Deep learning in voice analysis for diagnosing vocal cord pathologies: a systematic review.

OBJECTIVES: With smartphones and wearable devices becoming ubiquitous, they offer an opportunity for large-scale voice sampling. This systematic review explores the application of deep learning models for the automated analysis of voice samples to detect vocal cord pathologies. METHODS: We conducted a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. We searched MEDLINE and Embase databases for original publications on deep learning applications for diagnosing vocal cord pathologies between 2002 and 2022. Risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). RESULTS: Out of the 14 studies that met the inclusion criteria, data from a total of 3037 patients were analyzed. All studies were retrospective. Deep learning applications targeted Reinke's edema, nodules, polyps, cysts, unilateral cord paralysis, and vocal fold cancer detection. Most pathologies had detection accuracy above 90%. Thirteen studies (93%) exhibited a high risk of bias and concerns about applicability. CONCLUSIONS: Technology holds promise for enhancing the screening and diagnosis of vocal cord pathologies. While current research is limited, the presented studies offer proof of concept for developing larger-scale solutions.

A Prospective, Single-Arm Study to Evaluate the Safety and Efficacy of an Autologous Blood Clot Product in the Treatment of Anal Fistula.

BACKGROUND: Surgical treatment of complex perianal fistula is technically challenging, associated with risk of failure, and may require multiple procedures. In recent years, several biologic agents have been developed for permanently eradicating anal fistulous disease with variable success. In this study, the treatment is an autologous whole-blood product created from the patients' blood. It forms a provisional matrix that was found to be safe and effective in healing acute and chronic cutaneous wounds. OBJECTIVE: The study aimed to assess the efficacy and safety of an autologous blood clot product as a treatment for transsphincteric perianal fistulas. DESIGN: A prospective single-arm study. SETTINGS: A single tertiary medical center. PATIENTS: Patients with simple or complex transsphincteric fistulas confirmed by MRI were included in the study. Cause was either cryptoglandular or Crohn's disease related (in the absence of active luminal bowel disease). INTERVENTION: The outpatient procedure was performed under general anesthesia and consisted of: 1) physical debridement and cleansing of the fistula tract; 2) suture closure of the internal opening; and 3) instillation of the autologous blood clot product into the entire tract. MAIN OUTCOME MEASURES: Safety and efficacy at 6- and 12-months after surgery. RESULTS: Fifty-three patients (77% men) with a median age of 42 (20-72) years were included in the study. Three patients withdrew consent, and 1 patient was lost to follow-up. At the time of this interim analysis, 49 and 33 patients completed the 6- and 12-month follow-up period. Thirty-four of the 49 patients achieved complete healing (69%) at 6 months, but 20 of the 33 patients (60%) achieved healing after 1 year. All patients who achieved healing at 6 months remained healed at the 1-year mark. In a subgroup analysis of patients with Crohn's disease, 7 of 9 patients completed 1-year follow-up, with 5 patients (71%) achieving clinical remission. No major side effects or postoperative complications were noted, but 2 adverse events occurred (admission for pain control and coronavirus 2019 infection). LIMITATIONS: Noncomparative single-arm pilot study. CONCLUSIONS: Treatment with an autologous blood clot product in perianal fistular disease was found to be feasible and safe, with an acceptable healing rate in both cryptoglandular and Crohn's disease fistula-in-ano. Further comparative assessment is required to determine its potential role in the treatment paradigm of fistula-in-ano. See Video Abstract . BRAZO PARA EVALUAR LA SEGURIDAD Y EFICACIA DE RDVER, UN COGULO DE SANGRE AUTLOGO, EN EL TRATAMIENTO DE LA FSTULA ANAL: ANTECEDENTES:El tratamiento quirúrgico de la fístula perianal compleja es técnicamente desafiante, se asocia con riesgo de fracaso y puede requerir múltiples procedimientos. En los últimos años, se han desarrollado varios agentes biológicos con el fin de erradicar permanentemente la enfermedad fistulosa anal con éxito variable. El tratamiento RD2-Ver.02 es un producto de sangre total autólogo creado a partir de la sangre de los pacientes, que forma una matriz provisional que resultó segura y eficaz para curar heridas cutáneas agudas y crónicas.OBJETIVO:Evaluar la eficacia y seguridad de RD2-Ver.02 como tratamiento para las fístulas perianales transesfinterianas.DISEÑO:Un estudio prospectivo de un solo brazo.LUGARES:Un único centro médico terciario.PACIENTES:Se incluyeron en el estudio pacientes con fístulas transesfinterianas simples o complejas confirmadas mediante resonancia magnética. La etiología fue criptoglandular o relacionada con la enfermedad de Crohn (en ausencia de enfermedad intestinal luminal activa).INTERVENCIÓN:El procedimiento ambulatorio se realizó bajo anestesia general y consistió en: 1) desbridamiento físico y limpieza del trayecto fistuloso; 2) cierre con sutura de la abertura interna; y 3) instilación de RD2-Ver.02 en todo el tracto.PRINCIPALES MEDIDAS DE VALORACIÓN:Seguridad y eficacia a los 6 y 12 meses después de la cirugía.RESULTADOS:Se incluyeron en el estudio 53 pacientes (77% varones) con una mediana de edad de 42 (20-72) años. Tres pacientes retiraron su consentimiento y un paciente se perdió durante el seguimiento. En el momento de este análisis intermedio, 49 y 33 pacientes completaron el período de seguimiento de 6 y 12 meses, respectivamente. Treinta y cuatro (34) pacientes lograron una curación completa (69%) a los 6 meses, mientras que 20 de 33 pacientes (60%) lograron una curación después de un año. Todos los pacientes que lograron la curación a los 6 meses permanecieron curados al año. En un análisis de subgrupos de pacientes con enfermedad de Crohn, 7/9 pacientes completaron un seguimiento de un año y 5 pacientes (71%) alcanzaron la remisión clínica. No se observaron efectos secundarios importantes ni complicaciones postoperatorias, mientras que ocurrieron 2 eventos adversos (ingreso para control del dolor e infección por COVID-19).LIMITACIONES:Estudio piloto no comparativo de un solo brazo.CONCLUSIONES:Se encontró que el tratamiento con RD2-Ver.02 en la enfermedad fístula perianal es factible y seguro, con una tasa de curación aceptable tanto en la fístula criptoglandular como en la de Crohn en el ano. Se requiere una evaluación comparativa adicional para determinar su papel potencial en el paradigma de tratamiento de la fístula anal. (Pre-proofed version ).

