Using Concurrent Complication Reporting to Evaluate Resident Critical Thinking and Enhance Adult Learning.

OBJECTIVE: Critical thinking and accurate case analysis is difficult to quantify even within the context of routine morbidity and mortality reporting. We designed and implemented a HIPAA-compliant adverse outcome reporting system that collects weekly resident assessments of clinical care across multiple domains (case summary, complications, error analysis, Clavien-Dindo Harm, cognitive bias, standard of care, and ACGME core competencies). We hypothesized that incorporation of this system into the residency program's core curriculum would allow for identification of areas of cognitive weakness or strength and provide a longitudinal evaluation of critical thinking development. DESIGN: A validated, password-protected electronic platform linked to our electronic medical record was used to collect cases weekly in which surgical adverse events occurred. General surgery residents critiqued 1932 cases over a 4-year period from 3 major medical centers within our system. These data were reviewed by teaching faculty, corrected for accuracy and graded utilizing the software's critique algorithm. Grades were emailed to the residents at the time of the review, collected prospectively, stratified, and analyzed by post-graduate year (PGY). Evaluation of the resident scores for each domain and the resultant composite scores allowed for comparison of critical thinking skills across post-graduate year (PGY) over time. SETTING: Data was collected from 3 independently ACGME-accredited surgery residency programs over 3 tertiary hospitals within our health system. PARTICIPANTS: General surgery residents in clinical PGY 1-5. RESULTS: Residents scored highest in properly identifying ACGME core competencies and determining Clavien-Dindo scores (p < 0.006) with no improvement in providing accurate and concise clinical summaries. However, residents improved in recording data sufficient to identify error (p < 0.00001). A positive linear trend in median scores for all remaining domains except for cognitive bias was demonstrated (p < 0.001). Senior residents scored significantly higher than junior residents in all domains. Scores > 90% were never achieved. CONCLUSIONS: The use of an electronic standardized critique algorithm in the evaluation and assessment of adverse surgical case outcomes enabled the measure of residents' critical thinking skills. Feedback in the form of teaching faculty-facilitated discussion and emailed grades enhanced adult learning with a steady improvement in performance over PGY. Although residents improved with PGY, the data suggest that further improvement in all categories is possible. Implementing this standardized critique algorithm across PGY allows for evaluation of areas of individual resident weakness vs. strength, progression over time, and comparisons to peers. These data suggest that routine complication reporting may be enhanced as a critical thinking assessment tool and that improvement in critical thinking can be quantified. Incorporation of this platform into M&M conference has the potential to augment executive function and professional identity development.

Surgical Rehabilitation for Research Residents: A Pilot Program to Offset Surgical Skill Decay.

OBJECTIVE: Select general surgery residents in the surgeon-scientist pipeline dedicate time away from clinical residency to conduct research. However, these research residents (RR) are vulnerable to operative skill decay. The aim of this study is to assess the feasibility of implementation and impact of an organized intervention designed to combat skill decay experienced by RR. DESIGN: RR were enrolled in a pilot Surgical Rehabilitation Program (SRP). The SRP is comprised of 12 cadaver-based simulation sessions and supplemented with Fundamentals of Laparoscopic Surgery-based simulation workouts. The RR were integrated with the clinical residents (CR) during the cadaver sessions and were subsequently performance tested, surveyed, and interviewed. SETTING: One academic general surgery residency program graduating 8 chief residents yearly in New York. PARTICIPANTS: General surgery CR and residents on dedicated research years. RESULTS: Data were collected for all local RR (n = 8) and 77% (n = 37) of CR. Local RR conducted research within the same health system that sponsors the residency. RR experienced gaps in training ranging from 2 to 4 years. All RR were permitted to moonlight on surgical services, however performed 0 operations and only 0.88 procedures on average per shift. Although RR performed similarly to level-matched CR on basic laparoscopic tasks, they required significantly more time on laparoscopic suturing-based skills than CR (p < 0.001). RR had significantly lower confidence levels precadaver sessions but gained confidence postcadaver sessions (p < 0.05), whereas CR confidence was unchanged. Regarding the SRP, qualitative interviews revealed major themes emphasizing the integration of RR, exposure to CR and faculty, technical skill development, maintenance of surgical know-how, and improved confidence for RR. CONCLUSIONS: The implementation of such structured interventions, like our SRP, aimed at supporting RR over gap years is essential to help residents maintain skills and confidence needed to achieve their goals of becoming surgeon scientists.

