• Residency programs could increase in length to make up for the time lost to the 80-hour workweek rule. Four-fifths of surgical residents already elect to take a postresidency fellowship in a specialty or subspecialty area, so "any discussion of extending residency only applies to the 20% of residents who currently complete only general surgical residency and do not seek subspecialty training," they said. "Extending residency by 1 year to obtain more extensive training in general surgery per se would not seem to be an insurmountable issue if the benefits clearly warranted it."
• Surgical training should expand to include additional skills, such as the use of ultrasound for better diagnosis of conditions in breast, endocrine, vascular, and trauma diseases and the use of interventional catheter techniques for the diagnosis or treatment of a variety of conditions.
It’s not possible to reverse the changes that have occurred over the past 2 decades, and in fact the workweek could see further shortening, as has happened in Europe, the investigators noted. "The most effective way in which to address the changes is therefore to look at the things which can be changed in resident training, the many areas in which improvements in resident teaching are possible, and the areas in which residents’ capabilities could be productively expanded."
The investigators did not report any conflicts of interest.
Surgical residency programs have not kept up with radical changes in the practice of surgery over the past two decades, but innovations ranging from curriculum reform to increasing the length of residency could help to improve the overall performance of recent surgical residency graduates, according to an analysis in Annals of Surgery.
"The changes that have occurred have been disruptive to residency training, and to date there has been minimal compensation for these," Dr. Frank Lewis and Dr. Mary Klingensmith wrote. "Evidence is now emerging of significant issues in the overall performance of recent graduates from at least three sources – the evaluation of external agents who incorporate these graduates into their practice or group, the opinions of the residents themselves, and the performance of graduates on the oral examination of the American Board of Surgery during the last 8 years" (Ann. Surg. 2012;256:553-59).
The changes include not only the 80-hour workweek for surgical residents, but also clinical areas, according to Dr. Lewis, executive director of the American Board of Surgery, and Dr. Klingensmith, residency program director at Washington University in St. Louis.
The effect of the 80-hour workweek has been a reduction by 6 months to a year of in-hospital experience during 5 years of residency. Most of that reduced time corresponds to night and weekend experience, when residents would be more likely to see urgent and emergent conditions, and to have a greater degree of independent functioning, autonomy, and indirect supervision, they said.
The most significant clinical change has been the development of laparoscopic surgery for intra-abdominal surgical management, which is replacing open surgery and the abdominal incision. Because surgeons in academic settings have been slower to adopt laparoscopy, resident training in the use of this technology has proceeded slowly, they explained.
"While the Residency Review Committee (RRC) for Surgery has been steadily increasing the requirements for surgical resident training, it is still the rule that the most complex laparoscopic surgery is reserved for fellows in postresidency fellowships and not for residents during surgical training, although there is no reason this should be the case," they noted.
In addition, operations performed by general surgeons, and the way in which they are done, have changed significantly in the past 20 years, according to the analysis. For example, the advent of better medical management for benign peptic ulcer disease – along with flexible endoscopy and endoscopic retrograde cholangiopancreatography – means that fewer surgical interventions for peptic ulcer complications and biliary tree stone disease are necessary.
Furthermore, technological innovations have allowed vascular surgeons, rather than general surgeons, to perform most abdominal vascular surgery. Finally, the two surgeons reported, abdominal trauma injuries – which require surgical intervention in 80%-90% of cases – have declined dramatically since 1992.
These types of changes "will undoubtedly continue, and the directions in which surgery will evolve in the future are not predictable," Dr. Lewis and Dr. Klingensmith wrote.
They laid out seven potential ways in which surgical residency programs can address the changes:
• There should be a continuous process to define and continually update the surgical residency curriculum, which needs to keep pace with the fast-changing surgical practice landscape, and to "prune" information related to diseases that no longer are seen frequently in practice.
"The starting point for making changes in residency is to recognize that much of what is being taught is obsolete, and addresses diseases that are no longer a significant problem, or those for which surgical treatment is rarely needed," they said.
• Residency programs should improve the efficacy of resident learning by reducing clerical functions for residents, using physician extenders where appropriate, and utilizing mobile computing technology to deliver "a more defined and comprehensive curriculum to residents at an individual level."
