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Zickler WP, Zambetti BR, Zickler CL, Zickler MK, Byerly S, Garrett HE, Magnotti LJ. Impact of Patient and Procedural Factors on Outcomes Following Mesenteric Bypass. Am Surg 2024; 90:377-385. [PMID: 37655480 DOI: 10.1177/00031348231198118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
BACKGROUND Mesenteric bypass (MB) for patients with acute (AMI) and chronic mesenteric ischemia (CMI) is associated with cardiovascular (CV) and pulmonary morbidity. METHODS Patients with AMI and CMI from 2008 to 2019 were identified to determine independent predictors of CV (cardiac arrest, MI, DVT, and stroke) and pulmonary (pneumonia and ventilator time>48 h) morbidities in patients undergoing MB. RESULTS 377 patients were identified. Patients with AMI had higher rates of preoperative SIRS/sepsis (28 vs 12%, P < .0001), were more likely to be ASA class 4/5 (55 vs 42%, P = .005), were more likely to require bowel resection (19 vs 3%, P < .0001), and were more likely to have vein utilized as their bypass conduit (30 vs 14%, P < .0001). There were no differences in use of aortic or iliac inflow (P = .707) nor in return to the OR (24 vs 19%, P = .282). Both postoperative sepsis (12 vs 2.6%, P = .003) and mortality (31.4% vs 9.8%, P < .0001) were significantly increased in patients with AMI. After adjusting for both patient and procedural factors, multivariable logistic regression (MLR) identified international normalized ratio (INR) (OR 3.16; 95% CI 1.56-6.40, P = .001) and chronic heart failure (CHF) (OR 5.88; 95% CI 1.15-29.97, P = .033) to be independent predictors of pulmonary morbidity, while preoperative sepsis (OR 1.96; 95% CI 1.45-2.66, P < .0001) alone was predictive of CV morbidity in all patients undergoing MB. DISCUSSION Mesenteric bypass for mesenteric ischemia leads to high rates of morbidity and mortality, whether done in an acute or chronic setting. Preoperative sepsis, independent of AMI or CMI, predicts CV morbidity, regardless of bypass configuration or conduit, while elevated INR or underlying CHF carries a higher risk of pulmonary morbidity.
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Affiliation(s)
| | - Benjamin R Zambetti
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Christine L Zickler
- Florida International University Herbert Wertheim College of Medicine, Miami, FL, USA
| | | | - Saskya Byerly
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - H Edward Garrett
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Louis J Magnotti
- Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA
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Zambetti BR, Blitzer DN, Nagarsheth K, Toursavadkohi S. Outcomes and Predictors of Morbidity after Carotid Body Tumor Resection. Ann Vasc Surg 2024; 99:442-447. [PMID: 37914072 DOI: 10.1016/j.avsg.2023.09.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/12/2023] [Accepted: 09/03/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Carotid body tumors (CBTs) are uncommon neuroendocrine tumors at the carotid bifurcation treated with resection. The goal of this study was to examine patient outcomes after CBT resection and establish predictors of morbidity. METHODS Patients undergoing CBT resection were identified from the National Surgical Quality Improvement Program (NSQIP) database over 11 years. Demographics, past medical history, preoperative labs, procedural details, morbidity and mortality were recorded. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of morbidity. RESULTS From 2010 to 2020, 668 CBT resections were identified. The majority of patients were female (65%) and White (72%) with a mean age of 56 (standard deviation [SD] ± 16). Average body mass index (BMI) was 29.9 (SD ± 7.1). Arterial resection occurred in 81 patients (12%). 6% of patients experienced morbidity, most commonly re-operation (2.4%). Morbidity was more common in patients with higher BMI (33.1 vs. 29.7, P = 0.005), chronic obstruction pulmonary disease (10% vs. 1.9%, P = 0.012), higher American Society of Anesthesiologists (P = 0.005), and lower albumin (3.7 vs. 4, P = 0.016). Morbidity was not increased with arterial resection (P = 1) or based on length of operation (P = 0.169). Morbidity did not impact mortality (P = 0.06) though led to longer length of stay [LOS] (8 days vs. 2.4, P < 0.001). On MLR, preoperative BMI was the only risk factor for morbidity (odds ratio 1.06, 95% confidence interval 1.02-1.1, P = 0.005). CONCLUSIONS CBT resection is very well tolerated with low stroke rates, morbidity, and mortality. Arterial resection leads to increased transfusion requirements and LOS but did not increase stroke rates, mortality, or overall morbidity. Within the NSQIP database, preoperative BMI was the only predictor of postoperative morbidity, which leads to significantly longer LOS.
