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Price AD, Foote DC, Woeste MR, Winer LK, Montgomery KB, Al Yafi M, Nahmias JT, Postlewait LM, Sutton JM, Quillin RC, Cortez AR. Defining the Disparity: A Multi-Institutional Analysis of Factors Associated With Decreased Resident Operative Experience. J Surg Res 2024; 293:647-655. [PMID: 37837821 PMCID: PMC10877667 DOI: 10.1016/j.jss.2023.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 08/01/2023] [Accepted: 08/31/2023] [Indexed: 10/16/2023]
Abstract
INTRODUCTION Technical learning in surgical training is multifaceted and existing literature suggests a positive relationship between case volume and proficiency. Little is known about factors associated with a decreased volume of operative experience. This study aimed to identify resident and program factors associated with general surgery residents (GSR) in the bottom quartile of logged case volume upon program completion. METHODS A post hoc analysis of a multicenter study was used to examine case logs for categorical GSR. Participants included graduates between 2010 and 2020 from 20 programs. Residents below and above the 25th percentile for total operative volume were compared. RESULTS The present study includes 1343 GSR who graduated over the 11-y period. In total, 336 residents were below the 25th percentile and 1007 residents were above the 25th percentile. Those below the 25th percentile were more likely to be female (41% versus 34%, P = 0.02), identify as underrepresented in medicine (22% versus 14%, P < 0.01), and pursue fellowship (86% versus 80%, P = 0.01) compared to those above the 25th percentile. Residents below the 25th percentile were more likely to have graduated from a low volume program (55% versus 25%, P < 0.01) and from top National Institutes of Health funded institutions (57% versus 52%, P = 0.01). CONCLUSIONS This study identified individual and program characteristics associated with lower operative volume of GSR. Understanding such characteristics will aid surgical educators to achieve better equity in training.
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Affiliation(s)
- Adam D Price
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, Ohio
| | - Darci C Foote
- Department of Surgery, Beaumont Health, Royal Oak, Michigan; Department of Surgery, Center for Surgical Training and Research (CSTAR), University of Michigan, Ann Arbor, Michigan
| | - Matthew R Woeste
- Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Leah K Winer
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Kelsey B Montgomery
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Motaz Al Yafi
- Department of Surgery, University of Toledo, Toledo, Ohio
| | - Jeffry T Nahmias
- Department of Surgery, University of California, Irvine, Orange, California
| | | | - Jeffrey M Sutton
- Division of Oncologic and Endocrine Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - R Cutler Quillin
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, Ohio
| | - Alexander R Cortez
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, Ohio; Department of Surgery, University of San Francisco, San Francisco, California.
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Winer LK, Kader S, Abelson JS, Hammaker AC, Eruchalu CN, Etheridge JC, Cho NL, Foote DC, Ivascu FA, Smith S, Postlewait LM, Greenwell K, Meister KM, Montgomery KB, Zmijewski P, Byrd SE, Kimbrough MK, Stopenski SJ, Nahmias JT, Harvey J, Farr D, Callahan ZM, Marks JA, Stahl CC, Al Yafi M, Sutton JM, Elsaadi A, Campbell SJ, Dodwad SJM, Adams SD, Woeste MR, Martin RC, Patel P, Anstadt MJ, Nasim BW, Willis RE, Patel JA, Newcomb MR, George BC, Quillin RC, Cortez AR. Disparities in the Operative Experience Between Female and Male General Surgery Residents: A Multi-institutional Study From the US ROPE Consortium. Ann Surg 2023; 278:1-7. [PMID: 36994704 PMCID: PMC10896185 DOI: 10.1097/sla.0000000000005847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
OBJECTIVE To examine differences in resident operative experience between male and female general surgery residents. BACKGROUND Despite increasing female representation in surgery, sex and gender disparities in residency experience continue to exist. The operative volume of male and female general surgery residents has not been compared on a multi-institutional level. METHODS Demographic characteristics and case logs were obtained for categorical general surgery graduates between 2010 and 2020 from the US Resident OPerative Experience Consortium database. Univariable, multivariable, and linear regression analyses were performed to compare differences in operative experience between male and female residents. RESULTS There were 1343 graduates from 20 Accreditation Council for Graduate Medical Education-accredited programs, and 476 (35%) were females. There were no differences in age, race/ethnicity, or proportion pursuing fellowship between groups. Female graduates were less likely to be high-volume residents (27% vs 36%, P < 0.01). On univariable analysis, female graduates performed fewer total cases than male graduates (1140 vs 1177, P < 0.01), largely due to a diminished surgeon junior experience (829 vs 863, P < 0.01). On adjusted multivariable analysis, female sex was negatively associated with being a high-volume resident (OR = 0.74, 95% CI: 0.56 to 0.98, P = 0.03). Over the 11-year study period, the annual total number of cases increased significantly for both groups, but female graduates (+16 cases/year) outpaced male graduates (+13 cases/year, P = 0.02). CONCLUSIONS Female general surgery graduates performed significantly fewer cases than male graduates. Reassuringly, this gap in operative experience may be narrowing. Further interventions are warranted to promote equitable training opportunities that support and engage female residents.
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Affiliation(s)
- Leah K. Winer
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH
| | - Sarah Kader
- Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA
| | | | - Austin C. Hammaker
- Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA
| | | | | | - Nancy L. Cho
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Darci C. Foote
- Department of Surgery, Beaumont Health, Royal Oak, MI
- Department of Surgery, Center for Surgical Training and Research (CSTAR), University of Michigan, Ann Arbor, MI
| | | | | | | | | | | | | | - Polina Zmijewski
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Samuel E. Byrd
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Mary K. Kimbrough
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | | | | | - Jalen Harvey
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas TX
| | - Deborah Farr
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas TX
| | | | - Joshua A. Marks
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | | | - Motaz Al Yafi
- Department of Surgery, University of Toledo, Toledo, OH
| | - Jeffrey M. Sutton
- Division of Oncologic and Endocrine Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Ali Elsaadi
- Texas Tech University Health Sciences Center School of Medicine Lubbock, TX
| | - Samuel J. Campbell
- Texas Tech University Health Sciences Center School of Medicine Lubbock, TX
| | | | - Sasha D. Adams
- Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
| | | | | | - Purvi Patel
- Department of Surgery, Loyola University, Maywood, IL
| | | | - Bilal Waqar Nasim
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Ross E. Willis
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Jitesh A. Patel
- Department of Surgery, University of Kentucky, Lexington, KY
| | | | - Brian C. George
- Department of Surgery, Center for Surgical Training and Research (CSTAR), University of Michigan, Ann Arbor, MI
| | - Ralph C. Quillin
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH
| | - Alexander R. Cortez
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH
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Vaysburg DM, Delman AM, Ammann AM, Turner KM, Winer LK, Sussman JJ, Makley AT, Goodman MD, Quillin RC, Van Haren RM. General Surgery Residency Virtual Recruitment During the Pandemic: An Analysis of Applicant Surveys. J Surg Res 2023; 283:33-41. [PMID: 36368273 PMCID: PMC9642898 DOI: 10.1016/j.jss.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 09/07/2022] [Accepted: 10/15/2022] [Indexed: 11/09/2022]
Abstract
INTRODUCTION The COVID-19 pandemic forced a sudden change from in-person to virtual interviews for the general surgery residency match. General surgery programs and applicants adopted multiple strategies to best mimic in-person recruitment. The purpose of this study was to evaluate applicant opinions of the virtual recruitment format. MATERIALS AND METHODS Postinterview survey responses for applicants interviewing at a single general surgery residency program in the 2020-2021 and 2021-2022 cycles were evaluated. All interviewed applicants were sent an anonymous survey assessing the virtual interview structure, their impression of the program, and their opinions on recruitment in the future. RESULTS The response rate was 31.2% (n = 60). Most (88.4%) respondents reported a more favorable view of the program after a virtual interview. Factors that were most likely to create a favorable impression were residents (89.6%) and culture (81.0%). 50.8% of applicants favored virtual-only interviews. The majority of applicants (60.3%), however, preferred the virtual interview remain a component of the application process, 34.4% recommended that virtual interviews be used as an initial screen before in-person invites, while 19.0% suggested applicants should interview in-person or virtually without penalty. 62.1% favored capping the number of interviews offered by programs and accepted by applicants. CONCLUSIONS The virtual interview format for general surgery residency allows applicants to effectively evaluate a residency program. Applicants are in favor of a combination of virtual and in-person interviews in the future. Innovation in the recruitment process, including limiting the number of applications and incorporating virtual events, is supported by applicants.