• Educators could make better use of simulators in certain areas, such as laparoscopic surgery and endoscopic surgery.
• There should be an earlier specialty focus in residency training for those surgical residents who already know which specialty they would like to pursue.
• Surgical residency should include expanded laparoscopic surgery training.
• Residency programs could increase in length to make up for the time lost to the 80-hour workweek rule. Four-fifths of surgical residents already elect to take a postresidency fellowship in a specialty or subspecialty area, so "any discussion of extending residency only applies to the 20% of residents who currently complete only general surgical residency and do not seek subspecialty training," they said. "Extending residency by 1 year to obtain more extensive training in general surgery per se would not seem to be an insurmountable issue if the benefits clearly warranted it."
• Surgical training should expand to include additional skills, such as the use of ultrasound for better diagnosis of conditions in breast, endocrine, vascular, and trauma diseases and the use of interventional catheter techniques for the diagnosis or treatment of a variety of conditions.
It’s not possible to reverse the changes that have occurred over the past 2 decades, and in fact the workweek could see further shortening, as has happened in Europe, the investigators noted. "The most effective way in which to address the changes is therefore to look at the things which can be changed in resident training, the many areas in which improvements in resident teaching are possible, and the areas in which residents’ capabilities could be productively expanded."
The investigators did not report any conflicts of interest.
Surgical residency programs have not kept up with radical changes in the practice of surgery over the past two decades, but innovations ranging from curriculum reform to increasing the length of residency could help to improve the overall performance of recent surgical residency graduates, according to an analysis in Annals of Surgery.
"The changes that have occurred have been disruptive to residency training, and to date there has been minimal compensation for these," Dr. Frank Lewis and Dr. Mary Klingensmith wrote. "Evidence is now emerging of significant issues in the overall performance of recent graduates from at least three sources – the evaluation of external agents who incorporate these graduates into their practice or group, the opinions of the residents themselves, and the performance of graduates on the oral examination of the American Board of Surgery during the last 8 years" (Ann. Surg. 2012;256:553-59).
The changes include not only the 80-hour workweek for surgical residents, but also clinical areas, according to Dr. Lewis, executive director of the American Board of Surgery, and Dr. Klingensmith, residency program director at Washington University in St. Louis.
The effect of the 80-hour workweek has been a reduction by 6 months to a year of in-hospital experience during 5 years of residency. Most of that reduced time corresponds to night and weekend experience, when residents would be more likely to see urgent and emergent conditions, and to have a greater degree of independent functioning, autonomy, and indirect supervision, they said.
The most significant clinical change has been the development of laparoscopic surgery for intra-abdominal surgical management, which is replacing open surgery and the abdominal incision. Because surgeons in academic settings have been slower to adopt laparoscopy, resident training in the use of this technology has proceeded slowly, they explained.
"While the Residency Review Committee (RRC) for Surgery has been steadily increasing the requirements for surgical resident training, it is still the rule that the most complex laparoscopic surgery is reserved for fellows in postresidency fellowships and not for residents during surgical training, although there is no reason this should be the case," they noted.
In addition, operations performed by general surgeons, and the way in which they are done, have changed significantly in the past 20 years, according to the analysis. For example, the advent of better medical management for benign peptic ulcer disease – along with flexible endoscopy and endoscopic retrograde cholangiopancreatography – means that fewer surgical interventions for peptic ulcer complications and biliary tree stone disease are necessary.
Furthermore, technological innovations have allowed vascular surgeons, rather than general surgeons, to perform most abdominal vascular surgery. Finally, the two surgeons reported, abdominal trauma injuries – which require surgical intervention in 80%-90% of cases – have declined dramatically since 1992.
These types of changes "will undoubtedly continue, and the directions in which surgery will evolve in the future are not predictable," Dr. Lewis and Dr. Klingensmith wrote.
They laid out seven potential ways in which surgical residency programs can address the changes:
• There should be a continuous process to define and continually update the surgical residency curriculum, which needs to keep pace with the fast-changing surgical practice landscape, and to "prune" information related to diseases that no longer are seen frequently in practice.
"The starting point for making changes in residency is to recognize that much of what is being taught is obsolete, and addresses diseases that are no longer a significant problem, or those for which surgical treatment is rarely needed," they said.
