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Leitman IM. Closure of Mesenteric Defects During Gastric Bypass Reduces but Does Not Eliminate the Risk of Internal Hernia. JAMA Surg 2023:2804887. [PMID: 37163256 DOI: 10.1001/jamasurg.2023.1057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Affiliation(s)
- I Michael Leitman
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
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Waldman R, Kaplan H, Leitman IM. Were surgical outcomes for acute appendicitis impacted by the COVID-19 pandemic? BMC Surg 2023; 23:43. [PMID: 36823569 PMCID: PMC9948783 DOI: 10.1186/s12893-023-01930-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 02/01/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic disrupted healthcare systems throughout the world. We examine whether appendectomy outcomes in 2020 and 2021 were affected by the pandemic. METHODS We conducted a retrospective cohort study of 30-day appendectomy outcomes using the ACS-NSQIP database from 2019 through 2021. Logistic regression and linear regression analyses were performed to create models of post-operative outcomes. RESULTS There were no associations between the time period of surgery and death, readmission, reoperation, deep incisional SSI, organ space SSI, sepsis, septic shock, rate of complicated appendicitis, failure to wean from the ventilator, or days from admission to operation. During the first 21 months of the pandemic (April 2020 through December 2021), there was a decreased length of hospital stay (p = 0.016), increased operative time (p < 0.001), and increased likelihood of laparoscopic versus open surgery (p < 0.001) in compared to 2019. CONCLUSIONS There were minimal differences in emergent appendectomy outcomes during the first 21 months of the pandemic when compared to 2019. Surgical systems in the US successfully adapted to the challenges presented by the COVID-19 pandemic.
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Affiliation(s)
- Rachel Waldman
- grid.59734.3c0000 0001 0670 2351Department of Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1076, New York, NY 10029 USA
| | - Harrison Kaplan
- grid.59734.3c0000 0001 0670 2351Department of Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1076, New York, NY 10029 USA
| | - I. Michael Leitman
- grid.59734.3c0000 0001 0670 2351Department of Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1076, New York, NY 10029 USA
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Leitman IM, Muller D, Miller S, Hanss BG, Catron TF, Cooper WO, Filizola M. Implementation of an Online Reporting System to Identify Unprofessional Behaviors and Mistreatment Directed at Trainees at an Academic Medical Center. JAMA Netw Open 2022; 5:e2244661. [PMID: 36459140 PMCID: PMC9719046 DOI: 10.1001/jamanetworkopen.2022.44661] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
IMPORTANCE Unprofessional behaviors and mistreatment directed at trainees continue to challenge the learning environment. Academic medical institutions should encourage reports of inappropriate behavior and address such reports directly to create a safe learning environment. OBJECTIVE To determine the feasibility of creating and implementing an online reporting system for receiving and reviewing complaints of unprofessional behavior directed toward or experienced by students, postdoctoral trainees, and residents. DESIGN, SETTING, AND PARTICIPANTS This cohort study assessed implementation of an online reporting system (feedback form) with a method for triaging reports, providing both positive and negative feedback, as well as adjudication and transparent public disclosure of aggregate data. The system was launched at a large urban academic medical center with numerous trainees that is fully integrated with a health system of 8 hospitals. Participants included faculty who interact with trainees, medical students, graduate students and postdoctoral fellows, and residents and clinical fellows. Follow-up began in October 2019 (at the time of tool launch) and lasted through December 2021. Data were analyzed from January to March 2022. MAIN OUTCOMES AND MEASURES The primary outcomes were the numbers and types of reports according to the reporter and the person reported about. RESULTS Participants included 2900 faculty who interact with trainees, 600 medical students, more than 1000 graduate students and postdoctoral fellows, and 2600 residents and clinical fellows. Trainees submitted 196 reports, 173 (88.3%) of which described unprofessional interactions. Among the reports describing unprofessional behavior, 60 (34.7%) were from medical students, 96 (55.5%) were from residents and fellows, 17 (9.8%) were from graduate students or postdoctoral trainees, and 78 (45.1%) were from men. The majority of negative reports described behaviors by faculty (106 [61.3%]), followed by residents and fellows (24 [13.9%]). Twenty faculty (<1.0%) accounted for 52 (50.0%) of the 104 reports describing unprofessional behaviors. Since implementation, most trainees are aware of this process. An increasing number have reported instances of mistreatment, and those who shared concerns through the online system report satisfaction with the outcome of the response to the report. CONCLUSIONS AND RELEVANCE In this cohort study, the new reporting mechanism facilitated identification of the small number of individuals associated with unprofessional behaviors toward trainees and increased awareness of the school's commitment to creating a safe learning environment.
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Affiliation(s)
- I. Michael Leitman
- Medical Education and Surgery, Graduate Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York
| | - David Muller
- Medical Education and Medicine, Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sophie Miller
- Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Basil G. Hanss
- Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Thomas F. Catron
- Department of Medical Education, Vanderbilt Center for Patient and Professional Advocacy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - William O. Cooper
- Pediatrics and Health Policy, Faculty Affairs, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Marta Filizola
- Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount
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Kaplan HJ, Leitman IM. Race and insurance status outcome disparities following splenectomy in trauma patients are reduced in larger hospitals. A cross-sectional study. Ann Med Surg (Lond) 2022; 77:103516. [PMID: 35638010 PMCID: PMC9142383 DOI: 10.1016/j.amsu.2022.103516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/14/2022] [Accepted: 03/26/2022] [Indexed: 11/24/2022] Open
Abstract
Background Splenectomy, still a commonly performed treatment for splenic injury in trauma patients, has been shown to have a high rate of complications. The purpose of this study was to identify predictors, including race and insurance status, associated with adverse outcomes post-splenectomy in trauma patients. We discuss possible explanations and methods for reducing these disparities. Methods The American College of Surgeons – Trauma Quality Improvement Program (ACS-TQIP) participant user database was queried from 2010 to 2015 and patients who underwent total splenectomy were identified. All mechanisms of injury, including both blunt and penetrating trauma, were included. Patients with advance directives limiting care or aged under 18 were excluded. Propensity score matching was used to control for age, preexisting medical conditions, and the severity of the traumatic injury. A chi-squared test was used to find significant associations between available predictors and outcomes for this cross-sectional study. Results The post-splenectomy mortality rate was 9.2% (n = 1047), 8.0% (n = 918) of patients had three or more complications, and 20.3% (n = 2315) had major complications. A primary race of white (OR 0.7, 95% Confidence Interval (CI) 0.6–0.9, p < 0.01) and private insurance (OR 0.5, 95%CI 0.4–0.6, p < 0.01) were associated with lower risks of mortality A primary race of neither Black nor white (OR 1.3, 95%CI 1.03–1.7, p = 0.03) and a lack of health insurance (“self-pay”) (OR 1.6, 95%CI 1.3–1.9, p < 0.01) were both correlated with mortality. When limited to hospitals of 600+ beds, there were no associations between race and mortality. Conclusion The post-splenectomy mortality rate after trauma remains high. In U.S. trauma centers, a primary race of Black and payment status of “self-pay” are associated with adverse outcomes after splenectomy following a traumatic injury. These disparities are reduced when limiting analysis to larger hospitals. Efforts to reduce disparities in outcomes among trauma patients requiring a splenectomy should focus on improving resource availability and quality in smaller hospitals. The post-splenectomy mortality rate in trauma patients remains high. Mortality is less frequent in white patients, and more frequent in uninsured patients. Black patients were more likely to experience major complications following splenectomy. In hospitals with greater than 600 beds, there were no associations between race and mortality following splenectomy.
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Spiera Z, Ilonzo N, Kaplan H, Leitman IM. Loss of independence as a metric for racial disparities in lower extremity amputation for diabetes: A National Surgery Quality Improvement Program (NSQIP) analysis. J Diabetes Complications 2022; 36:108105. [PMID: 34916145 DOI: 10.1016/j.jdiacomp.2021.108105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION This study assessed the association between race/ethnicity and amputation with mortality and loss of independence (LOI) for diabetic gangrene. METHODS We analyzed the American College of Surgeons National Surgery Quality Improvement Program database from 2016 to 2019. Chi-squared tests were performed to evaluate differences in baseline characteristics and complications. Multivariable logistic regression was performed to model LOI and 30-day mortality. RESULTS 5250 patients with diabetes underwent lower extremity amputation as treatment for gangrene. Hispanic patients were more likely to undergo below the knee amputation (BKA) (P = 0.006). Guillotine amputation (GA) was associated with age > 65 (P < 0.0001), independent functional status prior to admission (P < 0.0001), and mortality (OR 1.989, 95%CI 1.29-3.065), but was not associated with LOI. Mortality was less frequent in Black patients (OR 0.432, 95%CI 0.207-0.902), but loss of independence (LOI) was more frequent in Black patients (OR 1.373, 95%CI 1.017-1.853). Hispanic patients were less likely to experience LOI (OR 0.575, 95%CI 0.477-0.693). CONCLUSIONS LOI and mortality provide contrasting perspectives on outcomes following lower extremity amputation. Further assessment of risk factors may illuminate healthcare disparities.
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Affiliation(s)
- Zachary Spiera
- Icahn School of Medicine at Mount Sinai, Department of Surgery, New York, NY, USA
| | - Nicole Ilonzo
- Icahn School of Medicine at Mount Sinai, Department of Surgery, New York, NY, USA
| | - Harrison Kaplan
- Icahn School of Medicine at Mount Sinai, Department of Surgery, New York, NY, USA
| | - I Michael Leitman
- Icahn School of Medicine at Mount Sinai, Department of Surgery, New York, NY, USA.
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Pawloski KR, Kolod B, Khan RF, Midya V, Chen T, Oduwole A, Camins B, Colicino E, Leitman IM, Nabeel I, Oliver K, Valvi D. Factors Associated with SARS-CoV-2 Infection in Physician Trainees in New York City During the First COVID-19 Wave. Journal of Scientific Innovation in Medicine 2021. [DOI: 10.29024/jsim.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract
Background and Objectives: With obesity rates rising in the United States, bariatric surgery has become a well-established and effective treatment for morbid obesity and its comorbid conditions. Laparoscopic Roux-en-Y gastric bypass and laparoscopic Sleeve Gastrectomy are two of the more common bariatric procedures. This study analyzes whether gender differences play a role in procedure selection and outcomes following either procedure. Methods: Using the American College of Surgeons National Surgical Quality Improvement Program database for years 2015 to 2017, we assessed demographics, postoperative complications, and readmission rates. Chi-square analysis, student t-test, and propensity analyses were performed appropriately. Results: Data review found that men presenting for bariatric surgery had a higher incidence of comorbidities and higher body mass index than women. More men than women underwent Sleeve Gastrectomy (68.5% vs 63.0%, P <0.0001), while more women than men underwent Laparoscopic Roux-en-Y gastric bypass (37.0% vs 31.5%, P < 0.0001). In the Laparoscopic Roux-en-Y group, men experienced more postoperative complications, including cardiac arrest (0.2% vs 0.1%, P = 0.02) and unplanned intubation (0.4% vs 0.2%, P = 0.02). In the Sleeve Gastrectomy group, men experienced more postoperative complications, including myocardial infarction (0.2% vs 0.1%, P = 0.006). In both groups, women experienced higher rates of unplanned readmissions (3.5% vs 2.8%, P = 0.0012). Conclusions: This study found that men are more likely to undergo Sleeve Gastrectomy than Laparoscopic Roux-en-Y gastric bypass, despite higher complication rates for both. Women have higher rates of unplanned readmission rates regardless of procedure, despite lower postoperative morbidity.