A novel miRNA mimic attenuates organ injury after hepatic ischemia/reperfusion.

INTRODUCTION: Extracellular cold-inducible RNA-binding protein (eCIRP) is a novel mediator of inflammation and tissue injury. It has been shown that miRNA 130b-3p acts as an endogenous inhibitor of eCIRP. Because RNA mimics are unstable after in vivo administration, we have chemically engineered miRNA 130b-3p mimic (named PS-OMe miR130) to improve its stability by protection from nuclease activity. We hypothesize that PS-OMe miR130 reduces eCIRP-mediated injury and inflammation in a murine model of hepatic ischemia/reperfusion (I/R), a model of sterile inflammation. METHODS: Adult male mice underwent 70% hepatic ischemia for 60 minutes and 24-hour reperfusion. At the start of reperfusion, mice were treated intravenously with vehicle (phosphate-buffered saline) or PS-OMe miR130. Blood and liver tissue were collected after 24 hours for biochemical analysis. Apoptosis in the liver tissue was determined by transferase dUTP nick-end labeling assay. RESULTS: After hepatic I/R, organ injury markers including aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase significantly decreased after PS-OMe miR130 treatment. Furthermore, histological analysis of liver sections demonstrated significantly less injury in PS-OMe miR130 treatment mice versus vehicle mice. In addition, tumor necrosis factor α mRNA, interleukin-1ß mRNA, and neutrophil infiltration (myeloperoxidase activity and granulocyte receptor 1 immunohistochemistry) were significantly attenuated after PS-OMe miR130 treatment. Finally, apoptosis significantly decreased in liver tissue after treatment. CONCLUSION: PS-OMe miR130 decreases eCIRP-mediated injury and inflammation in a murine model of hepatic I/R.

An engineered miRNA PS-OMe miR130 inhibits acute lung injury by targeting eCIRP in sepsis.

BACKGROUND: Sepsis is caused by the dysregulated immune response due to an initial infection and results in significant morbidity and mortality in humans. Extracellular cold inducible RNA binding protein (eCIRP) is a novel mediator identified in sepsis. We have previously discovered that microRNA 130b-3p inhibits eCIRP mediated inflammation. As RNA mimics are very unstable in vivo, we hypothesize that an engineered miRNA 130b-3p mimic named PS-OMe miR130, improves stability of the miRNA by protection from nuclease activity. We further hypothesize that PS-OMe miR130 reduces not only eCIRP-mediated inflammation and but also acute lung injury in a murine model of polymicrobial sepsis. METHODS: Single stranded PS-OMe miR130 was synthesized and the binding affinity to eCIRP was evaluated using surface plasmon resonance (SPR) and computational modeling. Macrophages were treated with PS-OMe miR130 with and without eCIRP and cell supernatant analyzed for cytokines. In vitro stability and the in vivo half-life of PS-OMe miR130 were also assessed. The effect of PS-Ome miR130 on eCIRP's binding to TLR4 was evaluated by SPR analysis and modeling. Finally, the effect of PS-OMe miR130 on inflammation and injury was assessed in a murine model of sepsis. RESULTS: We demonstrate via SPR and computational modeling that PS-OMe miR130 has a strong binding affinity to eCIRP. This engineered miRNA decreases eCIRP induced TNF-α and IL-6 proteins, and it is highly stable in vitro and has a long in vivo half-life. We further demonstrate that PS-OMe miR130 blocks eCIRP binding to its receptor TLR4. Finally, we show that PS-OMe miR130 inhibits inflammation and lung injury, and improves survival in murine sepsis. CONCLUSION: PS-OMe miR130 can be developed as a novel therapeutic by inhibiting eCIRP-mediated inflammation and acute lung injury in sepsis.

Streamlining and Consistency in Surgery: Lean Six Sigma to Improve Operating Room Efficiency.

