Prophylactic Enoxaparin Dosing Using Anti-Factor Xa Levels in Hepatic Surgery Patients: A Pilot Study.

This study examines the safety and efficacy of using peak anti-Xa levels to achieve prophylactic enoxaparin (Lovenox, Sanofi-Aventis) levels in patients who underwent hepatic surgery. Prospectively enrolled patients undergoing major and minor hepatic procedures received postoperative enoxaparin dosing. The enoxaparin dose was adjusted to attain a peak anti-Xa level ≥ 0.20 U/ml. This group was compared to a historical cohort of patients who underwent similar procedures and received standard postoperative VTE chemoprophylaxis dosing. Inpatient postoperative VTE rates were higher in the control group when compared to the experimental group (0 patients [0.00%] vs 4 patients [8.16%]; P = .035). There was no statistically significant difference in number of postoperative blood transfusions, discharge hemoglobin, or in-hospital bleeding events. Adjusting enoxaparin dosing to achieve prophylactic peak anti-Xa levels of ≥0.20 IU/ml was associated with a reduced incidence of symptomatic inpatient postoperative VTE in patients who underwent hepatic surgery without increasing postoperative bleeding events.

A Cohort Study of an Enhanced Recovery Pathway for Pancreatic Surgery at a Community Hospital.

BACKGROUND: Enhanced recovery after surgery (ERAS) pathways have been shown to improve pancreatic surgery outcomes, though feasibility in a community hospital remain unclear. We hypothesized that an ERAS protocol would reduce hospital length of stay (LOS) without increased morbidity. METHODS: An ERAS pathway was initiated for patients undergoing pancreatic surgery at a community cancer center and compared to a historical cohort. The primary outcome was hospital LOS. Secondary outcomes included 30-day readmission rates, comprehensive complication index (CCI®), textbook outcomes (TO), and mortality. RESULTS: A total of 144 patients were included, with 63 patients in the ERAS group and 81 in the control group. The mean LOS decreased significantly in the ERAS group (6.85 [± 4.8]) vs 9.96 [±6.8] days, P = .001), without an increase in 30-day admission rates or CCI. CONCLUSIONS: Implementation of an ERAS protocol in a community setting reduced LOS without a corresponding increase in readmission rates or morbidity.

Shared Decision-Making in Pancreatic Surgery.

Objective: The objective of this study is to determine the factors influencing pancreatic surgery patients' perceptions of the shared decision-making process (SDM). Background: Decision-making in pancreatic surgery is complicated by the risk of morbidity and mortality and risk of early recurrence of disease. Improvement in SDM has the potential to improve the receipt of goal- and value-concordant care. Methods: This cross-sectional survey included patients who underwent pancreatic surgery. The following components were studied in relation to SDM: modified satisfaction with decision scale (SWD), modified decisional regret scale (DRS), quality of physician and patient interaction, and the impact of quality of life (FACT-Hep). Correlations were computed using Pearson's correlation score and a regression model. Results: The survey completion rate was 72.2% (of 40/55) and the majority (72.5%) of patients underwent pancreaticoduodenectomy. There were significant positive relationships between the SDM measure and (DRS, SWD; r = 0.70, P < 0.001) and responses to questions regarding how well the patient's actual recovery matched their expectations before treatment (r = 0.62, P < 0.001). The quality of the physician-patient relationship correlated with how well recovery matched expectations (r = 0.53, P = 0.002). SDM measure scores were significant predictors of the decision evaluation measure (R2(adj) = 0.48, P < 0.001), FACT-Hep (R2(adj) = 0.15, P < 0.001), and recovery expectations measure (R2(adj) = 0.37, P < 0.001). Conclusions: Improved SDM in pancreatic surgery is associated with more realistic recovery expectations, decreased decisional regret, and improved quality of life.

SCORE-Based Simulated ABSITE Exam Performance as a Predictor of Performance on the ABSITE.