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Affiliation(s)
- Japjot Bal
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nicole Ilonzo
- Department of Surgery, The Mount Sinai Hospital, New York, NY
| | | | - I Michael Leitman
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
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Pawloski KR, Kolod B, Khan RF, Midya V, Chen T, Oduwole A, Camins B, Colicino E, Leitman IM, Nabeel I, Oliver K, Valvi D. Factors Associated with SARS-CoV-2 Infection in Physician Trainees in New York City during the First COVID-19 Wave. Int J Environ Res Public Health 2021; 18:5274. [PMID: 34063533 PMCID: PMC8156350 DOI: 10.3390/ijerph18105274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/11/2021] [Accepted: 05/13/2021] [Indexed: 01/25/2023]
Abstract
Occupational and non-occupational risk factors for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been reported in healthcare workers (HCWs), but studies evaluating risk factors for infection among physician trainees are lacking. We aimed to identify sociodemographic, occupational, and community risk factors among physician trainees during the first wave of coronavirus disease 2019 (COVID-19) in New York City. In this retrospective study of 328 trainees at the Mount Sinai Health System in New York City, we administered a survey to assess risk factors for SARS-CoV-2 infection between 1 February and 30 June 2020. SARS-CoV-2 infection was determined by self-reported and laboratory-confirmed IgG antibody and reverse transcriptase-polymerase chain reaction test results. We used Bayesian generalized linear mixed effect regression to examine associations between hypothesized risk factors and infection odds. The cumulative incidence of infection was 20.1%. Assignment to medical-surgical units (OR, 2.51; 95% CI, 1.18-5.34), and training in emergency medicine, critical care, and anesthesiology (OR, 2.93; 95% CI, 1.24-6.92) were independently associated with infection. Caring for unfamiliar patient populations was protective (OR, 0.16; 95% CI, 0.03-0.73). Community factors were not statistically significantly associated with infection after adjustment for occupational factors. Our findings may inform tailored infection prevention strategies for physician trainees responding to the COVID-19 pandemic.
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Affiliation(s)
- Kate R. Pawloski
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (K.R.P.); (B.K.); (R.F.K.); (V.M.); (T.C.); (A.O.); (E.C.); (I.N.); (K.O.)
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA;
| | - Betty Kolod
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (K.R.P.); (B.K.); (R.F.K.); (V.M.); (T.C.); (A.O.); (E.C.); (I.N.); (K.O.)
| | - Rabeea F. Khan
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (K.R.P.); (B.K.); (R.F.K.); (V.M.); (T.C.); (A.O.); (E.C.); (I.N.); (K.O.)
| | - Vishal Midya
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (K.R.P.); (B.K.); (R.F.K.); (V.M.); (T.C.); (A.O.); (E.C.); (I.N.); (K.O.)
| | - Tania Chen
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (K.R.P.); (B.K.); (R.F.K.); (V.M.); (T.C.); (A.O.); (E.C.); (I.N.); (K.O.)
| | - Adeyemi Oduwole
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (K.R.P.); (B.K.); (R.F.K.); (V.M.); (T.C.); (A.O.); (E.C.); (I.N.); (K.O.)
| | - Bernard Camins
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA;
| | - Elena Colicino
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (K.R.P.); (B.K.); (R.F.K.); (V.M.); (T.C.); (A.O.); (E.C.); (I.N.); (K.O.)
| | - I. Michael Leitman
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA;
- Department of Graduate Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Ismail Nabeel
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (K.R.P.); (B.K.); (R.F.K.); (V.M.); (T.C.); (A.O.); (E.C.); (I.N.); (K.O.)
| | - Kristin Oliver
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (K.R.P.); (B.K.); (R.F.K.); (V.M.); (T.C.); (A.O.); (E.C.); (I.N.); (K.O.)
| | - Damaskini Valvi
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (K.R.P.); (B.K.); (R.F.K.); (V.M.); (T.C.); (A.O.); (E.C.); (I.N.); (K.O.)
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Bal J, Ilonzo N, Spencer P, Hyakutake M, Leitman IM. Loss of independence after emergency inguinal hernia repair in elderly patients: How aggressive should we be? Am J Surg 2021; 223:370-374. [PMID: 33838864 DOI: 10.1016/j.amjsurg.2021.03.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/02/2021] [Accepted: 03/28/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Loss of independence (LOI) assesses patient quality of life after surgery and is associated with increased readmission and death. This paper compares LOI among the elderly who received elective versus emergent inguinal hernia repair. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant User Files from 2015 to 2017 were reviewed for inguinal hernia repairs in patients 70-years-old or older. Chi-square analysis, Student t-test, and backwards multivariate logistic analysis were performed appropriately. RESULTS Patients undergoing elective open or laparoscopic repair were less likely to experience LOI (OR 0.061, CI 0.035-0.106) and (OR 0.052 CI 0.024-0.113), respectively, and they were less likely to experience mortality (OR 0.07, CI 0.026-0.185) and (OR 0.059, CI 0.015-0.229), respectively. CONCLUSIONS Significant debility occurs following emergency inguinal hernia repair in elderly patients. Elective surgery may be indicated more often in order to reduce emergencies and LOI in elderly patients.
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Affiliation(s)
- Japjot Bal
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, USA
| | - Nicole Ilonzo
- The Mount Sinai Hospital, 1468 Madison Ave, New York, NY, 10029, USA
| | - Princess Spencer
- The Mount Sinai Hospital, 1468 Madison Ave, New York, NY, 10029, USA
| | - Misa Hyakutake
- The Mount Sinai Hospital, 1468 Madison Ave, New York, NY, 10029, USA
| | - I Michael Leitman
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, USA; 10 Union Square East, Suite 2M, New York, NY, 10003, USA.
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Bui AH, Shebeen M, Girdusky C, Leitman IM. Structured Feedback Enhances Compliance with Operating Room Debriefs. J Surg Res 2020; 257:425-432. [PMID: 32892141 DOI: 10.1016/j.jss.2020.07.079] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 07/15/2020] [Accepted: 07/17/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Surgical debriefs help reduce preventable errors in the operating room (OR) leading to patient injury. However, compliance with debriefs remains poor. The objective of this study was to evaluate the role of structured feedback to surgeons in improving compliance with and quality of surgical debriefs. MATERIALS AND METHODS Surgical cases at an 875-bed urban teaching hospital from January-June 2019 were audited via audio/video recording to evaluate debrief performance. Debriefs were evaluated for clinical completeness and teamwork quality via two structured forms. Surgeons received an evaluation of their debrief performance at two time points during the study period (February and April). Univariate and mixed-effects regression analyses were used to assess changes in debrief compliance and quality over time. RESULTS A total of 878 surgical cases performed by 61 surgeons were reviewed: 198 (22.6%) cases during Period 1 (P1), 371 (42.3%) P2, and 309 (35.1%) P3. The rate at which a debrief occurred was 62.1% in P1, 73.0% in P2, and 82.2% in P3 (P < 0.001). Debriefs were 1.96 (95% CI 1.31-2.95, P = 0.001) times more likely to be completed during P2 and 3.21 (95% CI 2.07-5.04, P < 0.001) times more likely during P3 compared to P1. The percent of debriefs initiated by the lead surgeon increased from 59.8% in P1, to 80.0% in P2, to 81.5% in P3 (P < 0.001). CONCLUSIONS Providing structured feedback to surgeons on their debrief performance was associated with improvements in compliance and completeness with debriefing protocols, OR teamwork and communication, and leadership and accountability from the lead surgeons.
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Affiliation(s)
- Anthony H Bui
- Department of Surgery, Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Minimole Shebeen
- Department of Surgery, Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Cynthia Girdusky
- Department of Surgery, Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York
| | - I Michael Leitman
- Department of Surgery, Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York.
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Haider S, Wood K, Bui A, Leitman IM. Racial Disparities in Outcomes After Common Abdominal Surgical Procedures-The Impact of Access to a Minimally Invasive Approach. J Surg Res 2020; 257:85-91. [PMID: 32818788 DOI: 10.1016/j.jss.2020.07.056] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 07/15/2020] [Accepted: 07/18/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND It is presently considered the standard of care to perform many routine intra-abdominal operations using a minimally invasive approach. The authors recently identified a racial disparity in access to a laparoscopic approach to inguinal hernia repair, cholecystectomy, appendectomy, and colectomy. The present study further evaluates this patient cohort to assess the relationship between the race and postoperative complications and test the mediating effect of the selected surgical approach. METHODS After institutional review board approval, patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent inguinal hernia repair, cholecystectomy, appendectomy, or colectomy in 2016 were identified. Patient demographics, including the self-reported race and ethnicity, as well as clinical, operative, and postoperative variables were recorded. After the exclusion of cases associated with diagnoses of cancer, a 4:1 propensity score matching algorithm generated a clinically balanced cohort of patients of white and black self-reported race. The mediating effect of an open approach to surgery on the relationship between black self-reported race and postoperative complications was evaluated via a series of regressions. RESULTS There were 41,340 unilateral inguinal hernia repairs, 3182 bilateral inguinal hernia repairs, 60,444 cholecystectomies, 50,523 appendectomies, and 58,012 colectomies included in the database in 2017. Exclusion of cases associated with cancer and subsequent propensity score matching returned 17,540 unilateral hernia repairs, 890 bilateral hernia repairs, 23,865 cholecystectomies, 11,660 appendectomies, and 12,320 colectomies. On mediation analysis, any complication, severe complication, and death were significant when regressed on black self-reported race (any: odds ratio [OR] = 1.210, 95% confidence interval [CI] = 1.132-1.291, P < 0.001; severe: OR = 1.352, 95% CI = 1.245-1.466, P < 0.001; death: OR = 1.358, 95% CI = 1.000-1.818, P = 0.044), and open surgery was a significant mediator in the incidence of any complication and severe complication (any: OR = 1.180, 95% CI = 1.105-1.260, P < 0.001 and severe: OR = 1.307, 95% CI = 1.203-1.418, P < 0.001). CONCLUSIONS These findings underscore the importance of access to a minimally invasive approach to surgery. However, other factors may contribute to racial disparities in postoperative complications after common abdominal operations.
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Affiliation(s)
- Syed Haider
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Kasey Wood
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Anthony Bui
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - I Michael Leitman
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York.
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Acheampong DO, Paul P, Boateng P, Leitman IM. Predictors and Outcomes of Cardiac Events following Thoracic Endovascular Aortic Repair in Descending Thoracic Aortic Aneurysm and Dissection. Aorta (Stamford) 2020; 8:6-13. [PMID: 32599627 PMCID: PMC7324254 DOI: 10.1055/s-0040-1701606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Cardiac events following thoracic endovascular aortic repair (TEVAR) have been associated with significant morbidity and mortality. However, predictors of post-TEVAR cardiac events in descending thoracic aortic aneurysm or dissection are poorly understood. METHODS A retrospective analysis of completed TEVAR procedures performed from 2010 to 2016 was conducted using the ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) participant user file database. Adult patients (≥18 years) who underwent TEVAR for descending thoracic aortic aneurysm or dissection were identified and 30-day outcomes were examined. An initial univariate analysis was performed to determine associations between all patient variables and cardiac events, defined as myocardial infarction or cardiac arrest that occurred ≤30 days of surgery. Multivariate logistic regression was subsequently performed to identify independent risk factors for cardiac events following TEVAR. RESULTS The study identified 150 out of 2,905 (5.2%) patients who underwent TEVAR for descending thoracic aortic aneurysm or dissection who developed cardiac events. No significant difference in incidence of cardiac events was noted among patients presenting with aortic aneurysm or dissection (p = 0.339). The overall 30-day mortality rate for all patients was 9.1%. Independent preoperative predictors of post-TEVAR cardiac events included emergency procedure (odds ratio [OR] 2.80, 95% confidence interval [CI] 1.9-4.1, p < 0.01); American Society of Anesthesiologists score >3 (OR 1.71, 95% CI 1.1-2.6, p = 0.01), ventilator dependence (OR 2.33, 95% CI 1.3-4.2, p < 0.01), renal failure (OR 2.53, 95% CI 1.50-4.3, p < 0.01), blood transfusion (OR 1.84, 95% CI 1.1-3.2, p = 0.03), and preoperative leukocytosis (OR 2.45, 1.6-3.8, p < 0.01). After TEVAR, unplanned reintubation (OR 5.52, 95% CI 3.5-8.8, p < 0.01), prolonged mechanical ventilation (OR 1.94, 95% CI 1.2-3.2, p = 0.011), and postoperative blood transfusion (OR 4.02, 95% CI 2.70-6.0, p < 0.01) were independent predictors of cardiac events. Cardiac events greatly increased mortality (60.7 vs. 5.5%), total length of hospital stay (13.2 ± 14.7 days vs. 8.3 ± 9.3 days), and readmission rates (19.3 vs. 8.2%, p < 0.01). CONCLUSIONS Cardiac events following TEVAR are associated with significant mortality. Patients with these risk factors should be appropriately monitored to improve outcomes.