[SURGICAL TREATMENT USING ROBOTIC APPROACH FOR OBSTRUCTED DEFECATION SYNDROME (ODS)].

INTRODUCTION: Obstructed Defecation Syndrome (ODS) is a complex surgical condition which involves structural and functional problems which significantly affects quality of life. There is limited information about the Da-Vinci Robotic System use in the treatment of this condition. This study examines the outcomes of robotic-assisted rectopexy. The primary outcome is recovery from surgery, with secondary outcomes including post-surgical complications, length of hospital stay, rehospitalization rate and recurrence after surgery. METHODS: A retrospective analysis was conducted of prospectively collected data for patients who underwent robotic assisted surgery for ODS between 2011-2022. A colorectal surgeon performed all surgeries at the Sheba Medical Center using the Da Vinci™ robotic system. This analysis uses descriptive statistics and presents the results as medians and ranges. RESULTS: Out of 33 patients included, 26 (84.9%) were female. Median age was 67 years (Range:19-85 years). Median American Society of Anesthesiology (ASA) score was 2 (1-3). Median Charlson's comorbidity score was 3 (0-4). Median patients' Body Mass Index (BMI) was 23.2 (15.6-33.4) kg/m2. Eight patients (24.4%) underwent previous procedure for ODS. Most (23) patients included (69.7%) underwent robotic assisted ventral rectopexy. Other interventions included combined anterior and posterior rectopexy (9.1%), combined ventral rectopexy and sacrocolpopexy (12.1%) and posterior rectopexy (9.1%). No cases of conversion to laparoscopic /open techniques were recorded. Median operation time was 135 minutes (70-270). One intra-operative complication recorded was an injury to the rectum during anterior dissection (3%). No significant blood loss was recorded. A total of 27 patients (81.8%) were operated using the Da Vinci Si system, and the rest (6) using the 6 Da Vinci Xi system. Two patients had post-operative complications. Median length of stay (LOS) was 4 days (2-6 days). Readmission rate within 30 days was 9.1%. Two patients (6.1%) had recurrence of rectal prolapse. Median follow-up was 60 (4-116) months. CONCLUSIONS: Robotic-assisted surgery for obstructed defecation syndrome is safe, with fast recovery of the patient and it is efficient during long-term follow-up.