• Residency programs should improve the efficacy of resident learning by reducing clerical functions for residents, using physician extenders where appropriate, and utilizing mobile computing technology to deliver "a more defined and comprehensive curriculum to residents at an individual level."
• Educators could make better use of simulators in certain areas, such as laparoscopic surgery and endoscopic surgery.
• There should be an earlier specialty focus in residency training for those surgical residents who already know which specialty they would like to pursue.
• Surgical residency should include expanded laparoscopic surgery training.
• Residency programs could increase in length to make up for the time lost to the 80-hour workweek rule. Four-fifths of surgical residents already elect to take a postresidency fellowship in a specialty or subspecialty area, so "any discussion of extending residency only applies to the 20% of residents who currently complete only general surgical residency and do not seek subspecialty training," they said. "Extending residency by 1 year to obtain more extensive training in general surgery per se would not seem to be an insurmountable issue if the benefits clearly warranted it."
• Surgical training should expand to include additional skills, such as the use of ultrasound for better diagnosis of conditions in breast, endocrine, vascular, and trauma diseases and the use of interventional catheter techniques for the diagnosis or treatment of a variety of conditions.
It’s not possible to reverse the changes that have occurred over the past 2 decades, and in fact the workweek could see further shortening, as has happened in Europe, the investigators noted. "The most effective way in which to address the changes is therefore to look at the things which can be changed in resident training, the many areas in which improvements in resident teaching are possible, and the areas in which residents’ capabilities could be productively expanded."
The investigators did not report any conflicts of interest.
EXPERT ANALYSIS FROM ANNALS OF SURGERY
Interventions Address Physician Burnout
NEW YORK – The adage that physicians are the worst patients has more than a grain of truth to it when it comes to mental health issues, psychiatrists said at a workshop on physician mental health presented at the American Psychiatric Association’s Institute on Psychiatric Services.
"Why is it so hard for doctors to seek help?" asked Dr. Michael Myers, of the department of psychiatry and behavioral sciences at the State University of New York in Brooklyn.
The stigma of mental illness as perceived by physicians themselves is often a barrier to seeking mental health services. In addition, there is often stigma within the helping professions, and an institutional denial that even physicians might be subject to the thousand natural shocks that other humans are heir to, Dr. Myers said.
"Not all doctors are comfortable looking after other physicians, and it makes them a little squeamish," he said.
Many patients also are ambivalent about being treated by a physician with health issues, making the impaired physician even more leery about getting help, he added.
Stigma reinforces denial and delay in getting help, compounds symptoms, increases refractoriness to treatment, and contributes to strains in personal relationships. Stigma also affects medication adherence, because physicians might think they know better than anyone else what drugs they need.
"Stigma kills," Dr. Myers said, noting that deeply depressed physicians or those who feel very isolated and alienated have increased symptoms of melancholia, guilt, shame, cognitive distortion, and suicidality that can lead to suicidal actions.
Additionally, some physicians with depression or bipolar disorder might have comorbid cocaine, opiate, or alcohol dependence, increasing their risk for death from unintentional overdose or from a cascade of problems associated with substance abuse, such as marital breakups, economic threats to their practices, or scrutiny from medical boards.
At-risk physicians also might hesitate to seek care because they don’t want to impose on others, they have a tendency toward self-reliance, or they are too wrapped up in their work to pay attention to their own needs. Physicians also might worry that breaches in confidentiality could harm their careers, Dr. Myers said.
Code of Conduct
Dr. Linda M. Worley noted that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) now requires accredited facilities to have a code of conduct defining acceptable behavior and specifying which behaviors are disruptive and inappropriate, and to have a process or action plan for managing disruptive staff members.
She teaches a distressed physicians’ course at Vanderbilt University in Nashville, Tenn., where she is an adjunct clinical professor of medicine. A maximum of six physicians take the 6-month CME course at one time; many are there as condition of their continued employment. There are four faculty members, including a physician, social worker, psychologist, and addiction/assessment counselor. One observer is also allowed for each session, but the rules specify that he or she must take part in the exercises.
Physicians who are referred to the course are first interviewed by telephone to make sure that the program is a good fit and that the participants are not currently substance abusers, and course staff also conduct collateral interviews to determine the mental health needs of prospective participants.