BACKGROUND: Improving perioperative efficiency helps reduce unnecessary surgical expenditure, increase operating room throughput, improve patient safety, and enhance staff and patient satisfaction. Lean Six Sigma (LSS) is a quality improvement model that has been successfully applied to eliminate inefficiencies in the business sector but has not yet been widely adopted in medicine. This study investigates the adaptation of LSS to improve operative efficiency for plastic surgery procedures. METHODS: The authors followed the define, measure, analyze, improve, and control phases to implement LSS. The key outcome measures gathered were operative times, including the cut-to-close time, and the total time the patient spent in the operating room. RESULTS: The study included a total of 181 patients who underwent immediate bilateral deep inferior epigastric perforator flap breast reconstruction between January of 2016 and December of 2019. The LSS interventions were associated with a decrease in total operative time from 636.36 minutes to 530.35 minutes, and a decrease in the time between incision to closure from 555.16 minutes to 458.85 minutes for a bilateral mastectomy with immediate deep inferior epigastric artery flap breast reconstruction. CONCLUSIONS: This study demonstrates that LSS is useful to improve perioperative efficiency during complex plastic surgery procedures. The workflow of the procedure was improved by determining the optimal spatial positioning and distinct roles for each surgeon and preparing surgeon-specific surgical trays. Two process maps were developed to visualize the positioning of the surgeons during each stage of the procedure and depict the parallel workflow that helped improve intraoperative efficiency.

Recovery of Skill Decay After COVID-19 Redeployments and Implications for Competency Attainment.

INTRODUCTION: The COVID-19 pandemic immediately interrupted procedural training. The lasting impact of reduced caseloads and service redeployments on procedural-resident training has been underexplored. This longitudinal study investigated the long-term perspectives of skill decay after short breaks in training and implications for ensuring resident competency attainment. METHODS: Web-based cross-sectional surveys distributed immediately after (June 2020) compared to 1 y after (July 2021) COVID-19 redeployments at two tertiary academic medical centers of an integrated health system in New York. Participants included general surgery, surgical subspecialty, and anesthesiology residents and faculty. RESULTS: Fifty-five residents and 33 faculty completed the survey. Ninety-point nine percent of residents and 36.4% of faculty were redeployed to COVID-ICUs. Sixty-three-point seven percent of residents and 75.0% of faculty reported a reduction in resident technical skills in the short-term, with significantly less (45.5% of residents and 21.2% of faculty) reporting persistent reduction in technical skill after 1 y (P = 0.001, P < 0.001). Seventy-five percent of residents and 100% of faculty were confident residents would be able to practice independently at the conclusion of their training. Sixty-five-point five percent of residents and 63.6% of faculty felt that residents experienced a durable improvement in critical care skills. Residents also reported a positive long-term impact on professional core competencies at 1 y. CONCLUSIONS: Longitudinal surveillance of residents after COVID-19 redeployments suggests washout of temporary skill decay and return of resident confidence upon resumption of traditional training. This may provide insight into the impact of other short-term training interruptions on resident skill and promote greater resident support upon training resumption to ensure competency attainment.

Systemic Determinants in Surgery: Nonclinical Factors Affecting Time to Operation for Incarcerated Ventral Hernias.

INTRODUCTION: We explore nonclinical factors affecting the amount of time from admission to the operating room for patients requiring nonelective repair of ventral hernias. METHODS: Using the 2005-2012 Nationwide Inpatient Sample, we identified adult patients with a primary diagnosis of ventral hernia without obstruction/gangrene, who underwent nonelective repair. The outcome variable of interest was time from admission to surgery. We performed univariate and multivariable analyses using negative binomial regression, adjusting for age, sex, race, income, insurance, admission day, comorbidity status (van Walraven score), diagnosis, procedure, hospital size, location/teaching status, and region. RESULTS: 7,253 patients met criteria, of which majority were women (n = 4,615) and white (n = 5,394). The majority of patients had private insurance (n = 3,015) followed by Medicare (n = 2,737). Median time to operation was 0 days. Univariate analysis comparing operation <1 day to ≥1 day identified significant differences in race, day of admission, insurance, length of stay, comorbidity status, hospital location, type, and size. Negative binomial regression showed that weekday admission (IRR 4.42, P < .0001), private insurance (IRR 1.53-2.66, P < .0001), rural location (IRR 1.39-1.76, P < .01), small hospital size (IRR 1.26-1.36, P < .05), white race (IRR 1.30-1.34, P < .01), healthier patients (van Walraven score IRR 1.05, P < .0001), and use of mesh (IRR 0.39-0.56, P < .02) were associated with shorter time until procedure. CONCLUSION: Shorter time from admission to the operating room was associated with several nonclinical factors, which suggest disparities may exist. Further prospective studies are warranted to elucidate these disparities affecting patient care.