The value of CA125 in predicting acute complicated colonic diverticulitis.

BACKGROUND: CA125 is a widely used serum marker for epithelial ovarian cancer which levels may also rise in benign conditions involving peritoneal irritation. We aimed to determine if serum CA125 levels can predict disease severity in patients presenting with acute diverticulitis. METHODS: We conducted a single-center prospective observational study, analyzing CA125 serum levels in patients who presented to the emergency department with computerized tomography-proven acute left-sided colonic diverticulitis. Univariate, multivariate, and receiver operating characteristic (ROC) analyses were used to correlate CA125 serum levels at time of initial presentation with the primary outcome (complicated diverticulitis) and secondary clinical outcomes (need for urgent intervention, length of hospital stay (LOS) and readmission rates). RESULTS: One hundred and fifty-one patients were enrolled between January 2018 and July 2020 (66.9% females, median age 61 years). Twenty-five patients (16.5%) presented with complicated diverticulitis. CA125 levels were significantly higher among patients with complicated (median: 16 (7-159) u/ml) vs. uncomplicated (8 (3-39) u/ml) diverticulitis (p < 0.001) and also correlated with the Hinchey severity class (p < 0.001). Higher CA125 levels upon admission were associated with a longer LOS and a greater chance to undergo invasive procedure during the hospitalization. In patients with a measurable intra-abdominal abscess (n = 24), CA125 levels were correlated with the size of the abscess (Spearman's r = 0.46, p = 0.02). On ROC analysis to predict complicated diverticulitis, the area under the curve (AUC) for CA125 (AUC = 0.82) was bigger than for the leukocyte count (AUC = 0.53), body temperature (AUC = 0.59), and neutrophil-lymphocyte ratio (AUC = 0.70) - all p values < 0.05. On multivariate analysis of factors available at presentation, CA125 was found to be the only independent predictor of complicated diverticulitis (OR 1.12 (95% CI 1.06-1.19), p < 0.001). CONCLUSIONS: The results from this feasibility study suggest that CA125 may accurately discriminate between simple and complicated diverticulitis, meriting further prospective investigation.

Neutrophil to Lymphocyte Ratio in Patients Who Received Neoadjuvant Treatment before Gastrectomy.

BACKGROUND: The neutrophil to lymphocyte ratio (NLR) has demonstrated prognostic value in various malignant conditions, including gastric adenocarcinoma. However, chemotherapy may affect NLR. OBJECTIVES: To evaluate the prognostic value of NLR as an accessory decision-making tool in terms of operating patients after neoadjuvant chemotherapy in patients with resectable gastric cancer. METHODS: We collected oncologic, perioperative, and survival data of patients with gastric adenocarcinoma who underwent curative intent gastrectomy and D2 lymphadenectomy between 2009 and 2016. The NLR was calculated from preoperative laboratory tests and classified as high (> 4) and low (≤ 4). The t-test, chi-square, Kaplan-Meier analysis, and Cox multivariate regression models were used to assess associations of clinical, histologic, and hematological variables with survival. RESULTS: For 124 patients the median follow-up was 23 months (range 1-88). High NLR was associated with greater rate of local complication (r=0.268, P < 0.01). The rate of major complications (Clavien-Dindo ≥ 3) was higher in the high NLR group (28% vs. 9%, P = 0.022). Among the 53 patients who received neoadjuvant chemotherapy, those with low NLR had significantly improved disease-free survival (DFS) (49.7 vs. 27.7 months, P = 0.025). Low NLR was not significantly associated with overall survival (mean survival, 51.2 vs. 42.3 months, P = 0.19). Multivariate regression identified NLR group (P = 0.013), male gender (P = 0.04), and body mass index (P = 0.026) as independently associated with DFS. CONCLUSIONS: Among gastric cancer patients planned for curative intent surgery who underwent neoadjuvant chemotherapy, NLR may have prognostic value, particularly regarding DFS and postoperative complications.