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Affiliation(s)
- Derrick O Acheampong
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Philip Paul
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Percy Boateng
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - I Michael Leitman
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
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Bui AH, Ripp JA, Oh KY, Basloe F, Hassan D, Akhtar S, Leitman IM. The impact of program-driven wellness initiatives on burnout and depression among surgical trainees. Am J Surg 2020; 219:316-321. [DOI: 10.1016/j.amjsurg.2019.10.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 10/11/2019] [Accepted: 10/14/2019] [Indexed: 10/25/2022]
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Affiliation(s)
- Allen Ninh
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kasey Wood
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Anthony H. Bui
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - I. Michael Leitman
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
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Reisman AM, Thomas AT, Boateng P, Leitman IM. Predictors of 30-day outcomes following mitral valve repair. Ann Med Surg (Lond) 2019; 47:5-12. [PMID: 31641493 PMCID: PMC6796495 DOI: 10.1016/j.amsu.2019.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 08/27/2019] [Accepted: 09/05/2019] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION Mitral valve repair has been established as the preferred treatment option in the management of degenerative mitral valve disease. Compared with other surgical treatment options, mitral valve repair is associated with increased survival and decreased rates of both complications and reoperations. However, among patients undergoing mitral valve repair, little is known about the predictors of postoperative outcomes. The purpose of this study is to identify preoperative patient risk factors associated with postoperative morbidity and mortality within 30 days of mitral valve repair. METHODS Data was derived from the American College of Surgeons National Surgical Quality Improvement Program database to assess patients who underwent mitral valve repair from 2011 through 2017. Preoperative risk factors were analyzed to determine their association with a variety of postoperative 30-day outcome measures. RESULTS One thousand three hundred and sixty-six patients underwent mitral valve repair; 849 (62.2%) males and 517 (37.8%) females. Ages ranged from 18 to 90 years, with a mean age of 64 years. The overall 30-day mortality was 3.1% (43 patients). Among the 12 identified risk factors associated with increased mortality on univariate analysis, pre-operative hematocrit level was the only variable significantly correlated with mortality after undergoing multivariate analysis. 259 patients (19.1%) were discharged to a location other than home, an outcome associated with 22 identified risk factors. Among these risk factors, female gender, age, dialysis, pre-operative serum sodium, pre-operative serum albumin, and partial or full living dependency remained statistically significant following multivariate analysis. 126 patients (9.2%) experienced unplanned readmission. This outcome was associated with five risk factors, of which only dyspnea upon mild exertion was significant on multivariate analysis. Reoperation occurred in 105 patients (7.7%). Of the seven identified variables associated with reoperation, patient age, pre-operative platelet count, dyspnea upon mild exertion were independent predictors on multivariate analysis. 53 patients (3.9%) underwent reintubation, which was associated with 11 identified risk factors. Among them, patient age and pre-operative INR value were predictive of reintubation on multivariate analysis. 26 patients (1.9%) experienced stroke, of whom age was the only associated risk factor on both univariate and multivariate analysis. 31 patients (2.3%) experienced acute renal failure, which correlated with 11 risk factors on univariate analysis. Of these, only patient age and pre-operative hematocrit were identified as independent predictors on multivariate analysis. CONCLUSIONS Outcomes are good following mitral valve repair. Although a substantial number of risk factors were found to be associated with adverse outcomes, only a small subset remained statistically significant following multivariate analysis. Identification of these risk factors may help guide clinical decision making with respect to which patients are the best candidates to undergo mitral valve repair.
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Affiliation(s)
- Adam M. Reisman
- Departments of Medical Education, Icahn School of Medicine at Mount Sinai, United States
| | - A. Taylor Thomas
- Departments of Medical Education, Icahn School of Medicine at Mount Sinai, United States
| | - Percy Boateng
- Departments of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, United States
| | - I. Michael Leitman
- Departments of Medical Education, Icahn School of Medicine at Mount Sinai, United States
- Departments of Surgery, Icahn School of Medicine at Mount Sinai, United States
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Ilonzo N, Gribben J, Neifert S, Pettke E, Leitman IM. Laparoscopic inguinal hernia repair in women: Trends, disparities, and postoperative outcomes. Am J Surg 2019; 218:726-729. [PMID: 31353033 DOI: 10.1016/j.amjsurg.2019.07.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/25/2019] [Accepted: 07/17/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION This study analyzed trends in laparoscopic inguinal hernia repair over time, rates of laparoscopic repair in women, and subsequent postoperative outcomes. METHODS Data for 237,503 patients undergoing repair of an initial, reducible inguinal hernia were analyzed using the National Surgical Quality Improvement Program (NSQIP) database for years 2006-2017. Data were analyzed by univariate and multivariate analysis. RESULTS Since 2006, there was an increased proportion of laparoscopic inguinal hernia surgeries, from 20.49% in 2006 to 36.36% in 2017 (p < .001). The percentage of women with bilateral inguinal hernias that underwent laparoscopic repair was less than the percentage of men (31.58% vs. 41.43%, p < .001). Based on multivariate analysis, women were less likely to have laparoscopic hernia repair (OR 0.74, CI 0.71-0.76). Postoperative complications were overall low. CONCLUSION A greater proportion of inguinal hernia repairs are performed laparoscopically. Women with bilateral inguinal hernias are more likely than men to undergo open rather than laparoscopic inguinal hernia repair.
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Affiliation(s)
- Nicole Ilonzo
- Icahn School of Medicine at Mount Sinai, United States
| | - Jeanie Gribben
- Mount Sinai St. Luke's-West, 425 West 59th Street, Suite 7B, New York, NY, 10019, United States
| | - Sean Neifert
- Mount Sinai St. Luke's-West, 425 West 59th Street, Suite 7B, New York, NY, 10019, United States
| | - Erica Pettke
- Icahn School of Medicine at Mount Sinai, United States.
| | - I Michael Leitman
- Mount Sinai St. Luke's-West, 425 West 59th Street, Suite 7B, New York, NY, 10019, United States
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Gribben JL, Ilonzo N, Neifert S, Hubert M, Leitman IM. Characteristics and Outcomes of Abdominal and Pelvic Trauma Patients With Psychiatric Illness. J Surg Res 2019; 243:440-446. [PMID: 31279984 DOI: 10.1016/j.jss.2019.05.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 04/15/2019] [Accepted: 05/30/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The association between psychiatric illness and outcomes in trauma patients in general has only recently been investigated. The aim of this study was to describe the unique characteristics, risk factors, and outcomes of patients with comorbid psychiatric illness and penetrating abdominal and pelvic injuries. MATERIALS AND METHODS This was a retrospective review of trauma patients with open injuries to the abdomen and pelvis identified in the 2010-2015 the American College of Surgeons Trauma Quality Improvement Program database. Baseline variables extracted included demographics, comorbidities, including a discrete "psychiatric illness" variable that preexisted in the database, and injury information. Outcome variables collected included in-hospital mortality, length of stay and intensive care unit stay, and complications. Categorical variables were analyzed using chi-square and Fisher's exact test. Logistic regression was used to assess independent predictors for mortality with odds ratios (ORs) and 95% confidence intervals (CIs) constructed about group differences. RESULTS There were 22,053 patients identified, 6.1% of whom were diagnosed with a psychiatric comorbidity. Patients with psychiatric illnesses were more likely to be aged ≥65 y (5.4% versus 3.2%, P < 0.0001), female (25.4% versus 12.4%, P < 0.0001), and have other comorbidities. Their injuries were more likely to be self-inflicted (34.9% versus 4.9%) and of a cut or piercing mechanism (33.7% versus 24.1%). Psychiatric comorbidity was an independent predictor of intensive care unit admission (OR 1.32, 95% CI 1.14-1.53) and was independently associated with decreased odds of mortality (OR 0.42, 95% CI 0.32-0.55) despite increased complication rates. CONCLUSIONS The presence of a psychiatric comorbidity may be independently associated with trauma patients' complications and outcomes. Patients with psychiatric comorbidities have a unique set of risk factors and health needs that must be recognized and addressed by multidisciplinary care teams.
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Affiliation(s)
- Jeanie L Gribben
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Nicole Ilonzo
- Department of Surgery, Mount Sinai St. Luke's, New York, New York
| | - Sean Neifert
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Maya Hubert
- Department of Psychiatry, Mount Sinai St. Luke's, New York, New York
| | - I Michael Leitman
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York.
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Reisman AM, Farrell K, Leitman IM. Cost Comparison of Elective Invasive Procedures between Elderly and Non-Elderly Patients at an Academic Medical Center. Journal of Scientific Innovation in Medicine 2019. [DOI: 10.29024/jsim.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Gribben JL, Ilonzo N, Neifert S, Forleiter C, Leitman IM. Patient Characteristics and Outcomes Following Operative Repair of Acute versus Chronic Traumatic Diaphragmatic Hernia. Journal of Scientific Innovation in Medicine 2019. [DOI: 10.29024/jsim.8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract
Background and Objectives: Disparities in health care outcomes and resources utilized are present in the treatment of many conditions and represent an area for targeted improvement. This study analyzes the differences in outcomes and total hospital charges between the highest and lowest income quartiles of patients undergoing sigmoid colectomy. Methods: This retrospective cohort study included patients undergoing sigmoid colectomy from 2013 to 2014 queried from the Agency for Healthcare Research and Quality National Inpatient Sample Database who were categorized as the lowest and highest income quartile based on average income of the patient's ZIP code. Patients were grouped into income quartiles, as defined by average income in the ZIP code of residence. In-hospital complications were the primary outcome of this study. We hypothesized that patients in the lowest income quartile would have poorer outcomes than those in the highest income quartile prior to data collection. Results: The lowest (n = 40,995) and highest (n = 40,940) income quartiles are not significantly different based on age or gender. The lowest income quartile was sicker, with higher mean scores for the All Patient Refined Diagnosis Related Group Severity Index and All Patient Refined Diagnosis Related Group Risk of Mortality Index. The lowest income quartile cohort had higher rates of postoperative complications and higher total charges than those in the highest income quartile. Adjusted regression analysis showed significantly lower total charges for the lowest income quartile but no significant differences in overall complications, mortality rates, or nonhome discharge. Conclusions: Patients in the highest income quartile utilize more hospital resources than the lowest income quartile. Additional study is required to understand why these differences exist. Key Points: 1. Significant differences in outcomes and hospital charges exist between socioeconomic groups undergoing sigmoidectomy. 2. There does not seem to be a difference in outcomes after sigmoidectomy among different socioeconomic groups. 3. Elective and laparoscopic sigmoid colectomy is more frequently applied to higher socioeconomic groups. 4. Hospital charges are also greater among patients of higher socioeconomic groups undergoing sigmoid colectomy. Question: Does socioeconomic status affect outcomes and total charges in patients undergoing sigmoid colectomy? Findings: Unadjusted analysis showed significant disparities between the highest and lowest income quartile in outcomes after sigmoid colon resection. Adjusted analysis showed no difference in outcomes, with patients in the highest income quartile having higher total charges. Meaning: There is a value difference between high-income and low-income patients undergoing sigmoid colectomy.