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Affiliation(s)
- Dennis M. Vaysburg
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Aaron M. Delman
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Allison M. Ammann
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Kevin M. Turner
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Leah K. Winer
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Jeffrey J. Sussman
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Amy T. Makley
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Michael D. Goodman
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Ralph C. Quillin
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Robert M. Van Haren
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio,Division of Thoracic Surgery, University of Cincinnati, Cincinnati, Ohio,Corresponding author. Department of Surgery, University of Cincinnati, 231 Albert Sabin Way ML—0558, Medical Sciences Building, Room 2472, Cincinnati, OH 45267-0558. Tel.: +1 513 584 4424
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Singer KE, Sussman JE, Kodali RA, Winer LK, Heh V, Hanseman D, Nomellini V, Pritts TA, Droege CA, Goodman MD. Hitting the Vasopressor Ceiling: Finding Norepinephrine Associated Mortality in the Critically Ill. J Surg Res 2021; 265:139-146. [PMID: 33940236 DOI: 10.1016/j.jss.2021.03.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/07/2021] [Accepted: 03/20/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND There is no consensus on what dose of norepinephrine corresponds with futility. The purpose of this study was to investigate the maximum infusion and cumulative doses of norepinephrine associated with survival for patients in medical and surgical intensive care units (MICU and SICU). MATERIALS AND METHODS A retrospective review was conducted of 661 critically ill patients admitted to a large academic medical center who received norepinephrine. Univariate, multivariate, and area under the curve analyses with optimal cut offs for maximum infusion rate and cumulative dosage were determined by Youden Index. RESULTS The population was 54.9% male, 75.8% white, and 58.7 ± 16.1 y old with 384 (69.8%) admitted to the MICU and 166 (30.2%) admitted to the SICU, including 38 trauma patients. Inflection points in mortality were seen at 18 mcg/min and 17.6 mg. The inflection point was higher in MICU patients at 21 mcg/min and lower in SICU patients at 11 mcg/min. MICU patients also had a higher maximum cumulative dosage of 30.7 mg, compared to 2.7 mg in SICU patients. In trauma patients, norepinephrine infusions up to 5 mcg/min were associated with a 41.7% mortality rate. CONCLUSION A maximum rate of 18 mcg/min and cumulative dose of 17.6 mg were the inflection points for mortality risk in ICU patients, with SICU patients tolerating lower doses. In trauma patients, even low doses of norepinephrine were associated with higher mortality. These data suggest that MICU, SICU, and trauma patients differ in need for, response to, and outcome from escalating norepinephrine doses.
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Affiliation(s)
- Kathleen E Singer
- Department of General Surgery, University of Cincinnati, Cincinnati Ohio
| | - Jonathan E Sussman
- Department of General Surgery, University of Cincinnati, Cincinnati Ohio
| | - Resha A Kodali
- Department of General Surgery, University of Cincinnati, Cincinnati Ohio
| | - Leah K Winer
- Department of General Surgery, University of Cincinnati, Cincinnati Ohio
| | - Victor Heh
- Department of General Surgery, University of Cincinnati, Cincinnati Ohio
| | - Dennis Hanseman
- Department of General Surgery, University of Cincinnati, Cincinnati Ohio
| | - Vanessa Nomellini
- Department of General Surgery, University of Cincinnati, Cincinnati Ohio
| | - Timothy A Pritts
- Department of General Surgery, University of Cincinnati, Cincinnati Ohio
| | | | - Michael D Goodman
- Department of General Surgery, University of Cincinnati, Cincinnati Ohio.
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Morris MC, Winer LK, Lee TC, Shah SA, Rafferty JF, Paquette IM. Omission of Adjuvant Chemotherapy in Rectal Cancer Patients with Pathologic Complete Response: a National Analysis. J Gastrointest Surg 2021; 25:1857-1865. [PMID: 32728821 PMCID: PMC7388436 DOI: 10.1007/s11605-020-04749-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/16/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND An increasing number of patients achieve a pathologic complete response (pCR) after neoadjuvant chemoradiation for locally advanced rectal cancer. Consensus guidelines continue to recommend oncologic resection followed by adjuvant chemotherapy in these patients. We hypothesize that there is significant variability in compliance with this recommendation. METHODS The National Cancer Database was queried from 2006 to 2015 for patients with locally advanced rectal cancer who underwent neoadjuvant chemoradiation followed by oncologic resection with a pCR (ypT0N0). Hierarchical logistic regression models were used to generate risk and reliability-adjusted rates of adjuvant chemotherapy utilization in patients with pCR at each hospital. RESULTS In total, 2421 pCR patients were identified. Five-year overall survival was improved in pCR patients who received adjuvant chemotherapy compared with those who did not (92 vs. 85%, p < 0.01). Multivariate analysis indicated that improvement in overall survival remained associated with adjuvant chemotherapy (HR 0.60, 95% CI 0.44-0.82, p < 0.01). The mean adjuvant chemotherapy utilization rate among hospitals was 32%. There was an upward trend in use over the past decade, but two-thirds still do not receive the recommended therapy. High chemotherapy utilizer hospitals were more likely to be academic centers (54.9 vs. 45.9%, p < 0.01) when compared with low chemotherapy utilizers. CONCLUSION Adjuvant chemotherapy is associated with improved survival in rectal cancer patients with pCR following neoadjuvant chemoradiation and oncologic resection. However, utilization among centers in the USA was only 32% with significant variability across centers. National efforts are needed to standardize treatment patterns according to national guidelines.