The participants engage in an initial 3-day session at Vanderbilt and have three subsequent 1-day sessions over the ensuing 6 months.
"It’s a transformative learning experience. This is an opportunity to critically reflect on their life events, and that helps them to change their beliefs and their behaviors," Dr. Worley said.
The techniques employed include intellectual didactics, peer group exercises, emotional awareness training, and helping participants identify triggers of their inappropriate behaviors.
Early Intervention
Many of the challenges that Dr. Worley and her colleagues address in experienced physicians also confront physicians in training, noted Dr. Mai-Lan Rogoff, an associate professor of psychiatry and associate dean of student affairs at the University of Massachusetts in Worcester.
Medical school wellness programs are primarily aimed at preventing burnout, a problem more common among students than alcohol, substance abuse, or suicidality, Dr. Rogoff said.
She defined burnout as a triad of components as measured by the Maslach Burnout Inventory, a rating instrument developed by Christina Maslach, Ph.D., professor of psychology at the University of California at Berkeley.
Burnout is a combination of emotional exhaustion (feelings of being emotionally overextended and exhausted by your work), depersonalization (feelings of being a cog in a machine, having an unfeeling response toward those who receive your services), and having a low sense of personal accomplishment.
Burnout is associated with a variety of negative outcomes, Dr. Rogoff noted, including loss of empathy, substance abuse, and suicidal ideation.
"There are personal and environmental risks for burnout that are known and described in burnout in various settings. The interesting thing is that if you look at medical students and medical school, both sets of risk factors exist there," she said.
"On a personal level, you’ve got perfectionism, low resilience, negative focus, and all those issues, and environmentally one of the risk factors for burnout is unclear or impossible requirements or excessive workloads. This is the way most medical students feel," she added.
Medical students also acutely feel that there is a lack of time and a lack of control over their own circumstances, and that they face major consequences from mistakes and often have to deal with angry, upset, or ungrateful patients.
Medical school wellness programs address both the personal and environmental risk factors for burnout, with an emphasis on the latter. In addition to making counseling and therapy services readily available to students, wellness programs such as that in place at the University of Massachusetts focus on providing students with an increased sense of institutional support and peer support through group and team activities and exercises.
Although there are no objective data showing that such wellness programs work, "there’s absolutely no question that students like these programs," Dr. Rogoff said.
Dr. Myers, Dr. Worley, and Dr. Rogoff all reported having no relevant conflicts of interest.
NEW YORK – The adage that physicians are the worst patients has more than a grain of truth to it when it comes to mental health issues, psychiatrists said at a workshop on physician mental health presented at the American Psychiatric Association’s Institute on Psychiatric Services.
"Why is it so hard for doctors to seek help?" asked Dr. Michael Myers, of the department of psychiatry and behavioral sciences at the State University of New York in Brooklyn.
The stigma of mental illness as perceived by physicians themselves is often a barrier to seeking mental health services. In addition, there is often stigma within the helping professions, and an institutional denial that even physicians might be subject to the thousand natural shocks that other humans are heir to, Dr. Myers said.
"Not all doctors are comfortable looking after other physicians, and it makes them a little squeamish," he said.
Many patients also are ambivalent about being treated by a physician with health issues, making the impaired physician even more leery about getting help, he added.
Stigma reinforces denial and delay in getting help, compounds symptoms, increases refractoriness to treatment, and contributes to strains in personal relationships. Stigma also affects medication adherence, because physicians might think they know better than anyone else what drugs they need.
"Stigma kills," Dr. Myers said, noting that deeply depressed physicians or those who feel very isolated and alienated have increased symptoms of melancholia, guilt, shame, cognitive distortion, and suicidality that can lead to suicidal actions.
Additionally, some physicians with depression or bipolar disorder might have comorbid cocaine, opiate, or alcohol dependence, increasing their risk for death from unintentional overdose or from a cascade of problems associated with substance abuse, such as marital breakups, economic threats to their practices, or scrutiny from medical boards.
At-risk physicians also might hesitate to seek care because they don’t want to impose on others, they have a tendency toward self-reliance, or they are too wrapped up in their work to pay attention to their own needs. Physicians also might worry that breaches in confidentiality could harm their careers, Dr. Myers said.