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Affiliation(s)
- Sean Neifert
- Icahn School of Medicine at Mount Sinai, New York, New York
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Reisman AM, Farrell K, Leitman IM. Value Analysis of the Costliest Elective Lifesaving Procedures at an Academic Medical Center. Journal of Scientific Innovation in Medicine 2018. [DOI: 10.29024/jsim.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Acheampong DO, Paul P, Guerrier S, Boateng P, Leitman IM. Effect of Resident Involvement on Morbidity and Mortality Following Thoracic Endovascular Aortic Repair. J Surg Educ 2018; 75:1575-1582. [PMID: 29709469 DOI: 10.1016/j.jsurg.2018.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 03/27/2018] [Accepted: 04/08/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To evaluate the effect of resident involvement in thoracic endovascular aortic repair (TEVAR). SUMMARY OF BACKGROUND DATA Although the influence of resident intraoperative involvement in several types of surgical procedures has been reported, the effect of resident participation in TEVAR is unknown. We evaluated patient outcomes in resident-involved TEVAR procedures. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was analyzed for TEVAR performed from 2010 to 2012. Current procedural terminology codes were used to identify adult patients (≥18 y) who underwent TEVAR. Patients were grouped into those with and without resident involvement. Descriptive and binomial logistic statistics were used to determine the effect of resident involvement on post-TEVAR outcomes. p values < 0.05 were considered statistically significant. RESULTS A total of 676 patients met inclusion criteria for this study. Of these, 517 (76.5%) had residents involved. Overall mortality was 9.8%, with no significant difference between the 2 groups (p = 0.88). Resident involvement was not a significant predictor of any post-TEVAR complication. Postoperative pneumonia (3.5% vs 6.9%, p = 0.06), prolonged mechanical ventilation (11.8% vs 11.9%, p = 0.96), stroke (2.7% vs 5.7%, p = 0.07), urinary tract infection (3.3% vs 4.4%, p = 0.50), progressive renal insufficiency (1.2% vs 2.5%, p = 0.22), acute renal failure (4.1% vs 5.0%, p = 0.60), cardiac arrest (2.9% vs 5.0%, p = 0.20), myocardial infarction (1.7% vs 1.9%, p = 0.91), deep venous thrombosis (1.7% vs 1.3%, p = 0.67), red blood cells transfusions (29.2% vs 36.5%, p = 0.08), sepsis (2.9% vs 4.4%, p = 0.35), septic shock (1.9% vs 3.8%, p = 0.18), and unplanned reintubation (8.7% vs 9.4%, p = 0.78) were not significantly affected. Additionally, resident involvement did not significantly affect operative time (176.1 ± 122.8 min vs 180.3 ± 119.1 min, p = 0.71) and anesthesia time (282.1 ± 146.6 min vs 278.3 ± 140.5 min, p = 0.78). CONCLUSIONS The participation of residents in TEVAR did not significantly affect all 30-day patient outcomes. Resident involvement in TEVAR is safe and should be encouraged. MINI ABSTRACT This study evaluated the effect of resident participation on postoperative outcomes of thoracic endovascular aortic repair (TEVAR) using the American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database. Results showed that resident involvement in TEVAR does not negatively affect patient outcomes.
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Affiliation(s)
- Derrick O Acheampong
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Philip Paul
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Shanice Guerrier
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Percy Boateng
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - I Michael Leitman
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York.
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Yim CK, Shumate L, Barnett SH, Leitman IM. Health literacy assessment and patient satisfaction in surgical practice. Ann Med Surg (Lond) 2018; 35:25-28. [PMID: 30263114 PMCID: PMC6156741 DOI: 10.1016/j.amsu.2018.08.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 08/17/2018] [Accepted: 08/27/2018] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Limited health literacy has been associated with poorer health outcomes and increased morbidity and mortality. Though caring for surgical patients requires communication about complex topics, there is limited literature on health literacy competency in this population. The objective of this study was to assess health literacy in an adult surgical outpatient clinic population, to explore potential determinants of adequate health literacy, and to assess patient satisfaction with physician-patient communication. MATERIALS AND METHODS A prospective cross-sectional study was performed and anonymous data including health literacy, demographics, and patient satisfaction with provider communication were collected. The study population included adult patients who visited an outpatient surgical practice over a one-month period. Health literacy was assessed using the Newest Vital Sign while the satisfaction questions came from the Outpatient Satisfaction Survey (Press-Ganey Associates, Chicago, IL). RESULTS 148 patients participated in the study. The mean age was 49 years, 41% of those who gender identified were male, and 76% were White/Caucasian. 34 (27%) of those who answered the question had received a four-year undergraduate/university degree. 55 (37%) of the patients were identified as having low health literacy. More years of education was significantly associated with adequate health literacy and those patients who were more educated and had adequate health literacy were more satisfied with provider communication. CONCLUSION Patients on average were highly satisfied with provider communication in this outpatient surgical clinic. Higher education levels were associated with better health literacy and patients with both characteristics were more satisfied with provider communication.
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Affiliation(s)
- Cindi K. Yim
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lauren Shumate
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Scott H. Barnett
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - I. Michael Leitman
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Leitman IM. Introducing the Journal of Scientific Innovation in Medicine-Editorial. Journal of Scientific Innovation in Medicine 2018. [DOI: 10.29024/jsim.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Acheampong D, Guerrier S, Lavarias V, Pechman D, Mills C, Inabnet W, Leitman IM. Unplanned postoperative reintubation following general and vascular surgical procedures: Outcomes and risk factors. Ann Med Surg (Lond) 2018; 33:40-43. [PMID: 30167302 PMCID: PMC6108072 DOI: 10.1016/j.amsu.2018.08.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 07/02/2018] [Accepted: 08/15/2018] [Indexed: 12/12/2022] Open
Abstract
Background Unplanned postoperative reintubation (UPR) is a marker for severe adverse outcomes following general and vascular surgery. Study design A retrospective analysis of 8809 adult patients, aged 18 years and older, who underwent major general and vascular surgery at a large single-center urban hospital was conducted from January 2013 to September 2016. Patients were grouped into those who experienced UPR and those who did not. Univariate and multivariate regression analyses were used to identify predictors of UPR, and association of UPR with adverse postoperative outcomes. All regression models had Hosmer-Lemeshow P > 0.05, and C-statistic >0.75, indicating excellent goodness-of-fit and discrimination. Results Of the 8809 patients included, 138 (1.6%) experienced UPR. There was no statistical difference in incidence of UPR between general and vascular surgery patients (p = 0.53). Independent predictors of UPR advanced age (OR 5.1, 95%CI 3.5–7.5, p < 0.01), higher ASA status (OR 7.9, 95%CI 5.6–11.1, p < 0.01), CHF (OR 7.0, 95%CI 3.6–13.9, p = 0.02), acute renal failure or dialysis (OR 3.1, 95%CI 1.8–5.7, p = 0.01), weight loss (OR 5.2, 95%CI 2.8–9.6, p = 0.01), systemic sepsis (OR 4.8, 95%CI 3.4–6.9, p < 0.01), elevated preoperative creatinine (OR 4.2, 95%CI 3.0–5.9, p = 0.01), hypoalbuminemia (OR 5.3, 95% CI 3.8–7.5, p = 0.01), and anemia (OR 4.0, 95%CI 2.8–5.9, p < 0.01). Following surgery, UPR was associated with increased mortality (OR 3.8, 95%CI 2.7–5.2, p < 0.01), pulmonary complications (OR 1.8, 95%CI 1.7–2.0, p < 0.01), renal complications (OR 2.6, 95%CI 1.7–3.5, p < 0.01), cardiac complications (OR 4.6, 95%CI 2.0–6.7, p < 0.01), postoperative RBC transfusion (OR 5.7, 95%CI 3.8–8.6,p < 0.01), and prolonged hospitalization (OR 1.8, 95%CI 1.5–2.4, p < 0.01). Conclusion UPR is significantly associated with postoperative morbidity and mortality. Perioperative management aimed at decreasing incidences of UPR after noncardiac surgery should target preoperative anemia in addition to previously identified predictors. Unplanned postoperative reintubation (UPR) is a marker for severe adverse outcome following surgery. UPR following major surgery occurred in 1.6% patients. Patients who required UPR had increased mortality. Underlying risk factors and postoperative complications may be a marker for other severe systemic disease.
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Acheampong D, Guerrier S, Lavarias V, Pechman D, Mills C, Inabnet W, Boateng P, Leitman IM. Risk factors contributing to cardiac events following general and vascular surgery. Ann Med Surg (Lond) 2018; 33:16-23. [PMID: 30147870 PMCID: PMC6105747 DOI: 10.1016/j.amsu.2018.08.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 07/02/2018] [Accepted: 08/01/2018] [Indexed: 11/19/2022] Open
Abstract
Background Cardiac events (CE) following surgery have been associated with morbidity and mortality. Defining risk factors that contribute to CE is essential to improve surgical outcomes. Study design This was a retrospective study at a large urban teaching hospital for surgery performed from 2013 to 2015. Adult patients (≥18 years) that underwent general and vascular surgery were analyzed. Patients were grouped into those who experienced postoperative CE and those who did not. Univariate and multivariate regression analyses were used to identify predictors of postoperative CE, and association of CE with adverse postoperative outcomes. Separate subgroup analyses were also conducted for general and vascular surgery patients to assess predictors of CE. Results Out of 8441 patients, 157 (1.9%) experienced CE after major general and vascular surgery. Underlying predictors for CE included age >65 years(OR 4.9, 95%CI 3.4–6.9,p < 0.01), ASA >3(OR 12.0, 95%CI 8.5–16.9,p < 0.01), emergency surgery(OR 3.7, 95%CI 2.7–5.1,p = 0.01), CHF(OR 11.2, 95%CI 6.4–16.7,p = 0.02), COPD(OR 3.9, 95%CI 2.4–6.4,p = 0.04), acute renal failure or dialysis(OR 8.0, 95%CI 5.2–12.1,p = 0.04), weight loss(OR 3.3, 95%CI 1.7–6.7,p < 0.01), preoperative creatinine >1.2 mg/dL(OR 5.1, 95%CI 3.7–7.1,p = 0.01), hematocrit <34%(OR 4.0, 95%CI 2.8–5.7,p < 0.01), and operative time >240 min(OR 2.0, 95%CI 1.3–3.3,p = 0.02). Following surgery, CE was associated with increased mortality(OR 3.5, 95%CI 1.2–6.5,p < 0.01), pulmonary complications(OR 5.0, 95%CI 3.1–8.9,p < 0.01), renal complications(OR 2.3, 95%CI 1.9–4.5,p < 0.01), neurologic complications(OR 2.5, 95%CI 1.4–5.2,p < 0.01), systemic sepsis(OR 2.2, 95%CI 1.7–4.0,p < 0.01), postoperative RBC transfusion(OR 4.4, 95%CI 2.7–6.5,p < 0.01), unplanned return to operating room(OR 4.0, 95%CI 2.3–6.9,p < 0.01), and prolonged hospitalization (OR 5.5, 95%CI 3.1–8.8,p = 0.03). There was no statistical difference in incidence of CE between general and vascular surgery patients (p = 0.44); however, predictors of CE differed between the two surgical groups. Conclusion Postoperative CE are associated with significant morbidity and mortality. Identified predictors of CE should allow for adequate risk stratification and optimization of perioperative surgical management. Cardiac events following general and vascular surgery were associated with a mortality rate of 55%. Underlying risk factors for cardiac events following general and vascular surgery include COPD, hypertension on medication, and renal failure. Return to the OR, deep wound infection, unplanned intubation and ventilator dependence are also associated with a post-op cardiac event.