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Affiliation(s)
- Mackenzie C. Morris
- grid.24827.3b0000 0001 2179 9593Department of Surgery, College of Medicine, University of Cincinnati, 2123 Auburn Ave #524, Cincinnati, OH 45219 USA
| | - Leah K. Winer
- grid.24827.3b0000 0001 2179 9593Department of Surgery, College of Medicine, University of Cincinnati, 2123 Auburn Ave #524, Cincinnati, OH 45219 USA
| | - Tiffany C. Lee
- grid.24827.3b0000 0001 2179 9593Department of Surgery, College of Medicine, University of Cincinnati, 2123 Auburn Ave #524, Cincinnati, OH 45219 USA
| | - Shimul A. Shah
- grid.24827.3b0000 0001 2179 9593Department of Surgery, College of Medicine, University of Cincinnati, 2123 Auburn Ave #524, Cincinnati, OH 45219 USA
| | - Janice F. Rafferty
- grid.24827.3b0000 0001 2179 9593Department of Surgery, College of Medicine, University of Cincinnati, 2123 Auburn Ave #524, Cincinnati, OH 45219 USA
| | - Ian M. Paquette
- grid.24827.3b0000 0001 2179 9593Department of Surgery, College of Medicine, University of Cincinnati, 2123 Auburn Ave #524, Cincinnati, OH 45219 USA
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Kassam AF, Cortez AR, Winer LK, Conzen KD, El-Hinnawi A, Jones CM, Matsuoka L, Watkins AC, Collins KM, Bhati C, Selzner M, Sonnenday CJ, Englesbe MJ, Diwan TS, Dick AAS, Quillin RC. Extinguishing burnout: National analysis of predictors and effects of burnout in abdominal transplant surgery fellows. Am J Transplant 2021; 21:307-313. [PMID: 32463950 DOI: 10.1111/ajt.16075] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [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: 04/07/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 01/25/2023]
Abstract
Burnout among surgeons has been attributed to increased workload and decreased autonomy. Although prior studies have examined burnout among transplant surgeons, no studies have evaluated burnout in abdominal transplant surgery fellows. The objective of our study was to identify predictors of burnout and understand its impact on personal and patient care during fellowship. A survey was sent to all abdominal transplant surgery fellows in an American Society of Transplant Surgeons-accredited fellowship. The response rate was 59.2% (n = 77) and 22.7% (n = 17) of fellows met criteria for burnout. Fellows with lower grit scores were more likely to exhibit burnout compared with fellows with higher scores (3.6 vs 4.0, P = .026). Those with burnout were more likely to work >100 hours per week (58.8% vs 27.6%, P = .023), have severe work-related stress (58.8% vs 22.4%, P = .010), consider quitting fellowship (94.1% vs 20.7%, P < .001), or make a medical error (35.3% vs 5.2%, P = .003). This national analysis of abdominal transplant fellows found that burnout rates are relatively low, but few fellows engage in self-care. Personal and program-related factors attribute to burnout and it has unacceptable effects on patient care. Transplant societies and fellowship programs should develop interventions to give fellows tools to prevent and combat burnout.
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Affiliation(s)
- Al-Faraaz Kassam
- Cincinnati Research on Education in Surgical Training (CREST), Cincinnati, Ohio, USA.,Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Alexander R Cortez
- Cincinnati Research on Education in Surgical Training (CREST), Cincinnati, Ohio, USA.,Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Leah K Winer
- Cincinnati Research on Education in Surgical Training (CREST), Cincinnati, Ohio, USA.,Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Kendra D Conzen
- Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Ashraf El-Hinnawi
- Department of Surgery, The Ohio State University, Columbus, Ohio, USA
| | | | - Lea Matsuoka
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anthony C Watkins
- Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Kelly M Collins
- Department of Transplantation and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Chandra Bhati
- Department of Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Markus Selzner
- Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | | | | | - Tayyab S Diwan
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - André A S Dick
- Department of Surgery, University of Washington, Seattle, Washington, USA.,Seattle Children's Hospital, Seattle, Washington, USA
| | - Ralph C Quillin
- Cincinnati Research on Education in Surgical Training (CREST), Cincinnati, Ohio, USA.,Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
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Winer LK, Salyer C, Beckmann N, Caldwell CC, Nomellini V. Enigmatic role of coagulopathy among sepsis survivors: a review of coagulation abnormalities and their possible link to chronic critical illness. Trauma Surg Acute Care Open 2020; 5:e000462. [PMID: 33094168 PMCID: PMC7570228 DOI: 10.1136/tsaco-2020-000462] [Citation(s) in RCA: 3] [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: 02/25/2020] [Revised: 08/27/2020] [Accepted: 09/14/2020] [Indexed: 12/23/2022] Open
Abstract
There are sparse clinical data addressing the persistence of disordered coagulation in sepsis and its role in chronic critical illness. Coagulopathy in the absence of anticoagulant therapy and/or liver disease can be highly variable in sepsis, but it tends to be prolonged in patients in the intensive care unit with a length of stay greater than 14 days. These coagulation abnormalities tend to precede multisystem organ failure and persistence of these coagulation derangements can predict 28-day mortality. The studies evaluated in this review consistently link sepsis-associated coagulopathy to poor long-term outcomes and indicate that disordered coagulation is associated with unfavorable outcomes in chronic critical illness. However, the causative mechanism and the definitive link remain unclear. Longer follow-up and more granular data will be required to fully understand coagulopathy in the context of chronic critical illness.
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Affiliation(s)
- Leah K Winer
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Christen Salyer
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Nadine Beckmann
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Charles C Caldwell
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Department of Research, Shriners Hospitals for Children Cincinnati, Cincinnati, Ohio, USA
| | - Vanessa Nomellini
- Department of Research, Shriners Hospitals for Children Cincinnati, Cincinnati, Ohio, USA.,Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, University of Cincinnati Academic Health Center, Cincinnati, Ohio, USA
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Winer LK, Cortez AR, Ahmad SA, Wima K, Olowokure O, Latif T, Kharofa J, Patel SH. Evaluating the Impact of ESPAC-1 on Shifting the Paradigm of Pancreatic Cancer Treatment. J Surg Res 2020; 259:442-450. [PMID: 33059910 DOI: 10.1016/j.jss.2020.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 08/09/2020] [Accepted: 09/22/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND In 2004, the European Study Group for Pancreatic Cancer (ESPAC)-1 long-term data concluded that adjuvant chemotherapy provided a survival benefit for patients with pancreatic ductal adenocarcinoma (PDAC), whereas adjuvant chemoradiation was associated with worse overall survival. In this study, we investigated how long it took for US practice patterns to change following this trial. METHODS The National Cancer Database was used to identify patients with stage I-III PDAC who underwent R0 or R1 resection followed by adjuvant chemotherapy or chemoradiation between 1998 and 2015. A multivariate analysis was performed to determine predictors of receiving adjuvant chemoradiation in the post-ESPAC-1 era. RESULTS Between 1998 and 2015, adjuvant chemotherapy use increased from 2.9% to 51.6%, whereas adjuvant chemoradiation decreased from 49.5% to 22.9%. In 2010, adjuvant chemotherapy utilization surpassed that of chemoradiation. For patients diagnosed in the post-ESPAC-1 era, adjuvant chemotherapy (n = 7733) and chemoradiation (n = 6969) groups were compared. Patients who underwent adjuvant chemoradiation were younger, had private insurance, underwent surgery at nonacademic centers, and had more pathologically advanced cancers (all P < 0.01). After 2010, R1 resection was the strongest independent predictor of adjuvant chemoradiation use by multivariate analysis (OR 2.05, CI 1.8-2.3, P < 0.01). CONCLUSIONS Adjuvant chemotherapy use exceeded that of adjuvant chemoradiation 6 y after the final publication of ESPAC-1 in 2004, highlighting the challenges of disseminating and adopting clinical data. After 2010, R1 disease was the most significant predictor of receiving adjuvant chemoradiation. Prospective studies are underway to definitively address the role of adjuvant chemoradiation in PDAC.