Pre-hospital caloric deficits in surgical patients.

BACKGROUND: The timing, route, and amount of nutrition for surgical patients with substantial caloric deficits remain active areas of study. Current guidelines are based on in-hospital days NPO after admission to the hospital. This historic process neglects the multiple days of caloric deficit patients experience prior to hospital admission. AIM: To determine the impact of pre-hospital caloric deficit (PHCD) for surgical patients on their outcomes. METHODS: 313 patients admitted with a diagnosis of small bowel obstruction, pancreatitis, or diverticulitis were analyzed for their PHCD's. PHCD's were estimated using patient-reported days with significant emesis, and absent oral intake. Patients with PHCD's were compared to patients with no PHCD for length of stay, status on discharge, disposition, and 30-day readmission rate. RESULTS: There were 313 patients and 42% of the patients were male. The median age was 65 years. Median number of days sick prior to hospital admission was 1 (IQR: 1 to 2). Median PHCD was 1882 kcal (IQR: 1355 to 3650). Median number of days NPO while in-hospital was 3 (IQR: 2 to 5). Median in-hospital caloric deficit was 4268 kcal (IQR: 2825 to 6610). No significant association was observed between discharge disposition, complication rate, ambulatory status, 30-day readmission rate and PHCD. In-hospital caloric deficit was associated with complications after surgery (p < 0.0001). CONCLUSION: Small PHCD's in patients with SBO's, pancreatitis, or diverticulitis do not negatively affect their outcomes. Further research of patients with large PHCD's is needed to best treat surgical patients at risk for malnutrition.

Laparoscopic Ventral Hernia Repair Postoperative Complications in End Stage Renal Disease Patients.

Background: The prevalence of patients with end stage renal disease (ESRD) requiring general surgical procedures is increasing. Our aim was to explore the effect of ESRD on patients undergoing elective laparoscopic ventral hernia repair. Methods: The American College of Surgeons National Surgical Quality Improvement Program (2010-2015) database was used to identify patients who underwent elective laparoscopic ventral hernia repair. Multivariable analysis was performed adjusting for risk variables including age, gender, race, comorbidity status, body mass index ≥ 35, and presence of ESRD. Results: A total of 8,789 patients undergoing elective laparoscopic ventral hernia repair were identified. Sixty-four patients (0.73%) had ESRD. ESRD was identified as an independent risk factor for postoperative pneumonia (odds ration [OR] 6.91, p = 0.00363), sepsis (OR 18.58, p = 0.000286), and length of stay (IRR 1.63, 95% confidence interval 1.19 - 2.27, p = 0.0036). Conclusions: ESRD patients undergoing elective laparoscopic ventral hernia repair had an increased risk of postoperative pneumonia, sepsis, and length of stay. Clinicians should be cognizant of these risks when performing elective operations on ESRD patients.

Inhibition of the Interaction of TREM-1 and eCIRP Attenuates Inflammation and Improves Survival in Hepatic Ischemia/Reperfusion.