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Affiliation(s)
| | | | | | | | | | | | | | - I. Michael Leitman
- Corresponding author. Department of Surgery, Mount Sinai Beth Israel, 10 Union Square East, 2M, New York, NY 10003, USA.
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Thomas AT, Leitman IM. Predictors of serious morbidity and mortality after endovascular repair of aortoiliac lesions. Surgery 2018; 164:365-369. [DOI: 10.1016/j.surg.2018.04.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 04/04/2018] [Accepted: 04/16/2018] [Indexed: 11/25/2022]
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Abstract
Background and Objectives Morbidity and mortality have been shown to increase several-fold in patients who have undergone bariatric surgery and returned to the operating room after their initial procedures. Failure-to-rescue (FTR) analyses allow for an understanding of patient management and outcomes that is more distinguished than assessments of adverse occurrences and mortality rates alone. The objective of this study was to assess failure to rescue (FTR) and the characteristics and outcomes of patients undergoing reoperation after laparoscopic gastric bypass (LGBP) and laparoscopic sleeve gastrectomy (LSG). Methods The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) participant data files were accessed to identify patients >18 years of age who underwent LGBP and LSG from 2011 through 2015. Patients were further classified into 3-day reoperation and nonreoperation cohorts. Patient demographics, comorbidities, and baseline health characteristics were collected. Pertinent outcomes, complications, and FTR were analyzed. Results A total of 96,538 patients were included. Of those, 1,850 (1.92%) returned to the operating room, and 94,688 (98.08%) did not. Patients who underwent reoperation had a greater likelihood of having any complication (72.20% vs. 51.29%; P < .0001) and had a higher overall mortality rate (1.46% vs. 0.10%, P < .0001). The FTR rates were 2.01% in the reoperation group and 0.14% in the nonreoperation group (P < .0001). Conclusion Patients who undergo LGBP and LSG and have reoperations are at higher risk of developing complications with subsequent mortality.
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Affiliation(s)
- Jeanie L Gribben
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nicole Ilonzo
- Department of Surgery, Mount Sinai St. Luke's, New York, New York, USA
| | - Sean Neifert
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - I Michael Leitman
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Bui AH, Feldman DL, Brodman ML, Shamamian P, Kaleya RN, Rosenblatt MA, D'Angelo D, Somerville D, Mudiraj S, Kischak P, Leitman IM. Provider preferences for postoperative analgesia in obese and non-obese patients undergoing ambulatory surgery. J Pharm Policy Pract 2018; 11:9. [PMID: 29796284 PMCID: PMC5956826 DOI: 10.1186/s40545-018-0138-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 03/22/2018] [Indexed: 11/30/2022] Open
Abstract
Background Few guidelines exist on safe prescription of postoperative analgesia to obese patients undergoing ambulatory surgery. This study examines the preferences of providers in the standard treatment of postoperative pain in the ambulatory setting. Methods Providers from five academic medical centers within a single US city were surveyed from May–September 2015. They were asked to provide their preferred postoperative analgesic routine based upon the predicted severity of pain for obese and non-obese patients. McNemar’s tests for paired observations were performed to compare prescribing preferences for obese vs. non-obese patients. Fisher’s exact tests were performed to compare preferences based on experience: > 15 years vs. ≤15 years in practice, and attending vs. resident physicians. Results A total of 452 providers responded out of a possible 695. For mild pain, 119 (26.4%) respondents prefer an opioid for obese patients vs. 140 (31.1%) for non-obese (p = 0.002); for moderate pain, 329 (72.7%) for obese patients vs. 348 (77.0%) for non-obese (p = 0.011); for severe pain, 398 (88.1%) for obese patients vs. 423 (93.6%) for non-obese (p < 0.001). Less experienced physicians are more likely to prefer an opioid for obese patients with moderate pain: 70 (62.0%) attending physicians with > 15 years in practice vs. 86 (74.5%) with ≤15 years (p = 0.047), and 177 (68.0%) attending physicians vs. 129 (83.0%) residents (p = 0.002). Conclusions While there is a trend to prescribe less opioid analgesics to obese patients undergoing ambulatory surgery, these medications may still be over-prescribed. Less experienced physicians reported prescribing opioids to obese patients more frequently than more experienced physicians.
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Affiliation(s)
- Anthony H Bui
- 1Icahn School of Medicine at Mount Sinai, New York, NY 10029 USA
| | - David L Feldman
- 1Icahn School of Medicine at Mount Sinai, New York, NY 10029 USA.,Hospitals Insurance Company, New York, NY USA
| | | | - Peter Shamamian
- 3Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY USA
| | | | - Meg A Rosenblatt
- 1Icahn School of Medicine at Mount Sinai, New York, NY 10029 USA
| | | | | | | | | | - I Michael Leitman
- 1Icahn School of Medicine at Mount Sinai, New York, NY 10029 USA.,5Department of Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1076, New York, NY 10029 USA
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Bui AH, Guerrier S, Feldman DL, Kischak P, Mudiraj S, Somerville D, Shebeen M, Girdusky C, Leitman IM. Is video observation as effective as live observation in improving teamwork in the operating room? Surgery 2018; 163:1191-1196. [PMID: 29625708 DOI: 10.1016/j.surg.2018.01.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 12/03/2017] [Accepted: 01/29/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Teamwork in the operating room decreases the risk of preventable patient harm. Observation in the operating room allows for evaluation of compliance with best-practice surgical guidelines. This study examines the relative ability of video and live observation to promote operating room teamwork. METHODS Video and audio cameras were installed in 2014 into all operating rooms at an 875-bed, urban teaching hospital. Recordings were chosen at random for review by an internal quality improvement team. Concurrently, live observers were deployed into a random selection of operations. A customized tool was used to evaluate compliance to TeamSTEPPS skills during surgical briefs and debriefs. RESULTS A total of 1,410 briefs were evaluated: 325 (23%) through live observation and 1,085 (77%) through video; 1,398 debriefs were evaluated: 166 (12%) live and 1,232 (88%) video. For briefs, greater compliance was observed under live observation compared to video for recognition of team membership (87% vs 44%, P<.001), anticipation of complex procedural events (61% vs 45%, P<.001), and monitoring of resources (58% vs 42%, P<.001). For debriefs, greater compliance was observed under live observation for determination of team structure (90% vs 60%, P<.001), establishment of a leader (70% vs 51%, P<.001), postoperative planning (77% vs 48%, P<.001), case review and feedback (49% vs 33%, P<.001), team engagement (64% vs 41%, P<.001), and check back (61% vs 46%, P<.001) compared to video. CONCLUSION Video observations may not be as effective as evaluating live performance in promoting teamwork in the OR. Live observation enables immediate feedback, which may improve behavior and decrease barriers to compliance with surgical safety practices.
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Affiliation(s)
- Anthony H Bui
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shanice Guerrier
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David L Feldman
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Hospitals Insurance Company, New York, NY, USA
| | | | | | | | - Minimole Shebeen
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Cynthia Girdusky
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - I Michael Leitman
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Affiliation(s)
- Cindi K Yim
- currently medical student at Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rocco Ferrandino
- currently medical student at Icahn School of Medicine at Mount Sinai, New York, New York
| | - James Chelnis
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - I Michael Leitman
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
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Boodaie BD, Bui AH, Feldman DL, Brodman M, Shamamian P, Kaleya R, Rosenblatt M, Somerville D, Kischak P, Leitman IM. A perioperative care map improves outcomes in patients with morbid obesity undergoing major surgery. Surgery 2017; 163:450-456. [PMID: 29195738 DOI: 10.1016/j.surg.2017.09.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 09/05/2017] [Accepted: 09/27/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND The surgical management of patients with morbid obesity (body mass index ≥ 40) is notable for a relatively high risk of complications. To address this problem, a perioperative care map was developed using precautions and best practices commonly employed in bariatric surgery. It requires additional medical assessments, sleep apnea surveillance, more stringent guidelines for anesthetic management, and readily available bariatric operating room equipment, among other items. This care map was implemented in 2013 at 4 major urban teaching hospitals for use in patients undergoing all types of nonambulatory surgery with a body mass index greater than 40 kg/m2. The impact on patient outcomes was evaluated. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was used to compare 30-day outcomes of morbidly obese patients before the year 2013 and after the years 2015 care-map implementation. In addition, trends in 30-day outcomes for morbidly obese patients were compared with those for non-obese patients. RESULTS Morbidly obese patients, between 2013 and 2015, saw an adjusted decrease in the rate of unplanned return to the operating room (OR = 0.49; P = .039), unplanned readmission (OR = 0.57; P = .006), total duration of stay (-0.87 days; P = .009), and postoperative duration of stay (-0.69 days; P = .007). Of these, total duration of stay (-0.86 days; P = .015), and postoperative duration of stay (-0.69 days; P = .012) improved significantly more for morbidly obese patients than for nonmorbidly obese patients. CONCLUSION Outcomes in morbidly obese patients improved from 2013 to 2015. Implementation of a perioperative care map may have contributed to these improvements. The care map should be further investigated and considered for more widespread use.
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Affiliation(s)
| | - Anthony H Bui
- Icahn School of Medicine at Mount Sinai, Surgery, New York, NY
| | - David L Feldman
- Icahn School of Medicine at Mount Sinai, Surgery, New York, NY; Hospitals Insurance Company, New York, NY
| | - Michael Brodman
- Icahn School of Medicine at Mount Sinai, Surgery, New York, NY
| | - Peter Shamamian
- Montefiore Medical Center Albert Einstein College of Medicine, Surgery, Bronx, NY
| | - Ronald Kaleya
- Maimonides Medical Center, Department of Surgery, Brooklyn, NY
| | - Meg Rosenblatt
- Icahn School of Medicine at Mount Sinai, Surgery, New York, NY
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Blankush JM, Shah BJ, Barnett SH, Badran G, Mercado A, Karani R, Muller D, Leitman IM. What are the associations between the quantity of faculty evaluations and residents' perception of quality feedback? Ann Med Surg (Lond) 2017; 16:40-43. [PMID: 28386393 PMCID: PMC5369264 DOI: 10.1016/j.amsu.2017.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 03/01/2017] [Indexed: 11/17/2022] Open
Abstract
Objectives To determine if there is a correlation between the numbers of evaluations submitted by faculty and the perception of the quality of feedback reported by trainees on a yearly survey. Method 147 ACGME-accredited training programs sponsored by a single medical school were included in the analysis. Eighty-seven programs (49 core residency programs and 38 advanced training programs) with 4 or more trainees received ACGME survey summary data for academic year 2013–2014. Resident ratings of satisfaction with feedback were analyzed against the number of evaluations completed per resident during the same period. R-squared correlation analysis was calculated using a Pearson correlation coefficient. Results 177,096 evaluations were distributed to the 87 programs, of which 117,452 were completed (66%). On average, faculty submitted 33.9 evaluations per resident. Core residency programs had a greater number of evaluations per resident than fellowship programs (39.2 vs. 27.1, respectively, p = 0.15). The average score for the “satisfied with feedback after assignment” survey questions was 4.2 (range 2.2–5.0). There was no overall correlation between the number of evaluations per resident and the residents' perception of feedback from faculty based on medical, surgical or hospital-based programs. Conclusions Resident perception of feedback is not correlated with number of faculty evaluations. An emphasis on faculty summative evaluation of resident performance is important but appears to miss the mark as a replacement for on-going, data-driven, structured resident feedback. Understanding the difference between evaluation and feedback is a global concept that is important for all medical educators and learners. Residents and fellows do not perceive that regular evaluations are the same as feedback. The quantity of faculty evaluations does not correlate the resident perception of quality feedback. A greater emphasis is necessary to instruct faculty on providing regular, timely and data-driven feedback to residents and fellows with specific comments on performance. Faculty summative evaluation of resident performance is important but this is not a replacement for structured feedback.