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Affiliation(s)
- Leah K Winer
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alexander R Cortez
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Syed A Ahmad
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati College of Medicine, Cincinnati, Ohio; Department of Surgery, Section of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Koffi Wima
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Olubenga Olowokure
- Department of Hematology & Oncology, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Tahir Latif
- Department of Hematology & Oncology, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Jordan Kharofa
- Department of Radiation Oncology, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Sameer H Patel
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati College of Medicine, Cincinnati, Ohio; Department of Surgery, Section of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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Kassam AF, Singer KE, Winer LK, Browne D, Sussman JJ, Goodman MD, Makley AT. Acquisition and retention of surgical skills taught during intern surgical boot camp. Am J Surg 2020; 221:987-992. [PMID: 32981654 DOI: 10.1016/j.amjsurg.2020.09.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/11/2020] [Accepted: 09/11/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Surgical residencies have implemented boot-camps for early acquisition of basic technical skills for interns. However, educators worry that retention is poor. We hypothesized that a structured boot-camp curriculum would improve skills. METHODS Interns underwent eight boot-camp sessions at the beginning of residency. Interns completed pre-, post-boot-camp, and end-of-year skills assessments, as well as post-boot camp and end-of-year porcine procedure labs. Proficiency was measured on a 5-point scale and by completion time. RESULTS After boot-camp, interns improved all domains of knot-tying. Median time decreased for skin-closure (8.3 vs 9.9 min, p < 0.01), peg transfer (57 vs 87 s, p < 0.01), intracorporeal (178 vs 300 s, p < 0.01), and extracorporeal knot-tying (140 vs 259 s, p < 0.01). At the end-of-year assessment, interns exhibited retention of all skills and improved in knot-tying and central line skills. During the retention porcine lab, interns progressed basic but not complex skills. CONCLUSIONS An eight-week boot-camp effectively improved technical skills among surgery interns. Interns retained all skills and improved upon techniques frequently practiced during intern year.
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Affiliation(s)
- Al-Faraaz Kassam
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Kathleen E Singer
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Leah K Winer
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Deborah Browne
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Jeffrey J Sussman
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Michael D Goodman
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Amy T Makley
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA.
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Cortez AR, Morris MC, Brown NG, Winer LK, Safdar K, Poreddy S, Shah SA, Quillin RC. Is Surgery Necessary? Endoscopic Management of Post-transplant Biliary Complications in the Modern Era. J Gastrointest Surg 2020; 24:1639-1647. [PMID: 31228080 DOI: 10.1007/s11605-019-04292-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 05/29/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Biliary complications are common following liver transplantation (LT) and traditionally managed with Roux-en-Y hepaticojejunostomy. However, endoscopic management has largely supplanted surgical revision in the modern era. Herein, we evaluate our experience with the management of biliary complications following LT. METHODS All LTs from January 2013 to June 2018 at a single institution were reviewed. Patients with biliary bypass prior to, or at LT, were excluded. Patients were grouped by biliary complication of an isolated stricture, isolated leak, or concomitant stricture and leak (stricture/leak). RESULTS A total of 462 grafts were transplanted into 449 patients. Ninety-five (21%) patients had post-transplant biliary complications, including 56 (59%) strictures, 28 (29%) leaks, and 11 (12%) stricture/leaks. Consequently, the overall stricture, leak, and stricture/leak rates were 12%, 6%, and 2%, respectively. Endoscopic management was pursued for all stricture and stricture/leak patients, as well as 75% of leak patients, reserving early surgery only for those patients with an uncontrolled leak and evidence of biliary peritonitis. Endoscopic management was successful in the majority of patients (stricture 94%, leak 90%, stricture/leak 90%). Only six patients (5.6%) received additional interventions-two required percutaneous transhepatic cholangiography catheters, three underwent surgical revision, and one was re-transplanted. CONCLUSIONS Endoscopic management of post-transplant biliary complications resulted in long-term resolution without increased morbidity, mortality, or graft failure. Successful endoscopic treatment requires collaboration with a skilled endoscopist. Moreover, multidisciplinary transplant teams must develop treatment protocols based on the local availability and expertise at their center.
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Affiliation(s)
- Alexander R Cortez
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Mackenzie C Morris
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Nicholas G Brown
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH, USA
| | - Leah K Winer
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Kamran Safdar
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH, USA
| | - Sampath Poreddy
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH, USA
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA.,Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - R Cutler Quillin
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA. .,Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA.
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11
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Lee TC, Cortez AR, Kassam AF, Morris MC, Winer LK, Silski LS, Quillin RC, Cuffy MC, Jones CR, Diwan TS, Shah SA. Outcomes of en bloc simultaneous liver-kidney transplantation compared to the traditional technique. Am J Transplant 2020; 20:1181-1187. [PMID: 31605561 DOI: 10.1111/ajt.15655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 10/03/2019] [Accepted: 10/05/2019] [Indexed: 01/25/2023]
Abstract
Simultaneous liver-kidney transplantation (SLKT) is indicated for patients with end-stage liver disease (ESLD) and concurrent renal insufficiency. En bloc SLKT is an alternative to traditional separate implantations, but studies comparing the two techniques are limited. The en bloc technique maintains renal outflow via donor infrahepatic vena cava and inflow via anastomosis of donor renal artery to donor splenic artery. Comparison of recipients of en bloc (n = 17) vs traditional (n = 17) SLKT between 2013 and 2017 was performed. Recipient demographics and comorbidities were similar. More recipients of traditional SLKT were dialysis dependent (82.4% vs 41.2%, P = .01) with lower baseline pretransplant eGFR (14 vs 18, P = .01). En bloc SLKT was associated with shorter kidney cold ischemia time (341 vs 533 minutes, P < .01) and operative time (374 vs 511 minutes, P < .01). Two en bloc patients underwent reoperation for kidney allograft inflow issues due to kinking and renal steal. Early kidney allograft dysfunction (23.5% in both groups), 1-year kidney graft survival (88.2% vs 82.4%, P = 1.0), and posttransplantation eGFR were similar between groups. In our experience, the en bloc SLKT technique is safe and feasible, with comparable outcomes to the traditional method.