INTRODUCTION: Triggering receptor expressed on myeloid cells-1 (TREM-1) has important implications in sepsis and inflammation and is a novel receptor for extracellular cold-inducible RNA-binding protein (eCIRP). We hypothesize that the inhibition of TREM-1 via its interaction with eCIRP by novel peptide inhibitor M3 or knockout gene will attenuate the inflammation and injury associated with severe hepatic ischemia/reperfusion (I/R). METHODS: Wild-type (WT) C57BL/6 and TREM-1-/- mice underwent 60 min of 70% hepatic ischemia, with 24 h of reperfusion. Additionally, WT mice underwent hepatic I/R and were treated with M3 (10 mg/kg body weight) or vehicle (normal saline) at the start of reperfusion. Blood and ischemic liver tissues were collected, and analysis was performed using enzymatic assays, enzyme-linked immunosorbent assay, reverse-transcription quantitative polymerase chain reaction, and pathohistology techniques. For survival surgery, mice additionally underwent resection of non-ischemic lobes of the liver and survival was monitored for 10 days. RESULTS: There was an increase in serum levels of tissue markers including aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase as well as cytokine levels (IL-6) and histological scoring of hematoxylin and eosin sections in WT I/R mice. These markers decreased substantially in TREM-1-/- mice. Additionally, neutrophil infiltration markers and markers of local inflammation (myeloperoxidase, macrophage inflammatory protein-2, cyclooxygenase-2) were attenuated in TREM-1-/- mice. Similarly, we show a significant decrease in injury and inflammation markers with M3 treatment. Additionally, we demonstrate decreased apoptosis with TREM-1 inhibition. Finally, M3 treatment improved the survival rate from 42% to 75% after hepatic I/R. CONCLUSION: TREM-1 is an important eCIRP receptor in the inflammatory response of hepatic I/R, and deficiency of TREM-1 via knockout gene or peptide inhibition attenuated liver injury and inflammation, and improved survival. Inhibition of the TREM-1 and eCIRP interaction in hepatic I/R may have important therapeutic potential.

Joint-Venture Ambulatory Surgery Centers: The Perfect Partnership.

BACKGROUND: Ambulatory surgery growth has increased in the last few decades as ambulatory surgery centers have been shown to succeed in cost efficiencies through their smaller size and breadth, specialization of care, and ability to quickly participate in perioperative process improvement and education. METHODS: A 5-year retrospective fiscal review was performed for all Northwell Health-physician ambulatory surgery center joint ventures. The outcome measures studied included model of ownership, specialty types, and gross revenue. Additional facility characteristics were studied, including growth trajectory, facility size, and cost to build a de novo facility. RESULTS: Eleven free-standing ambulatory surgery centers were identified at Northwell Health during the 5-year study period. The total gross revenue for all Northwell clinical joint ventures for 2019 alone was $102,854,000. Northwell Health is a majority stakeholder in eight of their joint venture ambulatory surgery centers, with an average Northwell ownership of 53 percent and an average number of physician owners per facility of 11. The number of hospital-physician joint-venture ambulatory surgery centers grew from two to 11 facilities during the study period (450 percent). Surgical volume followed a similar trajectory, increasing 295 percent over the same time period. CONCLUSIONS: The ambulatory surgery center setting provides a vast number of possibilities for key stakeholders, including patients themselves, to benefit from financial and clinical efficiencies. Ambulatory surgery centers have been popular, as they meet patient expectations for convenience of elective surgery, reduce payer and clinical pressures to minimize length of stay in hospitals, and achieve similar or higher quality care with less intense resources.

Comparing Surgical Outcomes Among Patients Admitted for Small Bowel Obstruction on Weekend vs. Weekday.

INTRODUCTION: Surgical intervention is important in reducing morbidity and mortality among patients admitted for small bowel obstruction (SBO). Patient-specific variables such as age and comorbidities are risk factors for adverse outcomes after surgery for SBO. However, the effect of weekend admission on outcomes has not been well delineated in the literature. Our aim was to determine whether weekend admission affects mortality and length of stay (LOS) in patients who were admitted for SBO and were managed operatively. MATERIALS AND METHODS: Using the 2006-2012 Nationwide Inpatient Sample (NIS) database, we identified adult patients who were admitted with a primary diagnosis of SBO and had a primary procedure of exploratory laparotomy, lysis of adhesions, or small bowel resection. We performed univariate analysis comparing cases that were admitted on the weekend vs. weekday. We then performed negative binomial regression with LOS as the dependent variable, adjusting for risk variables. RESULTS: 2804 patients were studied, of which 728 (26.0%) were admitted on the weekend. Univariate analysis showed no statistically significant difference in mortality or LOS for patients admitted on a weekday vs. weekend. Multivariate analysis showed that several factors were associated with increased LOS, including third quartile van Walraven score (P < .0001) and large hospital size (P = .0031). Other factors were associated with decreased LOS, including fourth quartile of income (P = .0022) and weekend admission (P = .048). DISCUSSION: There is no significant difference in mortality between patients admitted on weekend vs. weekday for SBO, but patients admitted on weekend are more likely to have a decreased LOS.