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Affiliation(s)
- Joseph M Blankush
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, USA
| | - Brijen J Shah
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, USA
| | - Scott H Barnett
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, USA
| | - Gaber Badran
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, USA
| | - Amanda Mercado
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, USA
| | - Reena Karani
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, USA
| | - David Muller
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, USA
| | - I Michael Leitman
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, USA
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Abstract
In recent years, medical educators have been making meaningful attempts to rethink how premedical students are prepared for medical school, and how medical students are prepared for residency. Among the many challenges to redesigning premedical and medical school curricula, one that stands out is the constraint imposed by our current methods of assessing aptitude, particularly our use of the Medical College Admissions Test (MCAT) and the United States Medical Licensing Examination (USMLE). For much of the past century, medical school and residency admissions committees have relied heavily on MCAT and USMLE scores to evaluate and rank candidates to their programs. These high-stakes exams determine to a large extent what is taught, and what is stressed, in preparation for and during medical school-despite the fact that scores have limited ability to predict future success in clinical medicine or biomedical research. Additionally, evidence indicates that students from disadvantaged and minority backgrounds do not fare as well on these exams and, as a result, may be disproportionately excluded from the medical profession. While medical school admissions committees have made limited incremental gains in holistic review, residency programs appear to be increasingly focused on USMLE Step scores and veering away from the spirit of holistic review. The authors propose that substantive change will remain slow in coming unless members of the medical education community radically rethink how we report scores from these exams, and how we use them in our selection of future medical students and residents.
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Affiliation(s)
- Peter Gliatto
- P. Gliatto is senior associate dean, Undergraduate Medical Education and Student Affairs, and associate professor of medical education, medicine, and geriatrics and palliative medicine, Icahn School of Medicine at Mount Sinai, New York, New York. I.M. Leitman is senior associate dean, Graduate Medical Education, and professor of medical education and surgery, Icahn School of Medicine at Mount Sinai, New York, New York. D. Muller is dean, Medical Education, and professor of medical education and medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Blankush JM, Freeman R, McIlvaine J, Tran T, Nassani S, Leitman IM. Implementation of a novel postoperative monitoring system using automated Modified Early Warning Scores (MEWS) incorporating end-tidal capnography. J Clin Monit Comput 2016; 31:1081-1092. [PMID: 27766526 DOI: 10.1007/s10877-016-9943-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 10/11/2016] [Indexed: 01/03/2023]
Abstract
Modified Early Warning Scores (MEWS) provide real-time vital sign (VS) trending and reduce ICU admissions in post-operative patients. These early warning calculations classically incorporate oxygen saturation, heart rate, respiratory rate, systolic blood pressure, and temperature but have not previously included end-tidal CO2 (EtCO2), more recently identified as an independent predictor of critical illness. These systems may be subject to failure when physiologic data is incorrectly measured, leading to false alarms and increased workload. This study investigates whether the implementation of automated devices that utilize ongoing vital signs monitoring and MEWS calculations, inclusive of a score for end-tidal CO2 (EtCO2), can be feasibly implemented on the general care hospital floor and effectively identify derangements in a post-operative patient's condition while limiting the amount of false alarms that would serve to increase provider workload. From July to November 2014, post-operative patients meeting the inclusion criteria (BMI > 30 kg/m2, history of obstructive sleep apnea, or the use of patient-controlled analgesia (PCA) or epidural narcotics) were monitored using automated devices that record minute-by-minute VS included in classic MEWS calculations as well as EtCO2. Automated messages via pagers were sent to providers for instances when the device measured elevated MEWS, abnormal EtCO2, and oxygen desaturations below 85 %. Data, including alarm and message details from the first 133 patients, were recorded and analyzed. Overall, 3.3 alarms and pages sounded per hour of monitoring. Device-only alarms sounded 2.7 times per hour-21 % were technical alarms. The remaining device-only alarms for concerning VS sounded 2.0/h, 70 % for falsely recorded VS. Pages for abnormal EtCO2 sounded 0.4/h (82 % false recordings) while pages for low blood oxygen saturation sounded 0.1/h (55 % false alarms). 143 times (0.1 pages/h) the devices calculated a MEWS warranting a page (rise in MEWS by 2 or 5 or greater)-62 % were false scores inclusive of falsely recorded VS. An abnormal EtCO2 value resulted in or added to an elevated MEWS score in 29 % of notifications, but 50 % of these included a falsely abnormal EtCO2 value. To date, no adverse events have occurred. There were no statistically significant demographic, post-operative condition, or pre-existing comorbidity differences between patients who had a majority of true alarms from those who had mostly false-positive alarms. Although not statistically significant, the group of patients in whom automated MEWS suggested greater utility included those with a history of hypertension (p = 0.072) and renal disease (p = 0.084). EtCO2 monitoring was more likely to be useful in patients with a history of type 2 diabetes, coronary artery disease, and obstructive sleep apnea (p < 0.05). These patients were also more likely to have been on a PCA post-operatively (p < 0.05). Overall, non-invasive physiologic monitoring incorporating an automated MEWS system, modified to include end-tidal CO2 can be feasibly implemented in a hospital ward. Further study is needed to evaluate its clinical utility, including an end-tidal CO2 score, is feasibly implemented and can be useful in monitoring select post-operative patients for derangements in physiologic metrics. Like any other monitoring system, false alarms may occur at high rates. While further study is needed to determine the additive utility of EtCO2 in MEWS calculations, this study suggests utility of EtCO2 in select post-operative patients.
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Affiliation(s)
- Joseph M Blankush
- Department of Surgery, Mount Sinai Beth Israel - Icahn School of Medicine at Mount Sinai, 10 Union Square East, Suite 2M, New York, NY, 10003, USA
| | - Robbie Freeman
- Department of Surgery, Mount Sinai Beth Israel - Icahn School of Medicine at Mount Sinai, 10 Union Square East, Suite 2M, New York, NY, 10003, USA
| | - Joy McIlvaine
- Department of Surgery, Mount Sinai Beth Israel - Icahn School of Medicine at Mount Sinai, 10 Union Square East, Suite 2M, New York, NY, 10003, USA
| | - Trung Tran
- Department of Surgery, Mount Sinai Beth Israel - Icahn School of Medicine at Mount Sinai, 10 Union Square East, Suite 2M, New York, NY, 10003, USA
| | - Stephen Nassani
- Department of Surgery, Mount Sinai Beth Israel - Icahn School of Medicine at Mount Sinai, 10 Union Square East, Suite 2M, New York, NY, 10003, USA
| | - I Michael Leitman
- Department of Surgery, Mount Sinai Beth Israel - Icahn School of Medicine at Mount Sinai, 10 Union Square East, Suite 2M, New York, NY, 10003, USA.
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Solsky I, Edelstein A, Brodman M, Kaleya R, Rosenblatt M, Santana C, Feldman DL, Kischak P, Somerville D, Mudiraj S, Leitman IM, Shamamian P. Perioperative care map improves compliance with best practices for the morbidly obese. Surgery 2016; 160:1682-1688. [PMID: 27622571 DOI: 10.1016/j.surg.2016.07.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/19/2016] [Accepted: 07/23/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND Morbid obesity can complicate perioperative management. Best practice guidelines have been published but are typically followed only in bariatric patients. Little is known regarding physician awareness of and compliance with these clinical recommendations for nonbariatric operations. Our study evaluated if an educational intervention could improve physician recognition of and compliance with established best practices for all morbidly obese operatively treated patients. METHODS A care map outlining best practices for morbidly obese patients was distributed to all surgeons and anesthesiologists at 4 teaching hospitals in 2013. Pre- and postintervention surveys were sent to participants in 2012 and in 2015 to evaluate changes in clinical practice. A chart audit performed postintervention determined physician compliance with distributed guidelines. RESULTS In the study, 567 physicians completed the survey in 2012 and 375 physicians completed the survey in 2015. Postintervention, statistically significant improvements were seen in the percentage of surgeons and anesthesiologists combined who reported changing their management of morbidly obese, operatively treated patients to comply with best practices preoperatively (89% vs 59%), intraoperatively (71% vs 54%), postoperatively (80% vs 57%), and overall (88% vs 72%). Results were similar when surgeons and anesthesiologists were analyzed separately. A chart audit of 170 cases from the 4 hospitals found that 167 (98%) cases were compliant with best practices. CONCLUSION After care map distribution, the percentage of physicians who reported changing their management to match best practices significantly improved. These findings highlight the beneficial impact this educational intervention can have on physician behavior. Continued investigation is needed to evaluate the influence of this intervention on clinical outcomes.
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Affiliation(s)
- Ian Solsky
- Montefiore Medical Center/Albert Einstein College of Medicine, Surgery, Bronx, NY
| | - Alex Edelstein
- Icahn School of Medicine at Mount Sinai, Surgery, New York, NY
| | - Michael Brodman
- Icahn School of Medicine at Mount Sinai, Surgery, New York, NY
| | - Ronald Kaleya
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY
| | - Meg Rosenblatt
- Icahn School of Medicine at Mount Sinai, Surgery, New York, NY
| | - Calie Santana
- Montefiore Medical Center/Albert Einstein College of Medicine, Surgery, Bronx, NY
| | | | | | | | | | | | - Peter Shamamian
- Montefiore Medical Center/Albert Einstein College of Medicine, Surgery, Bronx, NY.
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Blankush JM, Leitman IM, Soleiman A, Tran T. Association between elevated pre-operative glycosylated hemoglobin and post-operative infections after non-emergent surgery. Ann Med Surg (Lond) 2016; 10:77-82. [PMID: 27570622 PMCID: PMC4990567 DOI: 10.1016/j.amsu.2016.07.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 07/26/2016] [Accepted: 07/26/2016] [Indexed: 01/04/2023] Open
Abstract
Background A chronic state of impaired glucose metabolism affects multiple components of the immune system, possibly leading to an increased incidence of post-operative infections. Such infections increase morbidity, length of stay, and overall cost. This study evaluates the correlation between elevated pre-operative glycosylated hemoglobin (HbA1c) and post-operative infections. Study design Adult patients undergoing non-emergent procedures across all surgical subspecialties from January 2010 to July 2014 had a preoperative HbA1c measured as part of their routine pre-surgical assessment. 2200 patient charts (1100 < 6.5% HbA1c and1100 ≥ 6.5% HbA1c) were reviewed for evidence of post-operative infection (superficial surgical site infection, deep wound/surgical space abscess, pneumonia, and/or urinary tract infection as defined by Centers for Disease Control criteria) within 30 days of surgery. Results Patients with HbA1c < 6.5% and those with HbA1c ≥ 6.5% showed no statistically significant difference in overall infection rate (3.8% in the HbA1c < 6.5% group vs. 4.5% in the HbA1c ≥ 6.5% group, p = 0.39). Both linear regression and multivariate analysis did not identify HbA1c as an individual predictor of infection. Elevated HbA1c was, however, predictive of significantly increased risk of post-operative infection when associated with increased age (≥81 years of age) or dirty wounds. Conclusions The risk factors of post-operative infection are multiple and likely synergistic. While pre-operative HbA1c level is not independently associated with risk of post-operative infection, there are scenarios and patient subgroups where pre-operative HbA1c is useful in predicting an increased risk of infectious complications in the post-operative period. This study reviews the impact of pre-operative HbA1c across many specialties undergoing elective surgery. The risk factors of post-operative infection are multiple and likely synergistic. Elevated serum HbA1c is not independently associated with an increased risk of post-operative infection.