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Affiliation(s)
- Tiffany C Lee
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, Ohio.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alexander R Cortez
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, Ohio.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Al-Faraaz Kassam
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mackenzie C Morris
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, Ohio.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Leah K Winer
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, Ohio.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Latifa S Silski
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ralph C Quillin
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, Ohio.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Madison C Cuffy
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Courtney R Jones
- Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Tayyab S Diwan
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Shimul A Shah
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, Ohio.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Cortez AR, Winer LK, Katsaros GD, Kassam AF, Shah SA, Diwan TS, Cutler Quillin R. Resident Operative Experience in Hepatopancreatobiliary Surgery: Exposing the Divide. J Gastrointest Surg 2020; 24:796-803. [PMID: 31012042 DOI: 10.1007/s11605-019-04226-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 03/29/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Accreditation Council for Graduate Medical Education (ACGME) requires an experience in hepatopancreatobiliary (HPB) surgery as part of general surgery residency training. The composition of this experience, however, is unclear. We set out to evaluate current trends in the HPB experience of US general surgery residents. METHODS National ACGME operative case logs from 1990 to 2016 were examined with a focus on the HPB operative domains. Time-trend analysis was performed using ANOVA and linear regression analysis. RESULTS Median biliary, liver, and pancreatic operative volumes increased by 30%, 33%, and 27% over the 27-year study period (all p < 0.05). Both core and advanced HPB cases increased, but the rate of increase for core was four times greater than that of advanced. However, when cholecystectomy was excluded, this trend reversed such that HPB core operations decreased by 11 cases over the study period. Further analysis demonstrated that laparoscopic cholecystectomy comprised 90% of all biliary cases and 77% of all HPB cases for graduates in 2016. Finally, operative volume variability-the difference in case numbers between high and low volume residents-increased by 16%, 21%, and 73% for the biliary, liver, and pancreatic domains, respectively (all p < 0.05). CONCLUSIONS Despite increases in overall HPB operative volume, the HPB experience is changing for today's surgical trainees. Moreover, the HPB experience is comprised largely of a single operation-the cholecystectomy. Awareness of these trends is important for surgical educators to facilitate adequate exposure to HPB surgery among general surgery residents.
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Affiliation(s)
- Alexander R Cortez
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267-0558, USA.
| | - Leah K Winer
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267-0558, USA
| | - Gianna D Katsaros
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Al-Faraaz Kassam
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267-0558, USA
| | - Shimul A Shah
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Tayyab S Diwan
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - R Cutler Quillin
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267-0558, USA
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
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13
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Winer LK, Vivero MP, Scully BF, Cortez AR, Kassam AF, Nowygrod R, Griesemer AD, Emond JC, Quillin RC. Exploring Medical Students' Perceptions of Organ Procurement: Need for a Formalized Medical Student Curriculum. J Surg Educ 2020; 77:329-336. [PMID: 31753606 DOI: 10.1016/j.jsurg.2019.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 09/13/2019] [Accepted: 10/04/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE We evaluated the medical student experience with a deceased-donor multiorgan procurement program at a single center. The program provided the opportunity to assist with organ procurement, but no formal curriculum was offered. DESIGN, SETTING, PARTICIPANTS In 2018, medical students who registered for the program between 2014 and 2017 completed a voluntary survey about the experience and its impact on surgery interest and organ donation knowledge and advocacy. RESULTS Of 139 respondents, 53.3% (N = 74) of students participated in at least one procurement. The experience was resoundingly positive: 81.7% (N = 58) believed it exceeded expectations, with less than one-third missing class and only 4.3% (N = 3) reporting a negative impact on academics. Although 60.6% (N = 43) students studied prior to procurement, 57.8% (N = 41) expressed the need for increased preparation. Preferred learning modalities included videos, discussion with the transplant fellows, and focused anatomy overview. Following participation, 53.5% (N = 38) of students had increased interest in pursuing an acting internship and career in surgery. However, participation was not associated with improved familiarity with organ donation concepts or advocacy. CONCLUSIONS Adding a structured curriculum may turn medical students from passive observers into active learners, maximizing the educational value of procurement and better equipping future providers to promote organ donation.
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Affiliation(s)
- Leah K Winer
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Matthew P Vivero
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Alexander R Cortez
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Al-Faraaz Kassam
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Roman Nowygrod
- Department of Surgery, Columbia University, New York, New York
| | - Adam D Griesemer
- Center for Liver Disease and Transplantation, Columbia University, New York, New York
| | - Jean C Emond
- Center for Liver Disease and Transplantation, Columbia University, New York, New York
| | - Ralph C Quillin
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio.
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14
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Kassam AF, Cortez AR, Winer LK, Kuethe JW, Athota KP, Quillin RC. The impact of medical student interest in surgery on clerkship performance and career choice. Am J Surg 2020; 219:359-365. [DOI: 10.1016/j.amjsurg.2019.09.040] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 09/05/2019] [Accepted: 09/30/2019] [Indexed: 11/25/2022]
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15
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Cortez AR, Winer LK, Kassam AF, Hanseman DJ, Kuethe JW, Quillin RC, Potts JR. See None, Do Some, Teach None: An Analysis of the Contemporary Operative Experience as Nonprimary Surgeon. J Surg Educ 2019; 76:e92-e101. [PMID: 31130507 DOI: 10.1016/j.jsurg.2019.05.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/08/2019] [Accepted: 05/13/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE The operative experience of today's general surgery resident has changed, but little is known about the modern experience as nonprimary surgeon. We set out to explore changes in the operative experience of general surgery residents as first assistant (FA) and teaching assistant (TA). DESIGN, SETTING, AND PARTICIPANTS This is a review of ACGME national operative log reports from 1990 to 2018. TA and FA cases were analyzed. Statistical analysis was performed using polynomial regression analysis and Kruskal-Wallis test. Statistical significance was set at p < 0.05. RESULTS 30,260 individuals completed general surgery residency during the study period with medians of 951 (interquartile range: 929-974) total major, 63 (31-184) FA, and 32 (25-48) TA cases. As a proportion of total cases completed, FA cases decreased from 21.8% of the total operative experience in 1990 to 2.5% in 2018, and TA cases declined from 7.4% of the total operative experience in 1990 to 3.5% in 2018. Regression modeling demonstrated that both operative roles decreased over time, but at a progressively decreasing rate, with FA cases reaching a "floor" around 2010 and TA cases reaching a "breakpoint" in 2008 at which time operative volume rebounded and began to increase. Among the core general surgery domains of abdomen and alimentary tract, compositional analysis revealed a decrease across each of the 11 operative subcategories (all p < 0.05) for FA, and for TA, a decrease in 6 of the 11 operative subcategories (stomach, small intestine, large intestine, anorectal, hernia, and biliary, all p < 0.05). CONCLUSIONS Over the past 3 decades, the resident operative experience as nonprimary surgeon has decreased dramatically, with today's residents graduating with fewer FA and TA cases. As surgical training has traditionally relied heavily on an apprenticeship model for learning technical skills, it is essential that surgical educators recognize and rectify these trends.
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Affiliation(s)
- Alexander R Cortez
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio.
| | - Leah K Winer
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Al-Faraaz Kassam
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Dennis J Hanseman
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Joshua W Kuethe
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Ralph Cutler Quillin
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - John R Potts
- Accreditation Council for Graduate Medical Education, Chicago, Illinois
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16
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Winer LK, Cortez AR, Kassam AF, Quillin RC, Goodman MD, Makley AT, Sussman JJ, Kuethe JW. The Impact of a Comprehensive Resident Curriculum and Required Participation in "This Week in SCORE" on General Surgery ABSITE Performance and Well-Being. J Surg Educ 2019; 76:e102-e109. [PMID: 31492638 DOI: 10.1016/j.jsurg.2019.08.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 08/11/2019] [Accepted: 08/12/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE This Week in SCORE (TWIS) is a biennial, general surgery curriculum comprised of weekly online modules, readings, and multiple-choice quizzes. In this study, we examined the impact of required TWIS on American Board of Surgery In-Training Examination (ABSITE) scores and well-being among categorical general surgery residents. DESIGN, SETTING, AND PARTICIPANTS TWIS quiz completion became required in 2017. Residents attended weekly lectures, and ABSITE performance was incentivized with educational stipends. Surveys were distributed to assess study preferences, learning styles, burnout, and grit. Thirty-six categorical general surgery residents who took ABSITE in both 2017 and 2018 were evaluated in a paired-sample, retrospective analysis. RESULTS After requiring TWIS, median ABSITE percentile increased by 12% (65%-77%, p = 0.001). Weekly TWIS completion (59% vs 89%, p < 0.001) and quiz results (62% vs 69%, p = 0.005) also improved. During this time, emotional exhaustion and depersonalization declined significantly, yet overall burnout scores did not change. Of 21 survey respondents, 66.7% (n = 14) increased weekly study time by a median of 2.5 hours. However, less than half used Surgical Council on Resident Education as their primary study tool. Only 23.8% (n = 5) reported that mandatory TWIS modified their study behavior, while 90.4% (n = 19) felt the culture of education had improved. CONCLUSIONS After TWIS participation became required, ABSITE performances improved. Formalized curriculum with frequent assessment may foster accountability among residents, enhancing educational climate, well-being, and test performance.