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Affiliation(s)
- Benjamin R Zambetti
- Division of Vascular Surgery, Department of Surgery, University of Maryland, Baltimore, MD.
| | - David N Blitzer
- Division of Vascular Surgery, Department of Surgery, University of Maryland, Baltimore, MD
| | - Khanjan Nagarsheth
- Division of Vascular Surgery, Department of Surgery, University of Maryland, Baltimore, MD
| | - Shahab Toursavadkohi
- Division of Vascular Surgery, Department of Surgery, University of Maryland, Baltimore, MD
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Patel DD, Zambetti BR, Magnotti LJ. Timing to Rib Fixation in Patients With Flail Chest. J Surg Res 2024; 294:93-98. [PMID: 37866069 DOI: 10.1016/j.jss.2023.09.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 09/09/2023] [Accepted: 09/15/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Flail chest (FC) after blunt trauma is associated with significant morbidity and prolonged hospitalizations. The goal of this study was to examine the relationship between timing of rib fixation (ORIF) and pulmonary morbidity and mortality in patients with FC. METHODS FC patients were identified from the Trauma Quality Improvement Program database over 3-year, ending 2019. Demographics, severity of injury and shock, time to ORIF, pulmonary morbidity, and mortality were recorded. Youden's index identified optimal time to ORIF. Patients were compared based on undergoing ORIF versus nonoperative management, then for patients undergoing ORIF based on time from admission to operation, utilizing Youden's index to determine the preferred time for fixation. Multivariable logistic regression determined predictors of pulmonary morbidity and mortality. RESULTS 20,457 patients were identified: 3347 (16.4%) underwent ORIF. The majority were male (73%) with median age and injury severity score of 58 and 22, respectively. Patients undergoing ORIF were clinically similar to those managed nonoperatively but had increased pulmonary morbidity (27.6 versus 15.2%, P < 0.0001) and reduced mortality (2.9 versus 11.7%, P < 0.0001). Multivariable logistic regression identified ORIF as the only modifiable risk factor significantly associated with reduced mortality (odds ratio: 0.26; 95% CI:0.21-0.32, P < 0.0001). Youden's index identified the inflection point for time to ORIF as 4 d postinjury: EARLY (≤4 d) and LATE (>4 d). EARLY fixation was associated with a significant decrease in ventilator days, intensive care unit and hospital length of stay, and pulmonary morbidity. CONCLUSIONS Patients undergoing ORIF for FC experienced increased pulmonary morbidity; however, had an associated reduced mortality benefit compared to the nonoperative cohort. EARLY ORIF was associated with a reduction in pulmonary morbidity, without impacting the mortality benefit found with ORIF. Thus, for patients with FC, ORIF performed within 4 d postinjury may help reduce pulmonary morbidity, length of stay, and mortality.
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Affiliation(s)
- Devanshi D Patel
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee.
| | - Benjamin R Zambetti
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
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4
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Zambetti BR, Zickler WP, Byerly S, Garrett HE, Magnotti LJ. Risk Factors for Acute Renal Failure After Endovascular Aneurysm Repair. Am Surg 2024; 90:55-62. [PMID: 37490565 DOI: 10.1177/00031348231191181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) after endovascular aortic aneurysm repair (EVAR) is uncommon though carries significant morbidity. Procedural risk factors are not well established for acute renal failure (ARF) that requires initiation of dialysis. The goal of this study was to examine the impact of ARF on patients undergoing EVAR and identify risk factors for ARF using a large, national dataset. METHODS Patients undergoing EVAR were identified from the National Surgical Quality Improvement Program (NSQIP) database over 9 years, ending in 2019. Demographics, indication for repair, comorbidities, procedural details, complications, hospital and ICU LOS, and mortality were recorded. Patients were stratified by presence of ARF and compared. Patients were further stratified by indication for EVAR and presence of ARF. Multivariable logistic regression (MLR) analysis was performed to determine the independent predictors of ARF. RESULTS 18 347 patients were identified. Of these 234 (1.3%) developed ARF requiring dialysis. Mortality (40 vs 1.8%, P < .0001), ICU LOS (5 vs 0 days, P < .0001), and hospital LOS (11 vs 2 days, P < .0001) were all significantly increased in patients with ARF. Multivariable logistic regression identified increasing diameter, creatinine, operative time, preoperative transfusions, ASA class, emergent repair, female gender, and juxtarenal/suprarenal proximal landing zone as predictors of ARF. CONCLUSIONS ARF after EVAR causes significant morbidity, prolongs hospitalizations, and increases mortality rates. Those patients at risk of ARF after EVAR should be closely monitored to reduce both morbidity and mortality.