Diffusion-weighted MRI for predicting and assessing treatment response of liver metastases from CRC - A systematic review and meta-analysis.

The evaluation of response to chemotherapy and targeted therapies in colorectal liver metastases has traditionally been based on size changes, as per the RECIST criteria. However, therapy may alter tissue composition and not only tumor size, therefore, functional imaging techniques such as diffusion-weighted magnetic resonance imaging (DWI) may offer a more comprehensive assessment of treatment response. The aim of this systematic review and meta-analysis was to evaluate the use of DWI in the prediction and assessment of response to treatment in colorectal liver metastases and to determine if there is a baseline apparent diffusion coefficient (ADC) cut-off value that can predict a favorable response. A literature search was conducted using the MEDLINE/PubMed database, and risk of bias was evaluated using the QUADAS-2 tool. The mean differences between responders and non-responders were pooled. A total of 16 studies met the inclusion criteria, and various diffusion-derived techniques and coefficients were found to have potential for predicting and assessing treatment response. However, discrepancies were noted between studies. The most consistent predictor of response was a lower baseline ADC value calculated using traditional mono-exponential methods. Non-mono-exponential techniques for calculating DWI-derived parameters were also reported. A meta-analysis of a subset of studies failed to establish a cut-off value of ADC due to heterogeneity, but revealed a pooled mean difference of -0.12 × 10-3 mm2/s between responders and non-responders. The results of this systematic review suggest that diffusion-derived techniques and coefficients may contribute to the evaluation and prediction of treatment response in colorectal liver metastases. Further controlled prospective studies are needed to confirm these findings and to guide clinical and radiological decision-making in the management of patients with CRC liver metastases.

Risk Factors for Readmission and Mortality Following Colonic Surgery: A Consecutive Retrospective Series of More Than 2500 Cases.

Introduction: The optimal strategy to reduce short-term readmission rates following colectomy remains unclear. Identifying possible risk factors can minimize the burden associated with surgical complications leading to readmissions. Materials and Methods: A retrospective review of all adult patients who underwent colectomies between January 2008 and December 2020 in a large tertiary medical center was conducted. Data were collected from patient's medical charts and analyzed. Results: Overall, 2547 patients were included in the study (53% females; mean age 68.3 years). The majority of patients (83%, n = 2112) were operated in an elective setting, whereas 435 patients (17%) underwent emergency colonic resection. Overall, the 30-day readmission rate was 8.3% (n = 218) with an overall 30-day mortality rate of 1.65% (n = 42). Multivariable analysis of possible risk factors for 30-day readmission demonstrated that patient age (odds ratio [OR] 0.98; P = .002), length of stay before surgery (OR 1.01; P = .003), and blood transfusion rate during hospitalization (OR 2.09; P < .001) were all independently associated with an increased risk. Laparoscopic colectomy (OR 0.53; P = .001) was associated with a reduced risk for readmission. Multivariable analysis of risk factors for mortality showed that age (OR 1.10; P < .001), cognitive decline (OR 12.35; P < .001), diabetes (OR 1.00; P = .004), and primary ostomy formation (OR 2.80; P = .006) were all associated with higher mortality. Conclusion: Patient age, history of cognitive decline, and blood transfusion along with a longer hospital stay were all correlated with an increased risk for 30-day patient readmission following colectomy.

Outcomes of Laser-Assisted Closure (SiLaC) Surgery for Chronic Pilonidal Sinus Disease.