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Affiliation(s)
- Leah K Winer
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alex R Cortez
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Al-Faraaz Kassam
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ralph C Quillin
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Michael D Goodman
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Amy T Makley
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jeffrey J Sussman
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Joshua W Kuethe
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati College of Medicine, Cincinnati, Ohio.
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17
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Cortez AR, Winer LK, Kassam AF, Hanseman DJ, Kuethe JW, Sussman JJ, Quillin RC. Exploring the relationship between burnout and grit during general surgery residency: A longitudinal, single-institution analysis. Am J Surg 2019; 219:322-327. [PMID: 31623881 DOI: 10.1016/j.amjsurg.2019.09.041] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 08/24/2019] [Accepted: 09/30/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND How burnout changes during general surgery residency remains unknown. METHODS From 2015 to 2018, general surgery residents completed the Maslach Burnout Inventory and Grit Scale. Statistical analyses were adjusted for repeated measures and compared to the incoming intern level. RESULTS Fifty-five residents participated in this study. Burnout rates varied by program level, with an increased risk occuring in the third clinical year (OR = 11.7, p = 0.03). Emotional exhaustion (EE) peaked during the first and third clinical years, depersonalization (DP) peaked during the first and second clinical years, and personal achievement (PA) reached a nadir during the third clinical year (all p < 0.05). Residents with burnout had lower grit scores compared to those without burnout (3.71 vs 4.02, p < 0.01). Increasing grit was linearly associated with decreasing EE, decreasing DP, and increasing PA (all p < 0.05). CONCLUSIONS Burnout varies throughout surgical residency, and grit is inversely related to burnout.
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Affiliation(s)
- Alexander R Cortez
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA.
| | - Leah K Winer
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Al-Faraaz Kassam
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Dennis J Hanseman
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Joshua W Kuethe
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Jeffrey J Sussman
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - R Cutler Quillin
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
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18
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Lee TC, Cortez AR, Kassam AF, Morris MC, Winer LK, Shah SA. Outcomes of en Bloc Simultaneous Liver-Kidney Transplantation Compared with the Traditional Technique. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.628] [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: 11/25/2022]
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19
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Lee TC, Kaiser TE, Luckett K, Wima K, Winer LK, Morris MC, Kassam AF, Safdar K, Bari K, Anwar N, Quillin RC, Shah SA. Use, Safety, and Effectiveness of Viremic Hepatitis B Virus Donor Livers: A Potential Opportunity to Expand the Donor Pool. Liver Transpl 2019; 25:1581-1584. [PMID: 31273919 DOI: 10.1002/lt.25595] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 06/18/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Tiffany C Lee
- Cincinnati Research on Outcomes and Safety in Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Tiffany E Kaiser
- Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Keith Luckett
- Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Koffi Wima
- Cincinnati Research on Outcomes and Safety in Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Leah K Winer
- Cincinnati Research on Outcomes and Safety in Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Mackenzie C Morris
- Cincinnati Research on Outcomes and Safety in Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Al-Faraaz Kassam
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kamran Safdar
- Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Khurram Bari
- Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Nadeem Anwar
- Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - R Cutler Quillin
- Cincinnati Research on Outcomes and Safety in Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.,Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Cincinnati Research on Outcomes and Safety in Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.,Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati, OH
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20
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Morris MC, Dhar VK, Stevenson MA, Winer LK, Lee TC, Wang J, Ahmad SA, Patel SH, Sussman JJ, Abbott DE. Adjuvant Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for patients at High-Risk of Peritoneal Metastases. Surg Oncol 2019; 31:33-37. [PMID: 31518971 DOI: 10.1016/j.suronc.2019.09.002] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 08/01/2019] [Accepted: 09/04/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Selection of patients for hyperthermic intraperitoneal chemotherapy (HIPEC) continues to evolve. We hypothesized that adjuvant HIPEC for patients at high-risk of peritoneal progression is safe and associated with favorable outcomes. METHODS The institutional database of a high-volume center was queried for patients with high-risk disease undergoing HIPEC with a peritoneal carcinomatosis index (PCI) of 0. High-risk patients were defined as those with ruptured primary tumors or locally advanced (T4) disease. RESULTS 37 patients underwent adjuvant HIPEC, with a median follow-up of 5.2 years. 54% had low-grade (LG) tumors while 46% had high-grade (HG) tumors. No patients underwent neoadjuvant chemotherapy, while eleven patients (32.4%) received adjuvant chemotherapy. There were no perioperative mortalities, and the overall complication rate was 43%. For the entire cohort, five year recurrence-free survival (RFS) and overall survival (OS) were 77% and 100%, respectively. Five year RFS and OS were 75% and 100% for LG patients and 81% and 100% for HG patients, respectively. CONCLUSIONS Adjuvant HIPEC for patients at high-risk of peritoneal progression, with PCI 0, is safe and associated with favorable long-term survival. Additional prospective investigation is needed to identify patient populations who may benefit most from HIPEC.
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Affiliation(s)
- Mackenzie C Morris
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Vikrom K Dhar
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Megan A Stevenson
- Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Leah K Winer
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tiffany C Lee
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jiang Wang
- Department of Pathology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sameer H Patel
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jeffrey J Sussman
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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21
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Cortez AR, Winer LK, Kassam AF, Kuethe JW, Athota KP, Quillin RC. The Impact of Medical Student Burnout on Surgery Clerkship Performance. J Surg Educ 2019; 76:1241-1247. [PMID: 30853486 DOI: 10.1016/j.jsurg.2019.02.009] [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] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/11/2019] [Accepted: 02/20/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Increasing reports on resident burnout have resulted in efforts to improve trainee well-being. Medical student burnout, however, is not well understood. We set out to evaluate burnout among third-year medical students and explore its impact on clerkship performance. DESIGN Analysis of prospectively-collected survey data from medical students on the third-year surgery clerkship was performed. Surveys included an institution-specific pre- and postclerkship survey, the 12-item Grit Scale, and the Maslach Burnout Inventory. SETTING University of Cincinnati College of Medicine. PARTICIPANTS Between 2016 and 2017, 166 students completed the surgery clerkship and were asked to complete the surveys. Sixty-two students (37.4%) completed all surveys and were included in this study. RESULTS Among the third-year medical student participants, there was no difference in burnout before vs after the clerkship (22.6% vs 17.7%, p = 0.41). Students with burnout had significantly lower grit scores (3.10 ± 0.66) compared to those without burnout (3.63 ± 0.50, p = 0.01). Linear regression analysis demonstrated that increasing grit was associated with decreasing emotional exhaustion (p = 0.01), decreasing depersonalization (p = 0.04), and increasing personal achievement (p = 0.03). Finally, 75% of students with resolution of burnout developed an interest in surgery, whereas all students who developed burnout after the clerkship had no interest in surgery (p = 0.03). Upon completion of the rotation, burnout was not associated with poorer quality of clerkship experience or decreased clerkship performance (p > 0.05 for each). CONCLUSIONS Although traditionally considered a difficult rotation, we found no increase in medical student burnout following the surgery clerkship. Higher grit scores were associated with decreased burnout, though burnout did not have a negative impact on student experience or performance. Clerkships should continue to set high expectations and maximize educational opportunities without significant apprehension that it may have a negative impact on students.