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Affiliation(s)
- Joseph M Blankush
- Department of Surgery, Mount Sinai Beth Israel, United States; Department of Surgery, Icahn School of Medicine at Mount Sinai, United States
| | - I Michael Leitman
- Department of Surgery, Mount Sinai Beth Israel, United States; Department of Surgery, Icahn School of Medicine at Mount Sinai, United States
| | - Aron Soleiman
- Department of Surgery, Mount Sinai Beth Israel, United States; Department of Surgery, Icahn School of Medicine at Mount Sinai, United States
| | - Trung Tran
- Department of Surgery, Mount Sinai Beth Israel, United States; Department of Surgery, Icahn School of Medicine at Mount Sinai, United States
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Sabat J, Gould S, Gillego E, Hariprashad A, Wiest C, Almonte S, Lucido DJ, Gave A, Leitman IM, Eiref SD. The use of finger-stick blood to assess lactate in critically ill surgical patients. Ann Med Surg (Lond) 2016; 10:41-8. [PMID: 27547397 PMCID: PMC4978218 DOI: 10.1016/j.amsu.2016.07.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 07/23/2016] [Accepted: 07/24/2016] [Indexed: 12/15/2022] Open
Abstract
Background Using finger-stick capillary blood to assess lactate from the microcirculation may have utility in treating critically ill patients. Our goals were to determine how finger-stick capillary lactate correlates with arterial lactate levels in patients from the surgical intensive care unit, and to compare how capillary and arterial lactate trend over time in patients undergoing resuscitation for shock. Methods Capillary whole blood specimens were obtained from finger-sticks using a lancet, and assessed for lactate via a handheld point-of-care device as part of an “investigational use only” study. Comparison was made to arterial blood specimens that were assessed for lactate by standard laboratory reference methods. Results 40 patients (mean age 68, mean APACHEII 18, vasopressor use 62%) were included. The correlation between capillary and arterial lactate levels was 0.94 (p < 0.001). Capillary lactate measured slightly higher on average than paired arterial values, with a mean difference 0.99 mmol/L. In patients being resuscitated for septic and hemorrhagic shock, capillary and arterial lactate trended closely over time: rising, peaking, and falling in tandem. Clearance of capillary and arterial lactate mirrored clinical improvement, normalizing in all patients except two that expired. Conclusion Finger-stick capillary lactate both correlates and trends closely with arterial lactate in critically ill surgical patients, undergoing resuscitation for shock. Finger-stick capillary lactate correlates with blood gas and core lab values. Capillary lactate trends closely over time with arterial lactate. Rising or falling capillary lactate reflects the adequacy of global perfusion. Capillary lactate measurements require a fraction of the time and blood to process. Preliminary results imply capillary lactate may be used in lieu of invasive methods.
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Affiliation(s)
- Joseph Sabat
- Division of Surgical-Critical Care, Department of Surgery, Icahn School of Medicine at Mount Sinai Beth Israel, First Avenue and 16th Street, New York, NY 10003, USA
| | - Scott Gould
- Division of Surgical-Critical Care, Department of Surgery, Icahn School of Medicine at Mount Sinai Beth Israel, First Avenue and 16th Street, New York, NY 10003, USA
| | - Ezra Gillego
- Division of Surgical-Critical Care, Department of Surgery, Icahn School of Medicine at Mount Sinai Beth Israel, First Avenue and 16th Street, New York, NY 10003, USA
| | - Anita Hariprashad
- Division of Surgical-Critical Care, Department of Surgery, Icahn School of Medicine at Mount Sinai Beth Israel, First Avenue and 16th Street, New York, NY 10003, USA
| | - Christine Wiest
- Division of Surgical-Critical Care, Department of Surgery, Icahn School of Medicine at Mount Sinai Beth Israel, First Avenue and 16th Street, New York, NY 10003, USA
| | - Shailyn Almonte
- Division of Surgical-Critical Care, Department of Surgery, Icahn School of Medicine at Mount Sinai Beth Israel, First Avenue and 16th Street, New York, NY 10003, USA
| | - David J Lucido
- Division of Surgical-Critical Care, Department of Surgery, Icahn School of Medicine at Mount Sinai Beth Israel, First Avenue and 16th Street, New York, NY 10003, USA
| | - Asaf Gave
- Division of Surgical-Critical Care, Department of Surgery, Icahn School of Medicine at Mount Sinai Beth Israel, First Avenue and 16th Street, New York, NY 10003, USA
| | - I Michael Leitman
- Division of Surgical-Critical Care, Department of Surgery, Icahn School of Medicine at Mount Sinai Beth Israel, First Avenue and 16th Street, New York, NY 10003, USA
| | - Simon D Eiref
- Division of Surgical-Critical Care, Department of Surgery, Icahn School of Medicine at Mount Sinai Beth Israel, First Avenue and 16th Street, New York, NY 10003, USA
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Desai NK, Leitman IM, Mills C, Lavarias V, Lucido DL, Karpeh MS. Open repair of large abdominal wall hernias with and without components separation; an analysis from the ACS-NSQIP database. Ann Med Surg (Lond) 2016; 7:14-9. [PMID: 27158489 PMCID: PMC4843100 DOI: 10.1016/j.amsu.2016.02.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 02/27/2016] [Accepted: 02/28/2016] [Indexed: 11/29/2022] Open
Abstract
Background Components separation technique emerged several years ago as a novel procedure to improve durability of repair for ventral abdominal hernias. Almost twenty-five years since its initial description, little comprehensive risk adjusted data exists on the morbidity of this procedure. This study is the largest analysis to date of short-term outcomes for these cases. Methods The ACS-NSQIP database identified open ventral or incisional hernia repairs with components separation from 2005 to 2012. A data set of cohorts without this technique, matched for preoperative risk factors and operative characteristics, was developed for comparison. A comprehensive risk-adjusted analysis of outcomes and morbidity was performed. Results A total of 68,439 patients underwent open ventral hernia repair during the study period (2245 with components separation performed (3.3%) and 66,194 without). In comparison with risk-adjusted controls, use of components separation increased operative duration (additional 83 min), length of stay (6.4 days vs. 3.8 days, p < 0.001), return to the OR rate (5.9% vs. 3.6%, p < 0.001), and 30-day morbidity (10.1% vs. 7.6%, p < 0.001) with no increase in mortality (0.0% in each group). Conclusions Components separation technique for large incisional hernias significantly increases length of stay and postoperative morbidity. Novel strategies to improve short-term outcomes are needed with continued use of this technique. The repair of large abdominal wall hernias is more frequently performed using components separation. While this technique appears to reduce recurrence, morbidity has not been previously studied. When compared to a large cohort, components separation has a higher complication rate than traditional open hernia repair.
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Affiliation(s)
- Nirav K Desai
- Department of Surgery, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - I Michael Leitman
- Department of Surgery, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher Mills
- Department of Surgery, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Valentina Lavarias
- Department of Surgery, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David L Lucido
- Department of Surgery, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Martin S Karpeh
- Department of Surgery, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Edwards SB, Leitman IM, Wengrofsky AJ, Giddins MJ, Harris E, Mills CB, Fukuhara S, Cassaro S. Identifying Factors and Techniques to Decrease the Positive Margin Rate in Partial Mastectomies: Have We Missed the Mark? Breast J 2016; 22:303-9. [DOI: 10.1111/tbj.12573] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Sara B. Edwards
- Department of Surgery; Mount Sinai Beth Israel; Icahn School of Medicine at Mount Sinai; New York New York
| | - I. Michael Leitman
- Department of Surgery; Mount Sinai Beth Israel; Icahn School of Medicine at Mount Sinai; New York New York
| | - Aaron J. Wengrofsky
- Department of Surgery; Mount Sinai Beth Israel; Icahn School of Medicine at Mount Sinai; New York New York
| | - Marley. J. Giddins
- Department of Surgery; Mount Sinai Beth Israel; Icahn School of Medicine at Mount Sinai; New York New York
| | - Emily Harris
- Department of Surgery; Mount Sinai Beth Israel; Icahn School of Medicine at Mount Sinai; New York New York
| | - Christopher B. Mills
- Department of Surgery; Mount Sinai Beth Israel; Icahn School of Medicine at Mount Sinai; New York New York
| | - Shinichi Fukuhara
- Department of Surgery; Mount Sinai Beth Israel; Icahn School of Medicine at Mount Sinai; New York New York
| | - Sebastiano Cassaro
- Department of Surgery; Mount Sinai Beth Israel; Icahn School of Medicine at Mount Sinai; New York New York
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Leitman IM. Graduate Medical Education-A System in Evolution. Am J Orthop (Belle Mead NJ) 2015; 44:E247. [PMID: 26161774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Kapur V, Krikhely M, Leitman IM. Operative management of splenic rupture and hepatic flexure injury during diagnostic colonoscopy in a patient with adenocarcinoma of the cecum. J Surg Case Rep 2015; 2015:rjv021. [PMID: 25786438 PMCID: PMC4363686 DOI: 10.1093/jscr/rjv021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Diagnostic colonoscopy has evolved to become the gold standard for the screening for carcinoma and other diseases of the colon. Injuries to the colon are rare and may be managed in a variety of ways. This includes observation and bowel rest or operative intervention and repair. Other organs are at risk during colonoscopy. The present report describes a patient who underwent colonoscopy for the work-up of anaemia. Following colonoscopy she developed signs of haemorrhagic shock and was found to have haemoperitoneum. She underwent surgery, and adenocarcinoma of the cecum was identified and managed during exploration. The clinical management is described.
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Affiliation(s)
- Varun Kapur
- Department of Surgery, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Merab Krikhely
- Department of Surgery, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - I Michael Leitman
- Department of Surgery, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Farivar BS, Flannagan M, Leitman IM. General surgery residents' perception of robot-assisted procedures during surgical training. J Surg Educ 2015; 72:235-42. [PMID: 25451717 DOI: 10.1016/j.jsurg.2014.09.008] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 09/10/2014] [Accepted: 09/10/2014] [Indexed: 05/28/2023]
Abstract
INTRODUCTION With the continued expansion of robotically assisted procedures, general surgery residents continue to receive more exposure to this new technology as part of their training. There are currently no guidelines or standardized training requirements for robot-assisted procedures during general surgical residency. The aim of this study was to assess the effect of this new technology on general surgery training from the residents' perspective. METHODS An anonymous, national, web-based survey was conducted on residents enrolled in general surgery training in 2013. The survey was sent to 240 Accreditation Council for Graduate Medical Education-approved general surgery training programs. RESULTS Overall, 64% of the responding residents were men and had an average age of 29 years. Half of the responses were from postgraduate year 1 (PGY1) and PGY2 residents, and the remainder was from the PGY3 level and above. Overall, 50% of the responses were from university training programs, 32% from university-affiliated programs, and 18% from community-based programs. More than 96% of residents noted the availability of the surgical robot system at their training institution. Overall, 63% of residents indicated that they had participated in robotic surgical cases. Most responded that they had assisted in 10 or fewer robotic cases with the most frequent activities being assisting with robotic trocar placement and docking and undocking the robot. Only 18% reported experience with operating the robotic console. More senior residents (PGY3 and above) were involved in robotic cases compared with junior residents (78% vs 48%, p < 0.001). Overall, 60% of residents indicated that they received no prior education or training before their first robotic case. Approximately 64% of residents reported that formal training in robotic surgery was important in residency training and 46% of residents indicated that robotic-assisted cases interfered with resident learning. Only 11% felt that robotic-assisted cases would replace conventional laparoscopic surgery in the future. CONCLUSIONS This study illustrates that although the most residents have a robot at their institution and have participated in robotic surgery cases, very few residents received formal training before participating in a robotic case.