Background: Management of pilonidal sinus (PNS) disease has changed notably in the past decade, with the introduction of novel surgical techniques and technological innovation. In this study, we summarized our initial experience with sinus laser-assisted closure (SiLaC) of pilonidal disease. Methods: A retrospective analysis of a prospective database of all patients who underwent minimally invasive surgery combined with laser therapy for PNS between September 2018 and December 2020 was performed. Patients' demographics, clinical and perioperative data, as well postoperative outcomes were recorded and analyzed. Results: A total of 92 patients (86 males, 93.4%) underwent SiLaC surgery for pilonidal sinus disease during the study period. Patients' median age was 22 (range 16-62 years), and 60.8% of them previously underwent abscess drainage due to PNS. SiLaC was performed under local anesthesia in 85.7% of cases (78 patients) with a median energy of 1081 J (range 13-5035 J). One patient was lost to follow-up, leaving 91 patients for final analysis. The primary outcome was complete healing rate, standing at 81.3% (74/91 patients). In 8 patients (8.8%), there was minor incomplete healing that did not require reintervention. Recurrent/nonhealing disease was seen in 9 patients (9.9%), requiring reoperation in 7 patients (8.4%). Of those, 4 patients underwent repeat SiLaC and 3 patients underwent wide excision. Analysis of risk factors for PNS recurrence demonstrated that general anesthesia (P = .02) was associated with increased risk for recurrence along with a trend for increased risk in patients with significant hairiness (P = .078). No differences were seen in age (P = .621), gender (P = .475), median sinus length (P = .397), and energy used (P = .904). Conclusion: Primary healing rate after SiLaC surgery for chronic PNS was >80% in our series. Ten percent of patients did not achieve complete healing but did not require surgery due to lack of symptoms.

Laser hemorrhoidoplasty for II-IV grade hemorrhoids: should we treat them the same?

Laser Hemorrhoidoplasty (LHP) is a novel therapeutic option for hemorrhoids. In this study, we aimed to evaluate the post-operative outcomes of patients undergoing LHP surgery based on hemorrhoid grade. A retrospective analysis of a prospective database of all patients who underwent LHP surgery between September 2018 and October 2021 was performed. Patients' demographics, clinical perioperative data, and post-operative outcomes were recorded and analyzed. One hundred and sixty two patients that underwent laser hemorrhoidoplasty (LHP) were included. Median operative time was 18 min (range 8-38). Median total energy applied was 850 Joule (450-1242). Complete remission of symptoms following surgery was reported by 134 patients (82.7%), while 21 patients (13%) reported partial symptomatic relief. Nineteen patients (11.7%) presented with post-operative complications, and 11 patients (6.75%) were re-admitted following surgery. Post-operative complication rate was significantly higher in patients with grade 4 hemorrhoids compared to grades 3 or 2, due to a higher rate of post-operative bleeding (31.6% vs. 6.5% and 6.7%, respectively; p = 0.004). Furthermore, post-operative readmission rate (26.3% vs. 5.4% and 6.2%; p = 0.01) and reoperation rate were also significantly higher in grade IV hemorrhoids (21.1% vs. 2.2% and 0%; p = 0.001). Multivariate analysis found that grade IV hemorrhoids had a significantly higher risk for post-operative bleeding (OR 6.98, 95% CI 1.68-28.7; p = 0.006), 30-day readmission (OR 5.82, 95% CI 1.27-25.1; p = 0.018), and hemorrhoids recurrence (OR 11.4, 95% CI 1.18-116; p = 0.028). LHP is an effective treatment for hemorrhoids grades II-IV, but carries significant risk for bleeding and re-intervention in patients with grade IV hemorrhoids.

Disparities in Receipt of Adjuvant Therapy After Upfront Surgical Resection for Pancreatic Ductal Adenocarcinoma.