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Affiliation(s)
- Alexander R Cortez
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio.
| | - Leah K Winer
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Al-Faraaz Kassam
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Joshua W Kuethe
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Krishna P Athota
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - R Cutler Quillin
- Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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22
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Winer LK, Hinrichs BH, Lu S, Hanseman D, Huang Y, Reyna C, Lewis J, Shaughnessy EA. Flat epithelial atypia and the risk of sampling error: Determining the value of excision after image-guided core-needle biopsy. Am J Surg 2019; 218:730-736. [PMID: 31399195 DOI: 10.1016/j.amjsurg.2019.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 04/26/2019] [Accepted: 07/16/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND We determined the sampling error rate of flat epithelial atypia (FEA) and evaluated current guidelines recommending excisional biopsy. METHODS A retrospective review of consecutive excisional biopsies after image-guided core-needle biopsy identified patients with isolated FEA diagnosed between 2014 and 2018. Clinical and pathologic parameters were evaluated. RESULTS Twenty-five women with 27 biopsies were included. Based on pathologic review of original core specimens, 44.4% (N = 12) were accurately diagnosed as FEA. Upon excision, lesions were upgraded to ductal carcinoma in situ (N = 2) or invasive ductal carcinoma (N = 1) in 11.1% of cases. Older age, black race, hormone replacement, and calcifications in the image-guided biopsy specimen were associated with the presence of high-risk or malignant lesions in the excisional biopsy (all p ≤ 0.05). CONCLUSIONS In this study, FEA was frequently overcalled. However, lesions suspicious for FEA warrant excision due to their association with malignancy or high-risk lesions, which may necessitate further surgical management and/or risk-reducing strategies.
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Affiliation(s)
- Leah K Winer
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267, USA
| | - Benjamin H Hinrichs
- Department of Pathology, University of Cincinnati College of Medicine, 234 Goodman Street, Suite 110, Cincinnati, OH, 45219, USA
| | - Sisi Lu
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267, USA
| | - Dennis Hanseman
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267, USA
| | - Yuan Huang
- Department of Pathology, University of Cincinnati College of Medicine, 234 Goodman Street, Suite 110, Cincinnati, OH, 45219, USA
| | - Chantal Reyna
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267, USA
| | - Jaime Lewis
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267, USA
| | - Elizabeth A Shaughnessy
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267, USA.
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23
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Winer LK, Dhar VK, Wima K, Morris MC, Lee TC, Shah SA, Ahmad SA, Patel SH. The Impact of Tumor Location on Resection and Survival for Pancreatic Ductal Adenocarcinoma. J Surg Res 2019; 239:60-66. [DOI: 10.1016/j.jss.2019.01.061] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 01/16/2019] [Accepted: 01/25/2019] [Indexed: 12/11/2022]
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24
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Dhar VK, Wima K, Lee TC, Morris MC, Winer LK, Ahmad SA, Shah SA, Patel SH. Perioperative blood transfusions following hepatic lobectomy: A national analysis of academic medical centers in the modern era. HPB (Oxford) 2019; 21:748-756. [PMID: 30497896 DOI: 10.1016/j.hpb.2018.10.022] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 10/15/2018] [Accepted: 10/25/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The purpose of the study was to characterize the prevalence and impact of perioperative blood use for patients undergoing hepatic lobectomy at academic medical centers. METHODS The University HealthSystem Consortium (UHC) database was queried for hepatic lobectomies performed between 2011 and 2014 (n = 6476). Patients were grouped according to transfusion requirements into high (>5 units, 7%), medium (2-5 units, 6%), low (1 unit, 8%), and none (0 units, 79%) during hospital stay for comparison of outcomes. RESULTS Over 20% of patients undergoing hepatic lobectomy received blood perioperatively, of which 35% required more than 5 units. Patients with high transfusion requirements had increased severity of illness (p < 0.01). High transfusion requirements correlated with increased readmission rates (23.4% vs. 19.2% vs. 16.6% vs. 13.5%), total direct costs ($31,982 vs. $20,859 vs. $19,457 vs. $16,934), length of stay (9 days vs. 8 vs. 7 vs. 6), and in-hospital mortality (10.8% vs. 2.0% vs. 0.9% vs. 2.0%) compared to medium, low, and no transfusion amounts (all p < 0.01). Neither center nor surgeon volume were associated with transfusion use. CONCLUSION High transfusion requirements after hepatic lobectomy in the United States are associated with worse perioperative quality measures, but may not be influenced by center or surgeon volume.
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Affiliation(s)
- Vikrom K Dhar
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Koffi Wima
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tiffany C Lee
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mackenzie C Morris
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Leah K Winer
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Syed A Ahmad
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sameer H Patel
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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25
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Xia BT, Beckmann N, Winer LK, Pugh AM, Pritts TA, Nomellini V, Gulbins E, Caldwell CC. Amitriptyline Reduces Inflammation and Mortality in a Murine Model of Sepsis. Cell Physiol Biochem 2019; 52:565-579. [PMID: 30897322 DOI: 10.33594/000000040] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 03/18/2019] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND/AIMS During sepsis, an unchecked pro-inflammatory response can be detrimental to the host. We investigated the potential protective effect of amitriptyline (AT). METHODS We used two murine models of sepsis: Cecal ligation and puncture and endotoxemia following LPS challenge. Aural temperatures were taken and cytokines quantified by cytometric bead assay. Lung injury was determined histologically and by protein determination in bronchoalveolar lavage fluid. Cell accumulation in the peritoneum was analyzed by flow cytometry, as well as cytokine production and p38-phosphorylation. Neutrophil chemotaxis was evaluated using an in vitro transwell assay. RESULTS Our findings demonstrate that AT-treated septic mice have improved survival and are protected from pulmonary edema. Treatment with AT significantly decreased serum levels of KC and monocyte chemoattractant protein-1, as well as the accumulation of neutrophils and monocytes in the peritoneum of septic mice. Peritoneal IL-10 levels in septic mice were increased upon AT treatment. Direct treatment of septic mice with IL-10 recapitulated the effects of AT. Endotoxemic mice also exhibited enhanced IL-10 production upon AT-administration and peritoneal macrophages were identified as the ATinfluenced producers of IL-10. Treatment of these cells with AT in vitro resulted in increased p38-phosphorylation and IL-10 generation, whereas ceramide and p38 inhibition had the opposite effect. CONCLUSION Altogether, AT treatment improved survival, increased IL-10 levels, and mitigated a pro-inflammatory response during sepsis. We conclude that AT is a promising therapeutic to temper inflammation during septic shock.