Code of Conduct
Dr. Linda M. Worley noted that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) now requires accredited facilities to have a code of conduct defining acceptable behavior and specifying which behaviors are disruptive and inappropriate, and to have a process or action plan for managing disruptive staff members.
She teaches a distressed physicians’ course at Vanderbilt University in Nashville, Tenn., where she is an adjunct clinical professor of medicine. A maximum of six physicians take the 6-month CME course at one time; many are there as condition of their continued employment. There are four faculty members, including a physician, social worker, psychologist, and addiction/assessment counselor. One observer is also allowed for each session, but the rules specify that he or she must take part in the exercises.
Physicians who are referred to the course are first interviewed by telephone to make sure that the program is a good fit and that the participants are not currently substance abusers, and course staff also conduct collateral interviews to determine the mental health needs of prospective participants.
The participants engage in an initial 3-day session at Vanderbilt and have three subsequent 1-day sessions over the ensuing 6 months.
"It’s a transformative learning experience. This is an opportunity to critically reflect on their life events, and that helps them to change their beliefs and their behaviors," Dr. Worley said.
The techniques employed include intellectual didactics, peer group exercises, emotional awareness training, and helping participants identify triggers of their inappropriate behaviors.
Early Intervention
Many of the challenges that Dr. Worley and her colleagues address in experienced physicians also confront physicians in training, noted Dr. Mai-Lan Rogoff, an associate professor of psychiatry and associate dean of student affairs at the University of Massachusetts in Worcester.
Medical school wellness programs are primarily aimed at preventing burnout, a problem more common among students than alcohol, substance abuse, or suicidality, Dr. Rogoff said.
She defined burnout as a triad of components as measured by the Maslach Burnout Inventory, a rating instrument developed by Christina Maslach, Ph.D., professor of psychology at the University of California at Berkeley.
Burnout is a combination of emotional exhaustion (feelings of being emotionally overextended and exhausted by your work), depersonalization (feelings of being a cog in a machine, having an unfeeling response toward those who receive your services), and having a low sense of personal accomplishment.
Burnout is associated with a variety of negative outcomes, Dr. Rogoff noted, including loss of empathy, substance abuse, and suicidal ideation.
"There are personal and environmental risks for burnout that are known and described in burnout in various settings. The interesting thing is that if you look at medical students and medical school, both sets of risk factors exist there," she said.
"On a personal level, you’ve got perfectionism, low resilience, negative focus, and all those issues, and environmentally one of the risk factors for burnout is unclear or impossible requirements or excessive workloads. This is the way most medical students feel," she added.
Medical students also acutely feel that there is a lack of time and a lack of control over their own circumstances, and that they face major consequences from mistakes and often have to deal with angry, upset, or ungrateful patients.
Medical school wellness programs address both the personal and environmental risk factors for burnout, with an emphasis on the latter. In addition to making counseling and therapy services readily available to students, wellness programs such as that in place at the University of Massachusetts focus on providing students with an increased sense of institutional support and peer support through group and team activities and exercises.
Although there are no objective data showing that such wellness programs work, "there’s absolutely no question that students like these programs," Dr. Rogoff said.
Dr. Myers, Dr. Worley, and Dr. Rogoff all reported having no relevant conflicts of interest.
NEW YORK – The adage that physicians are the worst patients has more than a grain of truth to it when it comes to mental health issues, psychiatrists said at a workshop on physician mental health presented at the American Psychiatric Association’s Institute on Psychiatric Services.
"Why is it so hard for doctors to seek help?" asked Dr. Michael Myers, of the department of psychiatry and behavioral sciences at the State University of New York in Brooklyn.
The stigma of mental illness as perceived by physicians themselves is often a barrier to seeking mental health services. In addition, there is often stigma within the helping professions, and an institutional denial that even physicians might be subject to the thousand natural shocks that other humans are heir to, Dr. Myers said.
"Not all doctors are comfortable looking after other physicians, and it makes them a little squeamish," he said.
Many patients also are ambivalent about being treated by a physician with health issues, making the impaired physician even more leery about getting help, he added.
Stigma reinforces denial and delay in getting help, compounds symptoms, increases refractoriness to treatment, and contributes to strains in personal relationships. Stigma also affects medication adherence, because physicians might think they know better than anyone else what drugs they need.