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Affiliation(s)
| | - William P Zickler
- Division of Vascular Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Saskya Byerly
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - H Edward Garrett
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
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Desai N, Zambetti BR, Wong DL, Schachter AE, Judge NP, Valaulikar GS, Ng T. Outcomes and predictors of survival for tracheal cancer. J Surg Oncol 2023; 128:1251-1258. [PMID: 37732718 DOI: 10.1002/jso.27447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/07/2023] [Accepted: 09/08/2023] [Indexed: 09/22/2023]
Abstract
INTRODUCTION Primary tracheal cancer is uncommon, with poor survival. While surgical resection is the mainstay of therapy, the role of chemotherapy and radiation is poorly defined. We aimed to study the impact of treatment modalities on survival. METHODS Patients with primary tracheal cancer were identified from the National Cancer Database over 12 years, 2004-2015. Patient characteristics, tumor characteristics, treatment modalities, and survival were recorded. Factors associated with survival were assessed using Cox Regression. RESULTS Of the 1726 patients identified, 59% were male, 83% White race, 62% had a comorbidity index of zero, median age 64 years, median tumor size 2.7 cm, and median survival was 28.5 months (89 months for patients undergoing surgical resection). Cox Regression for all patients found adenoid cystic carcinoma (ACC) (p < 0.001), radiation (p < 0.001), and surgical resection (p < 0.001) to be associated with improved survival, while increasing age (p < 0.001) decreased survival. For patients receiving resection, ACC (p < 0.001) was associated with improved survival, while increasing age (p < 0.001) and positive margins (p = 0.002) were associated with worse survival. For R0 resections, ACC (p < 0.001) was associated with improved survival, while increasing age (p < 0.001) decreased survival, with chemotherapy and radiation having no impact. For R1/2 resections, ACC (p < 0.001) and radiation (p < 0.001) were associated with improved survival, while increasing age (p < 0.001) decreased survival, with chemotherapy having no impact on survival. CONCLUSIONS Primary tracheal cancer is highly lethal, with surgical resection leading to the best chance of survival. For patients undergoing resection, radiation provided survival benefits for R1/2 but not R0, while chemotherapy did not impact survival regardless of margin status.
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Affiliation(s)
- Nidhi Desai
- Division of Thoracic Surgery and Department of Surgery, University of Tennessee Health Science Center, College of Medicine, Memphis, Tennessee, USA
| | - Benjamin R Zambetti
- Division of Thoracic Surgery and Department of Surgery, University of Tennessee Health Science Center, College of Medicine, Memphis, Tennessee, USA
| | - Denise L Wong
- Division of Thoracic Surgery and Department of Surgery, University of Tennessee Health Science Center, College of Medicine, Memphis, Tennessee, USA
| | - Aubrey E Schachter
- Division of Thoracic Surgery and Department of Surgery, University of Tennessee Health Science Center, College of Medicine, Memphis, Tennessee, USA
| | - Nathan P Judge
- Division of Thoracic Surgery and Department of Surgery, University of Tennessee Health Science Center, College of Medicine, Memphis, Tennessee, USA
| | - Ganpat S Valaulikar
- Division of Thoracic Surgery and Department of Surgery, University of Tennessee Health Science Center, College of Medicine, Memphis, Tennessee, USA
| | - Thomas Ng
- Division of Thoracic Surgery and Department of Surgery, University of Tennessee Health Science Center, College of Medicine, Memphis, Tennessee, USA
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Zambetti BR, Patel DD, Stuber JD, Zickler WP, Hosseinpour H, Anand T, Nelson AC, Stewart C, Joseph B, Magnotti LJ. Role of Endovascular Stenting in Patients with Traumatic Iliac Artery Injury. J Am Coll Surg 2023; 236:753-759. [PMID: 36728440 DOI: 10.1097/xcs.0000000000000540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Common and external iliac artery injuries (IAI) portend significant morbidity and mortality. The goal of this study was to examine the impact of mechanism of injury and type of repair on outcomes and identify the optimal repair for patients with traumatic IAI using a large, national dataset. STUDY DESIGN Patients undergoing operative repair for IAI were identified from the Trauma Quality Improvement Program database during a 5-year timespan, ending in 2019. Age, sex, race, severity of injury, severity of shock, type of iliac repair (open or endovascular), mechanism, morbidity and mortality were recorded. Patients with IAI were stratified by both type of repair and mechanism and compared. Multivariable logistic regression analysis was used to identify independent predictors of mortality. RESULTS Operative IAI was identified in 507 patients. Of these injuries, 309 (61%) were penetrating and 346 (68.2%) involved the external iliac artery. The majority of patients were male (82%) with a median age and ISS of 31 and 20, respectively. Endovascular repair was performed in 31% of cases. For patients with penetrating injuries, the type of repair impacted neither morbidity nor mortality. For blunt-injured patients, endovascular repair was associated with lower morbidity (29.3% vs 41.3%; p = 0.082) and significantly reduced mortality (14.6% vs 26.7%; p = 0.037) compared with the open-repair approach. Multivariable logistic regression identified endovascular repair as the only modifiable risk factor associated with decreased mortality (odds ratio 0.34; 95% CI 0.15 to 0.79; p = 0.0116). CONCLUSIONS Traumatic IAI causes significant morbidity and mortality. Endovascular repair was identified as the only modifiable predictor of decreased mortality in blunt-injured patients with traumatic IAI. Therefore, for select patients with blunt IAIs, an endovascular repair should be the preferred approach.