Facility of Origin Predicts Mortality After Colonic Perforation.

INTRODUCTION: Colonic perforation often requires emergent intervention and carries high morbidity and mortality. The objective of this study was to determine whether nonclinical factors, such as transition of care from outpatient facilities to inpatient settings, are associated with increased risk of mortality in patients who underwent emergent surgical intervention for colonic perforation. MATERIALS AND METHODS: Using the 2006-2015 ACS National Surgical Quality Improvement Program database, we identified adult patients who underwent emergent partial colectomy with primary anastomosis ± protecting ostomy or partial colectomy with ostomy with intraoperative finding of wound class III or IV for a diagnosis of perforated viscus. The outcome of interest was 30-day postoperative mortality. Univariate and multivariate analyses using logistic regression were performed. RESULTS: 4705 patients met criteria, of which 841 (17.9%) died. Univariate analysis showed that patients who died after emergent surgery for perforated viscus were more likely to present from a chronic care facility (13.4% vs. 4.4%, P < .0001) and had longer time from admission to undergoing surgery (mean 4.1 vs. 2.0 days, P < .0001. Logistic regression demonstrated that septic shock vs. none (OR 3.60, P < .0001), sepsis vs. none (OR 1.57, P = .00045), transfer from chronic care facility vs. home (OR 1.87, P < .0001), and increased time from admission vs. operation (OR 1.01, P = .0055) were independently associated with increased risk of death. DISCUSSION: Transfer from a chronic care facility was independently associated with increased mortality in patients undergoing emergent surgery for perforated viscus.

An extracellular cold-inducible RNA-binding protein-derived small peptide targeting triggering receptor expressed on myeloid cells-1 attenuates hemorrhagic shock.

BACKGROUND: Extracellular cold-inducible RNA-binding protein (eCIRP) is a damage-associated molecular pattern, which is released into the circulation after hemorrhagic shock (HS). Recently, we discovered that triggering receptor expressed on myeloid cells-1 (TREM-1) serves as a new receptor of eCIRP to exaggerate inflammation. Here, we hypothesize that by inhibiting the interaction between eCIRP and TREM-1 with the use of a novel short peptide derived from human eCIRP known as M3, we can inhibit the inflammatory response and acute lung injury in HS. METHODS: Hemorrhagic shock was induced using C57BL/6 mice by cannulating both femoral arteries. One femoral artery was used for removal of blood while the other was used for continuous monitoring of mean arterial blood pressure. The mean arterial pressure of 25 mm Hg to 30 mm Hg was maintained for 90 minutes, followed by a resuscitation phase of 30 minutes with 1 mL of normal saline. The treatment group was given 10 mg/kg of M3 during the resuscitation phase. Four hours after resuscitation, serum and lungs were collected and analyzed for various injury and inflammatory markers by using colorimetry, real-time polymerase chain reaction, and enzyme-linked immunosorbent assay. RESULTS: There was an increase in the serum levels of tissue injury markers (alanine aminotransferase, aspartate aminotransferase, and lactate dehydrogenase) as well as cytokines (TNF-α and IL-6) when comparing the vehicle group versus the sham group. This increase was significantly inhibited in the M3-treated group. The mRNA expression of proinflammatory cytokines TNF-α, IL-6, and IL-1ß and the chemokines MIP-2 and KC in lungs was significantly increased in the vehicle-treated HS mice, while their expression was significantly decreased in M3-treated HS mice. Finally, M3 treatment significantly decreased the lung injury score compared with vehicle-treated HS mice. CONCLUSION: The novel eCIRP-derived TREM-1 antagonist (M3) can be a potential therapeutic adjunct in the management of hemorrhagic shock.

Risk Factors for Early Readmission After Acute Pancreatitis: Importance of Timely Interventions.