"Stigma kills," Dr. Myers said, noting that deeply depressed physicians or those who feel very isolated and alienated have increased symptoms of melancholia, guilt, shame, cognitive distortion, and suicidality that can lead to suicidal actions.
Additionally, some physicians with depression or bipolar disorder might have comorbid cocaine, opiate, or alcohol dependence, increasing their risk for death from unintentional overdose or from a cascade of problems associated with substance abuse, such as marital breakups, economic threats to their practices, or scrutiny from medical boards.
At-risk physicians also might hesitate to seek care because they don’t want to impose on others, they have a tendency toward self-reliance, or they are too wrapped up in their work to pay attention to their own needs. Physicians also might worry that breaches in confidentiality could harm their careers, Dr. Myers said.
Code of Conduct
Dr. Linda M. Worley noted that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) now requires accredited facilities to have a code of conduct defining acceptable behavior and specifying which behaviors are disruptive and inappropriate, and to have a process or action plan for managing disruptive staff members.
She teaches a distressed physicians’ course at Vanderbilt University in Nashville, Tenn., where she is an adjunct clinical professor of medicine. A maximum of six physicians take the 6-month CME course at one time; many are there as condition of their continued employment. There are four faculty members, including a physician, social worker, psychologist, and addiction/assessment counselor. One observer is also allowed for each session, but the rules specify that he or she must take part in the exercises.
Physicians who are referred to the course are first interviewed by telephone to make sure that the program is a good fit and that the participants are not currently substance abusers, and course staff also conduct collateral interviews to determine the mental health needs of prospective participants.
The participants engage in an initial 3-day session at Vanderbilt and have three subsequent 1-day sessions over the ensuing 6 months.
"It’s a transformative learning experience. This is an opportunity to critically reflect on their life events, and that helps them to change their beliefs and their behaviors," Dr. Worley said.
The techniques employed include intellectual didactics, peer group exercises, emotional awareness training, and helping participants identify triggers of their inappropriate behaviors.
Early Intervention
Many of the challenges that Dr. Worley and her colleagues address in experienced physicians also confront physicians in training, noted Dr. Mai-Lan Rogoff, an associate professor of psychiatry and associate dean of student affairs at the University of Massachusetts in Worcester.
Medical school wellness programs are primarily aimed at preventing burnout, a problem more common among students than alcohol, substance abuse, or suicidality, Dr. Rogoff said.
She defined burnout as a triad of components as measured by the Maslach Burnout Inventory, a rating instrument developed by Christina Maslach, Ph.D., professor of psychology at the University of California at Berkeley.
Burnout is a combination of emotional exhaustion (feelings of being emotionally overextended and exhausted by your work), depersonalization (feelings of being a cog in a machine, having an unfeeling response toward those who receive your services), and having a low sense of personal accomplishment.
Burnout is associated with a variety of negative outcomes, Dr. Rogoff noted, including loss of empathy, substance abuse, and suicidal ideation.
"There are personal and environmental risks for burnout that are known and described in burnout in various settings. The interesting thing is that if you look at medical students and medical school, both sets of risk factors exist there," she said.
"On a personal level, you’ve got perfectionism, low resilience, negative focus, and all those issues, and environmentally one of the risk factors for burnout is unclear or impossible requirements or excessive workloads. This is the way most medical students feel," she added.
Medical students also acutely feel that there is a lack of time and a lack of control over their own circumstances, and that they face major consequences from mistakes and often have to deal with angry, upset, or ungrateful patients.
Medical school wellness programs address both the personal and environmental risk factors for burnout, with an emphasis on the latter. In addition to making counseling and therapy services readily available to students, wellness programs such as that in place at the University of Massachusetts focus on providing students with an increased sense of institutional support and peer support through group and team activities and exercises.
Although there are no objective data showing that such wellness programs work, "there’s absolutely no question that students like these programs," Dr. Rogoff said.
Dr. Myers, Dr. Worley, and Dr. Rogoff all reported having no relevant conflicts of interest.
AT THE AMERICAN PSYCHIATRIC ASSOCIATION'S INSTITUTE ON PSYCHIATRIC SERVICES