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Affiliation(s)
- Benjamin R Zambetti
- From the Division of Vascular Surgery, University of Maryland Medical Center, Baltimore, MD (Zambetti)
| | - Devanshi D Patel
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN (Patel, Stuber)
| | - Jacqueline D Stuber
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN (Patel, Stuber)
| | - William P Zickler
- Division of Vascular Surgery, Mount Sinai Hospital, New York, NY (Zickler)
| | - Hamidreza Hosseinpour
- Division of Trauma and Acute Care Surgery, University of Arizona, Tucson, AZ (Hosseinpour, Anand, Nelson, Stewart, Joseph, Magnotti)
| | - Tanya Anand
- Division of Trauma and Acute Care Surgery, University of Arizona, Tucson, AZ (Hosseinpour, Anand, Nelson, Stewart, Joseph, Magnotti)
| | - Adam C Nelson
- Division of Trauma and Acute Care Surgery, University of Arizona, Tucson, AZ (Hosseinpour, Anand, Nelson, Stewart, Joseph, Magnotti)
| | - Collin Stewart
- Division of Trauma and Acute Care Surgery, University of Arizona, Tucson, AZ (Hosseinpour, Anand, Nelson, Stewart, Joseph, Magnotti)
| | - Bellal Joseph
- Division of Trauma and Acute Care Surgery, University of Arizona, Tucson, AZ (Hosseinpour, Anand, Nelson, Stewart, Joseph, Magnotti)
| | - Louis J Magnotti
- Division of Trauma and Acute Care Surgery, University of Arizona, Tucson, AZ (Hosseinpour, Anand, Nelson, Stewart, Joseph, Magnotti)
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Zambetti BR, Lewis RH, Chintalapani SR, Desai N, Valaulikar GS, Magnotti LJ. Optimal time to thoracoscopy for trauma patients with retained hemothorax. Surgery 2022; 172:1265-1269. [PMID: 35868904 DOI: 10.1016/j.surg.2022.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/13/2022] [Accepted: 06/14/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Retained hemothorax remains a common problem after thoracic trauma with associated morbidity and prolonged hospitalizations. The goal of this study was to examine the impact of time to video assisted thoracoscopic surgery (VATS) on pulmonary morbidity using a large, national data set. METHODS Patients undergoing VATS for retained hemothorax within the first 14 days postinjury were identified from the Trauma Quality Improvement Program database over 5 years, ending in 2016. Demographics, mechanism, severity of injury, severity of shock, time to VATS, pulmonary morbidity, and mortality were recorded. Multivariable logistic regression analysis was performed to determine independent predictors of pulmonary morbidity. Youden's index was then used to identify the optimal time to VATS. RESULTS From the Trauma Quality Improvement Program database, 3,546 patients were identified. Of these, 2,355 (66%) suffered blunt injury. The majority were male (81%) with a median age and Injury Severity Score of 46 and 16, respectively. The median time to VATS was 134 hours. Both pulmonary morbidity (13 vs 17%, P = .004) and hospital length of stay (9 vs 12 days, P < .0001) were significantly reduced in patients undergoing VATS before 3.9 days. Multivariable logistic regression identified VATS during the first 7 days as the only modifiable risk factor significantly associated with reduced pulmonary morbidity (odds ratio 0.52; 95% confidence interval 0.43-0.63, P < .0001). CONCLUSION Patients undergoing VATS for retained hemothorax have significant morbidity and prolonged length of stay. VATS within the first week of admission results in fewer pulmonary complications and shorter length of stay. In fact, the optimal time to VATS was identified as 3.9 days and was the only modifiable risk factor associated with decreased pulmonary morbidity.
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Affiliation(s)
- Benjamin R Zambetti
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN.
| | - Richard H Lewis
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | | | - Nidhi Desai
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Ganpat S Valaulikar
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Louis J Magnotti
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
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Zambetti BR, Murphy WG, Craner D, Wong DL, Pettigrew BD, Webb DL, Voeller GR, Stoikes NFN. Laparoscopic Heller Myotomy With EGD and Balloon Dilation: A Durable Solution for Achalasia. Am Surg 2022:31348221101473. [PMID: 35544037 DOI: 10.1177/00031348221101473] [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] [Indexed: 11/17/2022]
Abstract
BACKGROUND Laparoscopic Heller myotomy (LHM) and esophageal balloon dilation (BD) are the two mainstays of achalasia treatment-this study examines the outcomes when they are performed simultaneously without fundoplication. METHODS All patients undergoing LHM&BD were reviewed for demographic and procedural data, and to see if additional procedures for achalasia had been performed. Patients were surveyed using the Eckardt score and the GERD quality-of-life score (GERD-HRQL) to assess the durability of repair. RESULTS From 2013-2020, 66 patients underwent LHM&BD. There were no esophageal perforations and a median LOS of 1 day. Seven patients have required additional operations or procedures at median 4-years follow up. 31 patients (47%) responded to the survey. The average Eckardt score was 2.9 (goal<4) with mean GERD-HRQL of 14.4 (goal<25). CONCLUSIONS LHM&BD allows for a safe, durable repair of achalasia. Reflux symptoms are manageable with PPI without fundoplication and the re-intervention rate similar to published values.