BACKGROUND: A multimodal approach of surgery and chemotherapy, with or without radiation, is the mainstay of therapy with curative-intent for resectable pancreatic ductal adenocarcinoma (PDAC). This study compared utilization trends and outcomes of upfront surgery with and without adjuvant therapy. METHODS: The National Cancer Database was queried for patients with a diagnosis of stage 1 or 2 PDAC who underwent upfront resection. Multivariable regression was applied to identify factors associated with initiation of adjuvant therapy. RESULTS: Of the 39,128 patients in the study, 67% initiated adjuvant therapy after resection, whereas 33% received upfront surgery alone. Receipt of adjuvant multimodal therapy increased from 59% in 2006 to 69% in 2017 (P < 0.0001). Non-white race was associated with lower odds of receiving adjuvant therapy after adjustment for income status, education attainment, and other variables (Hispanic/Spanish [odds ratio {OR}, 0.77; 95% confidence interval {CI}, 0.69-0.86] and non-Hispanic black [OR 0.84; 95% CI 0.78-0.91 vs non-Hispanic white; P < 0.001). The variables that contributed to receipt of adjuvant therapy were place of residence in high versus low education attainment area (OR 1.30; 95% CI 1.18-1.44; P < 0.0001) and lower odds for initiation of adjuvant therapy with increasing distance from the treating facility (> 50 miles [OR 0.51; 95% CI 0.47-0.54] vs <12.5 miles; P < 0.0001). The median unadjusted overall survival (OS) time was 18.2 months (95% CI 17.7-18.8 months) for upfront surgery alone and 25.3 months (95% CI 24.9-25.8 months) for surgery with adjuvant therapy. CONCLUSIONS: The patients who underwent upfront surgical resection for PDAC showed wide socioeconomic disparities in the use of adjuvant therapy independent of insurance status, facility type, or travel distance.

Seniority of the assistant surgeon and perioperative outcomes in robotic-assisted proctectomy for rectal cancer.

The background of this study is to evaluate the impact of the assistant surgeon's in robotic-assisted proctectomy (RAP) on perioperative outcomes. A retrospective analysis of all patients who underwent RAP for rectal adenocarcinoma between 2011 and 2020 was conducted. Patient cohort was divided into three groups based on the assistant surgeon's training level: post-graduate years (PGY) 1-3 surgical residents (Group 1), PGY 4-5 surgical residents (Group 2), and board-certified general surgeons (Group 3). Overall, 175 patients were included in the study: 29 patients (17%) in Group 1, 84 (48%) in Group 2, and 62 (35%) in Group 3. The median tumor distance from the anal verge was 8 cm in all groups (p = 0.73). The median operative time was similar across all groups: 290, 291, and 281 min in Groups 1, 2, and 3, respectively (p = 0.69). In a multivariable analysis, the lack of association between assistant training level and procedure time maintained when adjusting for the year of operation (p = 0.84). Patients operated with junior residents as assistant surgeons (Group 1) had a more postoperative complications (p = 0.01) and a slightly longer hospital length of stay [7 days, interquartile range (IQR) 3], compared to those operated by assistant surgeons that were senior residents or attendings (6 IQR 2.5, and 6 IQR 2 in Groups 2 and 3, respectively; p = 0.02). Conversion rates (p = 0.12), intraoperative complications (p = 0.39), major postoperative complications (Clavien-Dindo ≥ 3; p = 0.32), 30-day readmission (p = 0.45), and mortality (p = 0.99) were similar between the groups. Robotic-assisted proctectomy performed with the assistance of a junior resident was found to be correlated with worse postoperative outcomes compared to more experienced assistants. No difference was seen in intraoperative outcomes.

Impact of Rater Training on Residents Technical Skill Assessments: A Randomized Trial.