BACKGROUND: Despite improvements in the diagnosis and care of acute pancreatitis, the mortality, morbidity, and long-term complications of this disease currently account for an annual cost of $10 billion in the United States. Lack of high-quality consolidated clinical data about this ever-increasing national and global burden makes it challenging to be able to recognize at-risk populations and intervene to avoid early readmission (ER) (i.e., readmission within 30 d of hospital discharge or ER). METHODS: We reviewed the National Readmission Database for 2016. We retrieved 25,476 ER out of a total of 188,757 patients admitted with acute pancreatitis (ICD-10 diagnosis of K85), alive at discharge. Patients younger than 18 at the time of initial admission were excluded. Diagnostic characteristics and procedures performed were extracted from ICD-10 data. Based on patient demographics and the diagnostic and procedural profiles from their initial admission, we identified clusters of risk factors for ER using agglomerative hierarchical clustering. These are depicted in a correlation matrix. RESULTS: Acute pancreatitis is associated with a 13.5% overall ER rate. Certain pre-existing chronic diseases, particularly cardiovascular disease diagnoses and interventions at initial presentation increase the odds of ER. In contrast to interventions on the pancreas, interventions on the biliary system correlated with lower odds of ER. Furthermore, the earlier the biliary system intervention was performed during the initial hospitalization, the lower the odds of ER. We identified five clusters of interrelationships: age/comorbidity cluster, cirrhosis cluster, sepsis/pulmonary complication cluster, biliary intervention cluster, and high-risk of mortality cluster. CONCLUSIONS: We identified several potentially modifiable risk factors for ER of patients hospitalized with acute pancreatitis, which included timing of biliary interventions. Furthermore, we identified clusters of interrelationships that further illuminate which complications tend to occur concomitantly and ultimately contribute to ER. By identifying risk factors and elucidating their interactions, we have improved our understanding of this highly morbid disease and offer potential points of intervention to reduce ER.

Extracellular microRNA 130b-3p inhibits eCIRP-induced inflammation.

Although microRNAs regulate mRNA expression intracellularly, they are often released into the circulation in inflammatory diseases. During sepsis, secreted extracellular cold-inducible RNA-binding protein (eCIRP) acts as a damage-associated molecular pattern (DAMP), inducing tissue damage by elevating inflammatory cytokines and chemokines. Here, we report that the circulating microRNA 130b-3p inhibits eCIRP-mediated sterile and cecal ligation and puncture (CLP)-induced non-sterile inflammation. We find that levels of miR-130b-3p are increased in the serum of septic mice and patients and that it strongly interacts with recombinant murine (rm) CIRP in vitro and with eCIRP in the serum of septic mice in vivo. Combining a miR-130b-3p mimic with rmCIRP significantly decreases TNF-α release by macrophages compared to only rmCIRP-treated cells. This combined treatment also dose-dependently decreases the affinity of rmCIRP with its receptor TLR4/MD2. Finally, injection of a miR-130b-3p mimic significantly reduces rmCIRP- or CLP-induced systemic inflammation and acute lung injury in mice. These data show that extracellular miR-130b-3p functions as a novel endogenous inhibitor of eCIRP and point to an innovative therapeutic approach to treat inflammatory diseases.

Factors Influencing Patient Satisfaction in Plastic Surgery: A Nationwide Analysis.

BACKGROUND: Patient satisfaction surveys are an increasingly important part of health care, influencing the practice of physicians. Press Ganey has developed tools to assess physician and department performance that are used by 50 percent of hospitals in the United States and over 10,000 health care organizations. The authors sought to evaluate the factors that influence patient satisfaction in plastic surgery patients both locally and nationally. METHODS: A 24-item Press Ganey survey was distributed to patients of 686 participating plastic surgeons nationwide, including those at the authors' home institution. The responses from January to December of 2016 were analyzed retrospectively with Pearson correlation coefficients. The items "likelihood to recommend provider" and "likelihood to recommend practice" were correlated to all other items of the survey, as these items have been shown to be surrogates for overall satisfaction. RESULTS: There were 411 survey responses from patients in the Northwell Health System and 36,836 responses from patients nationally. Items that were not well correlated (r < 0.5) with "likelihood to recommend practice" or "provider" were items such as wait time and courtesy of registration staff. The items that were best correlated (r > 0.8) with "likelihood to recommend practice" or "provider" were the patient's confidence in the care provider and the provider's concern for questions. All correlations were statistically significant (p < 0.001). CONCLUSION: In an evolving patient centric culture, the patient's confidence and trust of the provider is more important than perception of the provider's office environment to maintaining patient loyalty and market share.