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Affiliation(s)
- Benjamin R Zambetti
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - William G Murphy
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Domenic Craner
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Denise L Wong
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Benjamin D Pettigrew
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - David L Webb
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Guy R Voeller
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Nathaniel F N Stoikes
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
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Hendrick LE, Zambetti BR, Wong DL, Dickson PV, Glazer ES, Shibata D, Fleming MD, Tsao M, Portnoy DC, Deneve JL. Visceral angiosarcoma: A nationwide analysis of treatment factors and outcomes. J Surg Oncol 2022; 125:1231-1237. [PMID: 35234280 DOI: 10.1002/jso.26826] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/03/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES Visceral angiosarcoma is rare and aggressive, accounting for 2% of soft tissue sarcomas. Using a national data set, we examine determinants of outcomes for patients presenting with this rare disease. METHODS The 2004-2015 National Cancer Database was queried for patients with visceral angiosarcoma. Trends in treatment and outcomes were examined. Factors affecting overall survival (OS) were assessed with log-rank and Cox regression. RESULTS Eight hundred and ninety-three patients with visceral angiosarcoma were identified (median age 65 years, male [63%], Charlson comorbidity index <1 [86%]). Tumor size was <5 cm in 20.7%, and 34.2% were moderate/high grade. Median OS was 3.8 months (95% CI: 3.4-4.4). By multivariate analysis, increased tumor grade and size, and liver/biliary origin demonstrated worse OS while surgery, radiation, and systemic chemotherapy demonstrated improved OS (all p < 0.001). Survival was similar between patients achieving R0 resection and those with R1/2 resection receiving chemotherapy by Kaplan-Meier analysis. CONCLUSIONS Visceral angiosarcomas are rare tumors with poor outcomes. Liver/biliary origin, higher tumor grade, and larger tumor size demonstrate worse outcomes. While R0 resection remains the mainstay of treatment, patients with R1/R2 resection have improved survival with addition of chemotherapy. Consideration should be made for multimodal therapy in these patients.
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Affiliation(s)
- Leah E Hendrick
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Benjamin R Zambetti
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Denise L Wong
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Paxton V Dickson
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Evan S Glazer
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - David Shibata
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Martin D Fleming
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Miriam Tsao
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - David C Portnoy
- Department of Medical Oncology, West Cancer Center and Research Institute, Memphis, Tennessee, USA
| | - Jeremiah L Deneve
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Zickler WP, Sharpe JP, Lewis RH, Zambetti BR, Jones MD, Zickler MK, Zickler CL, Magnotti LJ. In for a Penny, in for a Pound: Obesity weighs heavily on both cost and outcome in trauma. Am J Surg 2022; 224:590-594. [DOI: 10.1016/j.amjsurg.2022.03.024] [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] [Received: 01/26/2022] [Revised: 03/07/2022] [Accepted: 03/22/2022] [Indexed: 11/26/2022]
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Zambetti BR, Stiles ZE, Gupta PK, Stickley SM, Brahmbhatt R, Rohrer MJ, Kempe K. Analysis of Early Lower Extremity Re-amputation. Ann Vasc Surg 2021; 81:351-357. [PMID: 34780940 DOI: 10.1016/j.avsg.2021.10.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/09/2021] [Accepted: 10/04/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Data is scarce regarding the need for early re-amputation to a higher anatomic level. This study seeks to define outcomes and risk factors for re-amputation. METHODS Patients undergoing primary major lower extremity amputation were identified within the 2012-2016 ACS-NSQIP database. Demographics, outcomes, and peri-operative characteristics were compared, and multivariable logistic regression model was used to determine association with early re-amputation. RESULTS Over a four-year period, 8306 below knee amputations and 6367 above knee amputations were identified. Thirty-day re-amputation occurred in 262 patients (1.8%) and was associated with increased length of stay (12.9 vs. 7.3 days, p<0.001), higher rates of readmission (64.9% vs. 13.6%, p<0.001), and overall complications (69.5% vs. 39.3%, p<0.01). On multivariable analysis, advanced age (OR 1.02, CI 1.01-1.03), smoking (OR 1.75, CI 1.32-2.33), dialysis dependence (OR 1.67, CI 1.23-2.26), preoperative septic shock (OR 2.53, CI 1.29-4.97), and bleeding disorders (OR 1.72, CI 1.34-2.22) were associated with early re-amputation. CONCLUSIONS Thirty-day re-amputation rates are low, but are associated with significant morbidity, prolonged hospitalization, and frequent readmissions.
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Affiliation(s)
- Benjamin R Zambetti
- Department of Surgery, Division of Vascular Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Zachary E Stiles
- Department of Surgery, Division of Vascular Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Shaun M Stickley
- Department of Surgery, Division of Vascular Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Reshma Brahmbhatt
- Department of Surgery, Division of Vascular Surgery, University of Texas Health Science Center at San Antonio
| | - Michael J Rohrer
- Department of Surgery, Division of Vascular Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Kelly Kempe
- Department of Surgery, Division of Vascular Surgery, University of Oklahoma School of Community Medicine, Tulsa, Oklahoma.