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Affiliation(s)
- Brent T Xia
- Division of Research, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Nadine Beckmann
- Division of Research, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Leah K Winer
- Division of Research, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Amanda M Pugh
- Division of Research, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Timothy A Pritts
- Division of Research, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Vanessa Nomellini
- Division of Research, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Erich Gulbins
- Division of Research, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.,Department of Molecular Biology, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Charles C Caldwell
- Division of Research, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.,Division of Research, Shriners Hospital for Children, Cincinnati, OH, USA,
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26
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Winer LK, Beckmann N, Veile RA, Goodman MD, Caldwell CC, Nomellini V. Consumptive coagulopathy is associated with organ dysfunction during PICS. Am J Physiol Lung Cell Mol Physiol 2019; 316:L946-L952. [PMID: 30840483 DOI: 10.1152/ajplung.00521.2018] [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] [Indexed: 12/29/2022] Open
Abstract
Patients who survive the acute phase of sepsis can progress to persistent inflammation, immunosuppression, and catabolism syndrome (PICS). Although sepsis is characterized by early hypercoagulability and delayed hypocoagulability, coagulopathy during chronic critical illness is not fully understood. The objective of this study was to determine whether sepsis-induced PICS is associated with coagulation abnormalities. Using our previously described murine PICS model, outbred mice underwent cecal ligation and puncture, and coagulability was characterized after 8 days. We found that during PICS the spleen became markedly enlarged with increased splenocytes and splenic megakaryocytes without a concomitant increase in circulating platelets. Microscopy revealed a nearly sevenfold increase in pulmonary microvascular thrombi in PICS mice, along with significantly decreased pulmonary tidal volumes and inspiratory times and with significantly increased respiratory rates. Thromboelastometry showed that PICS mice had significantly delayed clot initiation time but increased clot firmness. Finally, PICS mice displayed delayed thrombin production and decreased overall thrombin concentrations. All together, these data demonstrate a general dysregulation of coagulation resulting in microthrombus formation and compromised lung function. On the basis of these findings, we propose that consumptive coagulopathy constitutes another cardinal feature of PICS and may contribute to the ongoing tissue damage and multiple organ failure that can occur in chronic critical illness.
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Affiliation(s)
- Leah K Winer
- Division of Research, Department of Surgery, University of Cincinnati College of Medicine , Cincinnati, Ohio
| | - Nadine Beckmann
- Division of Research, Department of Surgery, University of Cincinnati College of Medicine , Cincinnati, Ohio
| | - Rosalie A Veile
- Division of Research, Department of Surgery, University of Cincinnati College of Medicine , Cincinnati, Ohio
| | - Michael D Goodman
- Division of Research, Department of Surgery, University of Cincinnati College of Medicine , Cincinnati, Ohio.,Section of General Surgery, Department of Surgery, University of Cincinnati College of Medicine , Cincinnati, Ohio
| | - Charles C Caldwell
- Division of Research, Department of Surgery, University of Cincinnati College of Medicine , Cincinnati, Ohio.,Division of Research, Shriners Hospital for Children , Cincinnati, Ohio
| | - Vanessa Nomellini
- Section of General Surgery, Department of Surgery, University of Cincinnati College of Medicine , Cincinnati, Ohio.,Division of Research, Shriners Hospital for Children , Cincinnati, Ohio
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27
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Cortez AR, Winer LK, Kim Y, Hanseman DJ, Athota KP, Quillin RC. Predictors of medical student success on the surgery clerkship. Am J Surg 2019; 217:169-174. [DOI: 10.1016/j.amjsurg.2018.09.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 09/04/2018] [Accepted: 09/16/2018] [Indexed: 11/27/2022]
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28
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Winer LK, Pugh AM, Caldwell CC, Nomellini V. Altered Neutrophil Phenotypes in a Murine Model of Persistent Inflammation, Immunosuppression, and Catabolism Syndrome. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.110] [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: 10/28/2022]
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29
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Winer LK, Dhar VK, Wima K, Lee TC, Morris MC, Shah SA, Ahmad SA, Patel SH. Perioperative Net Fluid Balance Predicts Pancreatic Fistula After Pancreaticoduodenectomy. J Gastrointest Surg 2018; 22:1743-1751. [PMID: 29869090 DOI: 10.1007/s11605-018-3813-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [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: 04/05/2018] [Accepted: 05/09/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Our goal was to evaluate the relationship between perioperative fluid administration and the development of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD). METHODS Retrospectively, we analyzed fluid balance over the first 72 h in 104 consecutive patients who underwent PD between 2013 and 2017. Patients were categorized into tertiles (low, medium, and high) by net fluid balance. RESULTS POPF was identified in 17.3% of patients (n = 18). No significant demographic differences were identified among tertiles. Similarly, there were no differences in ASA, smoking status, hemoglobin A1C, pathologic findings, operative time, blood loss, intraoperative fluid administration, use of pancreatic stents, use of epidurals, or postoperative lactate. Patients with high 72-h net fluid balance had significantly increased rates of POPF compared with those in the medium and low tertiles (31.4% vs. 11.4% vs. 8.8%, p = 0.02). On multivariate analysis, increasing net fluid balance remained associated with CR-POPF (OR 1.26, CI 1.03-1.55, p = 0.03). CONCLUSION High net 72-h fluid balance is an independent predictor of POPF after PD. Given ongoing efforts to minimize PD morbidity, net fluid balance may represent a clinical predictor and, possibly, a modifiable target for prevention of POPF.
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Affiliation(s)
- Leah K Winer
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Vikrom K Dhar
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Koffi Wima
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tiffany C Lee
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mackenzie C Morris
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shimul A Shah
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Syed A Ahmad
- Section of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267-0558, USA
| | - Sameer H Patel
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
- Section of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267-0558, USA.
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30
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Ahmad SA, Xia BT, Bailey CE, Abbott DE, Helmink BA, Daly MC, Thota R, Schlegal C, Winer LK, Ahmad SA, Al Humaidi AH, Parikh AA. In Brief. Curr Probl Surg 2016. [DOI: 10.1067/j.cpsurg.2016.08.003] [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: 11/22/2022]
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31
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Ahmad SA, Xia BT, Bailey CE, Abbott DE, Helmink BA, Daly MC, Thota R, Schlegal C, Winer LK, Ahmad SA, Al Humaidi AH, Parikh AA. An update on gastric cancer. Curr Probl Surg 2016; 53:449-90. [PMID: 27671911 DOI: 10.1067/j.cpsurg.2016.08.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 08/03/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Syed A Ahmad
- Division of Surgical Oncology, University of Cincinnati Cancer Institute, University of Cincinnati College of Medicine, Cincinnati, OH.
| | - Brent T Xia
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH
| | - Christina E Bailey
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Beth A Helmink
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Meghan C Daly
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH
| | - Ramya Thota
- Division of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Cameron Schlegal
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Leah K Winer
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH
| | | | - Ali H Al Humaidi
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH
| | - Alexander A Parikh
- Division of Hepatobiliary, Pancreas and Gastrointestinal Surgical Oncology, Vanderbilt University Medical Center, Nashville, TN
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