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Affiliation(s)
- Behzad S Farivar
- Icahn School of Medicine at Mount Sinai, New York, New York; Department of Surgery, Mount Sinai Beth Israel, New York, New York
| | - Molly Flannagan
- Icahn School of Medicine at Mount Sinai, New York, New York; Department of Surgery, Mount Sinai Beth Israel, New York, New York
| | - I Michael Leitman
- Icahn School of Medicine at Mount Sinai, New York, New York; Department of Surgery, Mount Sinai Beth Israel, New York, New York.
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Abstract
BACKGROUND AND OBJECTIVES Percutaneous cholecystostomy is currently indicated for patients with cholecystitis who might be poor candidates for operative cholecystectomy. We performed a study to evaluate the long-term outcome of patients undergoing emergent tube cholecystostomy. METHODS This study was a retrospective chart review of patients who underwent tube cholecystostomy from July 1, 2005, to July 1, 2012. RESULTS During the study period, 82 patients underwent 125 cholecystostomy tube placements. Four patients (5%) died during the year after tube placement. The mean hospital length of stay for survivors was 8.8 days (range, 1-59 days). Twenty-eight patients (34%) required at least 1 additional percutaneous procedure (range, 1-6) for gallbladder drainage. Twenty-nine patients (34%) ultimately underwent cholecystectomy. Surgery was performed a mean of 7 weeks after cholecystostomy tube placement. Laparoscopic cholecystectomy was attempted in 25 operative patients but required conversion to an open approach in 8 cases (32%). In another 4 cases, planned open cholecystectomy was performed. Major postoperative complications were limited to 2 patients with postoperative common bile duct obstruction requiring endoscopic retrograde cholangiopancreatography, 1 patient requiring a return to the operating room for hemoperitoneum, and 2 patients with bile leak from the cystic duct stump. CONCLUSIONS In high-risk patients receiving cholecystostomy tubes for acute cholecystitis, only about one third will undergo surgical cholecystectomy. Laparoscopic cholecystectomy performed in this circumstance has a higher rate of conversion to open surgery and higher hepatobiliary morbidity rate.
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Affiliation(s)
- Kei Suzuki
- Department of Surgery, Mount Sinai Beth Israel Medical Center, NY, New York, USA
| | - Margaret Bower
- Department of Surgery, Mount Sinai Beth Israel Medical Center, NY, New York, USA
| | - Sebastiano Cassaro
- Department of Surgery, Mount Sinai Beth Israel Medical Center, NY, New York, USA
| | - Rajesh I Patel
- Departments of Interventional Radiology, Mount Sinai Beth Israel Medical Center, NY, New York, USA
| | - Martin S Karpeh
- Department of Surgery, Mount Sinai Beth Israel Medical Center, NY, New York, USA
| | - I Michael Leitman
- Department of Surgery, Mount Sinai Beth Israel Medical Center, NY, New York, USA
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Montgomery MM, Leitman IM. Endoscopic ultrasound and paracentesis in the evaluation of small volume ascites in patients with intra-abdominal malignancies. World J Gastroenterol 2014; 20:10219-10222. [PMID: 25132739 PMCID: PMC4130830 DOI: 10.3748/wjg.v20.i30.10219] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 02/19/2014] [Accepted: 05/05/2014] [Indexed: 02/06/2023] Open
Abstract
The evaluation of ascites in patients with known or suspected malignancy is a critical aspect of preoperative staging. Endoscopic evaluation by ultrasound of low volume ascites and sampling of the ascitic fluid by endoscopic ultrasound guided paracentesis (EUS-P) is both a sensitive and specific modality for the determination of peritoneal implants, which is not only an important prognostic indicator but a crucial factor in determining treatment strategy. It is common practice to utilize EUS for gastrointestinal malignancies such as pancreatic or gastric masses, with the performance of paracentesis during the same procedure for the purpose of imaging the abnormality and possibly performing fine needle aspiration for biopsy of the neoplasm itself. However, given the ability of EUS-P to adequately sample even minimal ascites, detecting much smaller volumes than traditional computed tomography or magnetic resonance imaging, EUS-P may be a useful modality for the standard metastatic workup of any newly diagnosed or suspected malignancy. In this “Field of Vision” commentary, we discuss the role of EUS-P, including the article by Suzuki et al reporting their experience with EUS-P using an automated spring-loaded needle device. We also review the utility of EUS-P for non-gastrointestinal malignancies, such as ovarian cancer, which has a high incidence of malignant ascites.
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Leitman IM, Suzuki K, Wengrofsky AJ, Menashe E, Poplawski M, Woo KM, Geller CM, Lucido D, Bernik T, Zeifer BA, Patton B. Early recognition of acute thoracic aortic dissection and aneurysm. World J Emerg Surg 2013; 8:47. [PMID: 24499618 PMCID: PMC3874654 DOI: 10.1186/1749-7922-8-47] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 10/31/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Thoracic aortic dissection (TAD) and aneurysm (TAA) are rare but catastrophic. Prompt recognition of TAD/TAA and differentiation from acute coronary syndrome (ACS) is difficult yet crucial. Earlier identification of TAA/TAD based upon routine emergency department screening is necessary. METHODS A retrospective analysis of patients that presented with acute thoracic complaints to the ED from January 2007 through June 2012 was performed. Cases of TAA/TAD were compared to an equal number of controls which consisted of patients with the diagnosis of ACS. Demographics, physical findings, EKG, and the results of laboratory and radiological imaging were compared. P-value of > 0.05 was considered statistically significant. RESULTS In total, 136 patients were identified with TAA/TAD, 0.36% of patients that presented with chest complaints. Compared to ACS patients, TAA/TAD group was older (68.9 vs. 63.2 years), less likely to be diabetic (13% vs 32%), less likely to complain of chest pain (47% vs 85%) and head and neck pain (4% vs 17%). The pain for the TAA/TAD group was less likely characterized as tight/heavy in nature (5% vs 37%). TAA/TAD patients were also less likely to experience shortness of breath (42% vs. 51%), palpitations (2% vs 9%) and dizziness (2% vs 13%) and had a greater incidence of focal lower extremity neurological deficits (6% vs 1%), bradycardia (15% vs. 5%) and tachypnea (53% vs. 22%). On multivariate analysis, increasing heart rate, chest pain, diabetes, head & neck pain, dizziness, and history of myocardial infarction were independent predictors of ACS. CONCLUSIONS Increasing heart rate, chest pain, diabetes, head & neck pain, dizziness, and history of myocardial infarction can be used to differentiate acute coronary syndromes from thoracic aortic dissections/aneurysms.
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Affiliation(s)
- I Michael Leitman
- Departments of Surgery, Albert Einstein College of Medicine-Beth Israel Medical Center, 10 Union Square East, Suite 2M, New York, NY 10003, USA
| | - Kei Suzuki
- Departments of Surgery, Albert Einstein College of Medicine-Beth Israel Medical Center, 10 Union Square East, Suite 2M, New York, NY 10003, USA
| | - Aaron J Wengrofsky
- Departments of Surgery, Albert Einstein College of Medicine-Beth Israel Medical Center, 10 Union Square East, Suite 2M, New York, NY 10003, USA
| | - Eyal Menashe
- Departments of Surgery, Albert Einstein College of Medicine-Beth Israel Medical Center, 10 Union Square East, Suite 2M, New York, NY 10003, USA
| | - Michal Poplawski
- Departments of Surgery, Albert Einstein College of Medicine-Beth Israel Medical Center, 10 Union Square East, Suite 2M, New York, NY 10003, USA
| | - Kar-Mun Woo
- Emergency Medicine, Albert Einstein College of Medicine-Beth Israel Medical Center, New York, NY, USA
| | - Charles M Geller
- Departments of Surgery, Albert Einstein College of Medicine-Beth Israel Medical Center, 10 Union Square East, Suite 2M, New York, NY 10003, USA
| | - David Lucido
- Departments of Surgery, Albert Einstein College of Medicine-Beth Israel Medical Center, 10 Union Square East, Suite 2M, New York, NY 10003, USA
| | - Thomas Bernik
- Departments of Surgery, Albert Einstein College of Medicine-Beth Israel Medical Center, 10 Union Square East, Suite 2M, New York, NY 10003, USA
| | - Barbara A Zeifer
- Radiology, Albert Einstein College of Medicine-Beth Israel Medical Center, New York, NY, USA
| | - Byron Patton
- Departments of Surgery, Albert Einstein College of Medicine-Beth Israel Medical Center, 10 Union Square East, Suite 2M, New York, NY 10003, USA
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Gandolfi BM, Leitman IM. A blood test for acute rejection after renal transplantation? Commentary on “Osteopontin level correlates with acute cellular renal allograft rejection”. J Surg Res 2013; 185:e49-50. [DOI: 10.1016/j.jss.2012.08.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2012] [Revised: 08/26/2012] [Accepted: 08/28/2012] [Indexed: 10/27/2022]
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Abstract
BACKGROUND AND OBJECTIVES The fascial anatomy of the anterior midline of the abdominal wall is permanently altered by the vertical plication of the rectus abdominis muscles commonly performed during abdominoplasty. In order to achieve safe and expeditious peritoneal entry in patients undergoing laparoscopy after a previous abdominoplasty, a modification of the standard midline open technique was developed. This not only facilitates entry and insufflation, but it also provides an acceptable cosmetic result following the laparoscopic surgery. MATERIALS AND METHODS A modified midline open Hasson technique of laparoscopic peritoneal entry that addresses the anatomical distortion created by a previous midline fascial plication was used in 24 consecutive patients undergoing elective laparoscopic cholecystectomy and is described herein. RESULTS AND CONCLUSIONS This modified entry technique consistently allowed safe and expeditious peritoneal entry in 24 consecutive patients undergoing laparoscopic surgery after a previous abdominoplasty.
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Affiliation(s)
- Sebastiano Cassaro
- 1 Department of Surgery, Kaweah Delta Health Care District , Visalia, California
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Iskandar ME, Radzio A, Krikhely M, Leitman IM. Laparoscopic cholecystectomy for a left-sided gallbladder. World J Gastroenterol 2013; 19:5925-5928. [PMID: 24124340 PMCID: PMC3793148 DOI: 10.3748/wjg.v19.i35.5925] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 07/11/2013] [Accepted: 07/19/2013] [Indexed: 02/06/2023] Open
Abstract
Cholecystectomy is a common procedure. Abnormalities in the anatomy of the biliary system are common but an abnormal location of the gallbladder is much rarer. Despite frequent pre-operative imaging, the aberrant location of the gallbladder is commonly discovered at surgery. This article presents a case of a patient with the gallbladder located to the left of the falciform ligament in the absence of situs inversus totalis that presented with right upper quadrant pain. A laparoscopic cholecystectomy was performed and it was noted that the cystic duct originated from the right side. The presence of a left sided gall bladder is often associated with various biliary, portal venous and other anomalies that might lead to intra-operative injuries. The spectrum of unusual positions and anatomical gallbladder abnormalities is reviewed in order to facilitate elective and emergent cholecystectomy as well as other hepatobiliary procedures. With proper identification of the anatomy, minimally invasive approaches are still considered safe.
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Marti JL, Leitman IM. Understanding the causes of hyperglycemia in burn patients. J Surg Res 2013; 182:205-6. [PMID: 22502905 DOI: 10.1016/j.jss.2012.03.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2012] [Revised: 03/04/2012] [Accepted: 03/21/2012] [Indexed: 01/04/2023]
Affiliation(s)
- Jennifer L Marti
- Department of Surgery, Albert Einstein College of Medicine-Beth Israel Medical Center, New York, NY 10003, USA
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