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Zambetti BR, Ng T. Commentary: Patient frailty also drives long-term outcomes after R0 resection for lung cancer. J Thorac Cardiovasc Surg 2021; 161:787-788. [PMID: 32868059 PMCID: PMC9974202 DOI: 10.1016/j.jtcvs.2020.06.115] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 06/27/2020] [Accepted: 06/28/2020] [Indexed: 10/23/2022]
Affiliation(s)
| | - Thomas Ng
- Division of Thoracic Surgery, University of Tennessee Health Science Center College of Medicine, Memphis, Tenn.
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13
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Fleming AM, Zambetti BR, Valaulikar GS. Bedside Mediastinotomy for Tension Pneumomediastinum with Tamponade in COVID-19. Ann Thorac Surg 2021; 112:e265-e266. [PMID: 33529601 PMCID: PMC8402946 DOI: 10.1016/j.athoracsur.2021.01.032] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 12/17/2020] [Accepted: 01/14/2021] [Indexed: 12/02/2022]
Abstract
Tension pneumomediastinum is a rare but life-threatening cause of tamponade. Mechanical ventilation is a described source of tension pneumomediastinum. Here, we present a case of a 72-year-old man who developed cardiovascular collapse from tension pneumomediastinum in the setting of coronavirus disease 2019–related acute respiratory distress syndrome. We successfully performed bedside mediastinotomy and mediastinal tube placement under local anesthetic to alleviate his hemodynamic instability. Bedside mediastinotomy can be used to relieve tension pneumomediastinum in this setting.
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Affiliation(s)
- Andrew M Fleming
- Department of Surgery, University of Tennessee Health Science Center, Memphis TN
| | - Benjamin R Zambetti
- Department of Surgery, University of Tennessee Health Science Center, Memphis TN
| | - Ganpat S Valaulikar
- Division of Cardiothoracic Surgery, University of Tennessee Health Science Center, Memphis TN.
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14
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Zambetti BR, Huang DD, Lewis RH, Fischer PE, Croce MA, Magnotti LJ. Use of Thoracic Endovascular Aortic Repair in Patients with Concomitant Blunt Aortic and Traumatic Brain Injury. J Am Coll Surg 2020; 232:416-422. [PMID: 33348014 DOI: 10.1016/j.jamcollsurg.2020.12.007] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Blunt aortic injury (BAI) and traumatic brain injury (TBI) represent the 2 leading causes of death after blunt trauma. The goal of this study was to examine the impact of TBI and use of thoracic endovascular aortic repair (TEVAR) on patients with BAI, using a large, national dataset. STUDY DESIGN Patients with BAI were identified from the Trauma Quality Improvement Program (TQIP) database over 10 years, ending in 2016. Patients with BAI were stratified by the presence of concomitant TBI and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of mortality in BAI patients with and without TBI. Youden's index was used to identify the optimal time to TEVAR in these patients. RESULTS 17,040 patients with BAI were identified, with 4,748 (28%) having a TBI. Patients with BAI and TBI were predominantly male, with a higher injury burden and greater severity of shock at presentation, underwent fewer TEVAR procedures, and had increased mortality compared with BAI patients without TBI. The optimal time for TEVAR was 9 hours. Mortality was significantly increased in patients undergoing TEVAR before 9 hours (12.9% vs 6.5%, p = 0.003). For BAI patients with and without TBI, MLR identified use of TEVAR as the only modifiable risk factor significantly associated with reduced mortality (odds ratio [OR] 0.41; 95%CI 0.32-0.54, p < 0.0001). CONCLUSIONS TBI significantly increases mortality in BAI patients. TEVAR and delayed repair both significantly reduced mortality. So, for patients with both BAI and TBI, an endovascular repair performed in a delayed fashion should be the preferred approach.
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Affiliation(s)
- Benjamin R Zambetti
- Department of Surgery, Division of Trauma and Surgical Critical Care, University of Tennessee Health Science Center, Memphis, TN
| | - Dih-Dih Huang
- Department of Surgery, Division of Trauma and Surgical Critical Care, University of Tennessee Health Science Center, Memphis, TN
| | - Richard H Lewis
- Department of Surgery, Division of Trauma and Surgical Critical Care, University of Tennessee Health Science Center, Memphis, TN
| | - Peter E Fischer
- Department of Surgery, Division of Trauma and Surgical Critical Care, University of Tennessee Health Science Center, Memphis, TN
| | - Martin A Croce
- Department of Surgery, Division of Trauma and Surgical Critical Care, University of Tennessee Health Science Center, Memphis, TN
| | - Louis J Magnotti
- Department of Surgery, Division of Trauma and Surgical Critical Care, University of Tennessee Health Science Center, Memphis, TN.