INTRODUCTION: The American Board of Surgery In-Training Examination (ABSITE) is a crucial, objective assessment of surgical knowledge during training. In 2014, the American Board of Surgery (ABS) announced the alignment of the ABSITE to the SCORE® (Surgical Council on Resident Education) Curriculum Outline for General Surgery Residency. We hypothesized that implementing a pre-ABSITE SCORE-based exam would help identify underperforming residents and provide early guidance to improve performance on the ABSITE. METHODS: In October 2014, our university-based surgical residency program began administering a yearly comprehensive pre-ABSITE SCORE-based exam consisting of 225 to 250 multiple-choice questions selected from the SCORE question bank to all our general surgery residents, preliminary and categorical. The 4-hour exam addresses both clinical management (80%) and applied sciences (20%). Residents receive reports with their scores (percentage correct). Residents performing at less than 60% meet with the Program Director for discussion and formulation of a study plan. Correlational analysis was performed between resident ABSITE scores, pre-ABSITE SCORE-based exam scores, gender, resident status (preliminary vs. categorical), postgraduate year (PGY), and the United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores. RESULTS: A total of 244 exam scores (122 pre-ABSITE SCORE-based exams and 122 matched ABSITE) were completed by 51 residents at different PGY levels (32 PGY1, 32 PGY2, 20 PGY3, 19 PGY4, and 18 PGY5). Fifty-seven percent were males, 62% were categorical residents, and 38% were preliminary residents. October pre-ABSITE SCORE-based exam scores were compared to the subsequent January ABSITE scores. Categorical residents completed 101 (83%) of the January exams, while preliminary residents completed 21 (17%) of these paired exams. We found strong correlations between the correct percentage on ABSITE and pre-ABSITE SCORE-based scores (r = 0.637, p < 0.001), between the correct percentage on ABSITE and PGY (r = 0.688, p < 0.001), and between ABSITE and resident status (r = 0.462, p < 0.001). Additionally, there was a weak to negligible correlation between the correct percentage on ABSITE and resident gender (r = 0.274, p = 0.001), USMLE-2 (r = 0.12, p = 0.16), and USMLE-1 (r = 0.04, p = 0.653). Multiple regression analysis, with all predictors, was performed to predict the percentage score on the ABSITE and produced R2 0.58, with an adjusted R2 of 0.57, with a large size effect, p < 0.001. After controlling for the other variables, three factors reached statistical significance (p < 0.05): pre-ABSITE SCORE-based exam scores, PGY, and resident gender. CONCLUSION: We found a strong correlation between performance on the pre-ABSITE SCORE-based exam and performance on the ABSITE exam. Surgery residents are encouraged to start studying earlier and to utilize SCORE contents as outlined by the ABS in their study plan.

Horner Syndrome from a Pediatric Otolaryngology Perspective.

INTRODUCTION: Horner syndrome is described as the clinical triad of miosis, ptosis, and anhidrosis. In pediatric patients the condition may be congenital or acquired from neoplastic, infectious or traumatic conditions, including birth trauma. Most cases of pediatric Horner syndrome present first to a pediatric ophthalmologist however since the neural pathways involve the cervical sympathetic chain otolaryngologists should understand the pathophysiology to avoid delay in management of potentially malignant cases. OBJECTIVES: To aid otolaryngologists in recognizing and managing pediatric Horner syndrome by describing 3 unique cases from malignant, traumatic and/or congenital causes. METHODS: Case report of 3 pediatric patients with Horner syndrome presenting to our pediatric otolaryngology department. RESULTS: Case #1 is 5-month-old female with ptosis and a left level II 1.5 cm neck mass. Magnetic resonance imaging showed the mass displacing the common carotid artery and excisional biopsy revealed a poorly differentiated neuroblastoma. Case #2 is a 9-year-old female with anisocoria appearing after suffering a severe playground injury. Case #3 is a 3-year-old-male who developed ptosis and anisocoria following re-excision of a recurrent cervical lymphatic malformation. CONCLUSION: Pediatric Horner syndrome may be a benign finding that is easily overlooked but may reflect a serious underlying condition. Otolaryngologists should be aware of the pathophysiology and differential diagnosis, including malignant causes, to appropriately manage patients.

Current Management of Gynecologic Trauma.

INTRODUCTION: To date, there are few reports describing the management of traumatic gynecologic injuries leaving physicians with little guidance. OBJECTIVE: Describe the injury patterns and the preferred management of these injuries. METHODS: A retrospective cohort study was performed using the National Trauma Data Bank (NTDB) from years 2011 to 2013. Female patients age 16 years and older with internal gynecologic injuries were identified based on diagnosis codes. Demographics, associated diagnoses and procedure codes were compiled for the cohort. RESULTS: 313 patients met inclusion criteria. The mechanism of injury was blunt in 236 (75%) patients, penetrating in 68 (21%), and other in 9 (4%). The mean Injury Severity Score was 16.6 ± 14.6. Mean age was 34 ± 21 years old. 226 (74.8%) patients had an ovarian and/or fallopian tube injury, 71 (25.2%) had a uterine injury, 8 (3%) had both, and 8 (3%) had injury to the ovarian or uterine vessels only. Of the 226 patients with ovarian and/or fallopian tube injury, 11(5%) underwent repair and 10 (4%) underwent salpingo-oophorectomy. Of the 71 uterine injuries, 15 (21%) underwent repair and 5 (7%) required a hysterectomy. CONCLUSIONS: Most traumatic internal gynecologic injuries result from blunt mechanism. Currently, these injuries are largely managed non-operatively. When surgery was performed, ovarian and uterine repair was more common than salpingo-oophorectomy and hysterectomy. Prospective large-scale studies are needed to establish a standard of treatment for the management of gynecologic trauma and to assess both short and long term outcomes and fertility rates.