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15
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Zambetti BR, Ng T. Commentary: Right middle lobe can be a friend or a foe after lobectomy. J Thorac Cardiovasc Surg 2020; 162:1424-1425. [PMID: 33618873 DOI: 10.1016/j.jtcvs.2020.08.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 08/29/2020] [Accepted: 08/31/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Benjamin R Zambetti
- Division of Thoracic Surgery, University of Tennessee Health Science Center College of Medicine, Memphis, Tenn
| | - Thomas Ng
- Division of Thoracic Surgery, University of Tennessee Health Science Center College of Medicine, Memphis, Tenn.
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16
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Zambetti BR, Stiles ZE, Gupta PK, Stickley SM, Brahmbhatt R, Rohrer MJ, Kempe K. Present-day analysis of early failure after forefoot amputation. Surgery 2020; 168:904-908. [PMID: 32736868 DOI: 10.1016/j.surg.2020.06.013] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/28/2020] [Accepted: 06/03/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Forefoot transmetatarsal amputation is performed commonly to achieve limb salvage, but transmetatarsal amputations have a high rate of failure, requiring more proximal amputations. Few contemporary studies have examined the incidence of major amputation (transtibial or transfemoral) after transmetatarsal amputation. The goal of this study is to determine risk factors and outcomes for a more proximal amputation after forefoot amputation. METHODS We queried the 2012 to 2016 database of the American College of Surgeons National Quality Improvement Program for patients undergoing a complete transmetatarsal amputation with wound closure by Current Procedural Terminology code. Patients requiring early (within 30 days) more proximal amputation after transmetatarsal amputation were compared with those who did not need further amputation. Characteristics of patients requiring more proximal amputation were examined, and a multivariable logistic regression model was created to identity risk factors for early more proximal amputation. RESULTS In the study, 1,582 transmetatarsal amputation were identified. Most patients were male (70%), white (59%), and diabetic (74%), with a median age of 63 years. More proximal amputation occurred in 4.2% of patients within the first 30 days postoperatively. This early failure was associated with greater hospital stays postoperatively (10 days vs 7 days), more wound complications (29% vs 11%), pneumonia (8% vs 2%), stroke (3% vs 0.1%), and overall complications (50% vs 28%; P ≤ .025 each). Although there was no difference in 30-day mortality (P = .27), there was a marked increase in unplanned readmission (59% vs 14%; P < .0001) for those undergoing reamputation. On multivariable analysis, preoperative systemic inflammatory response, sepsis, or septic shock (odds ratio 2.1; 95% confidence interval, 1.2-3.6) were independent predictors of more proximal amputation. CONCLUSION Early below-knee or above-knee amputation early after transmetatarsal amputation leads to increased morbidity. Because patients with preoperative sepsis may be at increased risk of failure after transmetatarsal amputation, the level of amputation should be considered carefully in these patients.
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Affiliation(s)
- Benjamin R Zambetti
- Department of Surgery, Division of Vascular Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Zachary E Stiles
- Department of Surgery, Division of Vascular Surgery, University of Tennessee Health Science Center, Memphis, TN
| | | | - Shaun M Stickley
- Department of Surgery, Division of Vascular Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Reshma Brahmbhatt
- Department of Surgery, Division of Vascular Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Michael J Rohrer
- Department of Surgery, Division of Vascular Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Kelly Kempe
- Department of Surgery, Division of Vascular Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK.
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17
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Zambetti BR, Hendrick LE, Garrett HE, Dickson PV, Yakoub D, Fleming MD, Glazer ES, Behrman SW, Shibata D, Deneve JL. Primary Malignant Cardiac Tumors: A Nationwide Analysis of Incidence, Treatment Factors, and Outcome. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.947] [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: 11/27/2022]
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18
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Stiles ZE, Zambetti BR, Dickson PV, Behrman SW. Current Use and Outcomes for Epidural Analgesia During Pancreaticoduodenectomy. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.363] [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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19
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Zambetti BR, Stiles ZE, Kempe K, Gupta PK, Stickley SM, Brahmbhatt R, Rohrer MJ. IP183. Analysis of Early Lower Extremity Reamputations. J Vasc Surg 2018. [DOI: 10.1016/j.jvs.2018.03.178] [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: 10/16/2022]
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20
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Shahan CP, Manley N, Zambetti BR, Rohrer MJ, Stickley SM, Kempe K, Gupta P, Brahmbhatt R. Patency and Follow Up of Endovascular Stents in the Treatment of Blunt Cerebrovascular Injury. Ann Vasc Surg 2018. [DOI: 10.1016/j.avsg.2018.01.033] [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: 10/17/2022]
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21
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Tucker C, Choby B, Moore A, Parker RS, Zambetti BR, Naids S, Scott J, Loome J, Gaffney S, Cianciolo AT, Hoffman LA, Kohn JR, O'Sullivan PS, Trowbridge RL. Teachers as Learners: Developing Professionalism Feedback Skills via Observed Structured Teaching Encounters. Teach Learn Med 2017; 29:373-377. [PMID: 29020524 DOI: 10.1080/10401334.2017.1365001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
This Conversations Starter article presents a selected research abstract from the 2017 Association of American Medical Colleges Southern Region Group on Educational Affairs annual spring meeting. The abstract is paired with the integrative commentary of 4 experts who shared their thoughts stimulated by the study. These thoughts explore the value of the Observed Structured Teaching Encounter in providing structured opportunities for medical students to engage with the complexities of providing peer feedback on professionalism.
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Affiliation(s)
- Constance Tucker
- a Office of the Provost , Oregon Health & Science University , Portland , Oregon , USA
| | - Beth Choby
- b Department of Medical Education , University of Tennessee Health Sciences Center , Memphis , Tennessee , USA
| | - Andrew Moore
- c Graduate Medical Education , University of Tennessee ; Memphis , Tennessee , USA
| | - Robert Scott Parker
- d University of Tennessee College of Medicine , Chattanooga , Tennessee , USA
| | - Benjamin R Zambetti
- e Department of Cardiovascular Surgery , University of Tennessee Health Science Center , Memphis , Tennessee , USA
| | - Sarah Naids
- c Graduate Medical Education , University of Tennessee ; Memphis , Tennessee , USA
| | - Jillian Scott
- f Department of Surgery , University of Tennessee College of Medicine , Chattanooga , Tennessee , USA
| | - Jennifer Loome
- c Graduate Medical Education , University of Tennessee ; Memphis , Tennessee , USA
| | - Sierra Gaffney
- g Department of Health Policy and Management , Emory University , Atlanta , Georgia , USA
| | - Anna T Cianciolo
- h Department of Medical Education , Southern Illinois University School of Medicine , Springfield , Illinois , USA
| | - Leslie A Hoffman
- i Department of Anatomy and Cell Biology , Indiana University School of Medicine , Fort Wayne , Indiana , USA
| | - Jaden R Kohn
- j Baylor College of Medicine , Houston , Texas , USA
| | - Patricia S O'Sullivan
- k Office of Medical Education , University of California San Francisco , San Francisco , California , USA
| | - Robert L Trowbridge
- l Department of Medicine , Tufts University School of Medicine , Portland , Maine , USA
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22
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Tucker CR, Choby BA, Moore A, Parker RS, Zambetti BR, Naids S, Scott J, Loome J, Gaffney S. Speaking up: using OSTEs to understand how medical students address professionalism lapses. Med Educ Online 2016; 21:32610. [PMID: 27814779 PMCID: PMC5097152 DOI: 10.3402/meo.v21.32610] [Citation(s) in RCA: 4] [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: 06/15/2016] [Revised: 08/31/2016] [Accepted: 09/26/2016] [Indexed: 05/27/2023]
Abstract
BACKGROUND Objective-structured teaching encounters (OSTEs) are used across many disciplines to assess teaching ability. The OSTE detailed in this paper assesses 191 fourth-year medical students' (M4) ability to identify and address lapses in professionalism based on Association of American Medical Colleges' professionalism competencies. The research questions addressed are How frequently do M4s address professionalism lapses observed during an OSTE? What factors influence whether M4s provide feedback when they observe professionalism lapses in an OSTE? METHODS Standardized patients (SPs) and standardized learners (SLs) were recruited and trained to participate in a standardized encounter with specific cognitive, social, and behavioral errors, including professionalism lapses. M4s viewed this encounter and then offered feedback to the SL, while remotely observed by faculty. Post-encounter, the SL and faculty completed identical checklists to assess both teaching readiness and ability to address professionalism concerns. RESULTS An analysis of frequencies showed that six of the Association of American Medical Colleges' nine professional competencies were addressed in the checklist and/or discussed in the focus group. Analysis of transcribed debriefing sessions confirmed that M4s did not consistently address professionalism lapses by their peers. CONCLUSIONS In focus groups, M4s indicated that, while they noticed professionalism issues, they were uncomfortable discussing them with the SLs. Findings of the current study suggest how medical educators might support learners' ability to address lapses in professionalism as well as topics for future research.
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Affiliation(s)
- Constance R Tucker
- Faculty Development, McGlothlin Medical Education Center, Virginia Commonwealth University School of Medicine, Richmond, VA, USA;
| | - Beth A Choby
- Department of Medical Education, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andrew Moore
- Graduate Medical Education, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Robert Scott Parker
- Graduate Medical Education, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Benjamin R Zambetti
- Graduate Medical Education, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Sarah Naids
- Graduate Medical Education, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jillian Scott
- Graduate Medical Education, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jennifer Loome
- Graduate Medical Education, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Sierra Gaffney
- Graduate Medical Education, University of Tennessee Health Science Center, Memphis, TN, USA
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23
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Abstract
Patient: Male, 55 Final Diagnosis: Plasmacytic aortitis Symptoms: Dizziness • nausea Medication: — Clinical Procedure: — Specialty: Surgery
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Affiliation(s)
- Benjamin R Zambetti
- Department of Cardiovascular Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Edward Garrett
- Department of Cardiovascular Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
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