OBJECTIVE: The ACS/APDS Resident Skills Curriculum's Objective Structured Assessment of Technical Skills (OSATS) consists of task-specific checklists and a global rating scale (GRS) completed by raters. Prior work demonstrated a need for rater training. This study evaluates the impact of a rater-training curriculum on scoring discrimination, consistency, and validity for handsewn bowel anastomosis (HBA) and vascular anastomosis (VA). DESIGN/ METHODS: A rater training video model was developed, which included a GRS orientation and anchoring performances representing the range of potential scores. Faculty raters were randomized to rater training or no rater training and were asked to score videos of resident HBA/VA. Consensus scores were assigned to each video using a modified Delphi process (Gold Score). Trained and untrained scores were analyzed for discrimination and score spread and compared to the Gold Score for relative agreement. RESULTS: Eight general and eight vascular surgery faculty were randomized to score 24 HBA/VA videos. Rater training increased rater discrimination and decreased rating scale shrinkage for both VA (mean trained score: 2.83, variance 1.88; mean untrained score: 3.1, variance 1.14, p = 0.007) and HBA (mean trained score: 3.52, variance 1.44; mean untrained score: 3.42, variance 0.96, p = 0.033). On validity analyses, a comparison between each rater group vs Gold Score revealed a moderate training impact for VA, trained κ=0.65 vs untrained κ=0.57 and no impact for HBA, R1 κ = 0.71 vs R2 κ = 0.73. CONCLUSION: A rater-training curriculum improved raters' ability to differentiate performance levels and use a wider range of the scoring scale. However, despite rater training, there was persistent disagreement between faculty GRS scores with no groups reaching the agreement threshold for formative assessment. If technical skill exams are incorporated into high stakes assessments, consensus ratings via a standard setting process are likely a more valid option than individual faculty ratings.

Inflammatory markers may predict post-operative complications and recurrence in Crohn's disease patients undergoing gastrointestinal surgery.

BACKGROUND: Most Crohn's Disease (CD) patients will require surgical intervention over their lifetime, with considerably high rates of post-operative complications. Risk stratification with reliable prognostic tools may facilitate clinical decision making in these patients. Blood cell interaction based inflammatory markers have proven useful in predicting patient outcomes in oncological and benign diseases. The aim of this study was to investigate their prognostic value in CD patients undergoing surgery. METHODS: A retrospective single institution study of CD patients who underwent surgery between the years 2008 and 2019 was conducted. Data were collected from medical records and analysed for association of Platelet-to-Lymphocyte Ratio (PLR), Neutrophil-to-Lymphocyte Ratio (NLR), Lymphocyte-to-Monocyte Ratio (LMR) and the modified Systemic Inflammatory Score (mSIS) with post-operative outcomes. RESULTS: A total of 81 patients were included in the analysis. Half were females; mean age was 36 ± 15.54 years. Fifty seven percent (n = 46) were operated in expedited settings, with 23.5% developing post-operative complications. In elective patients, higher pre-operative NLR (P = 0.029) and PLR (P = 0.034) were associated with major post-operative complications, higher NLR (P = 0.029) and PLR (P = 0.034) were associated with re-operation and higher PLR correlated with Clavien-Dindo score (P = 0.032). In patients operated in expedited operations, higher pre-operative NLR (P = 0.021) and lower pre-operative LMR (P = 0.018) were associated with thromboembolic events and higher mSIS was associated with major post-operative complications (P = 0.032). CONCLUSIONS: Blood cell interaction based inflammatory markers confer an association with post-operative complications in CD patients undergoing surgery. These indices may facilitate patient selection and optimization when considering the risks and benefits of surgical interventions.

Perioperative Pharmacologic Prophylaxis of Venous Thromboembolism: A Professional Liability Analysis.

BACKGROUND: Fear of medical liability is a major driver for broad administration of perioperative prophylactic anticoagulation, despite the persistently low rates of clinically symptomatic venous thromboembolism events (VTE) postoperatively. This study was undertaken to evaluate the medicolegal landscape of perioperative VTE and its pharmaceutical prophylaxis. METHODS: The Westlaw legal database was retrospectively searched for verdicts in medical professional liability cases in the United States between 2009 and 2020. One search strategy focused on perioperative VTE, and a second on claims of hemorrhagic complications in patients receiving perioperative anticoagulation. RESULTS: The search for VTE revealed 129 cases, and the search for hemorrhagic complications identified 24 cases. Almost half of the VTE cases were brought following orthopedic surgery (49%), and 29% following general surgery. The most common claims were failure to diagnose and treat during hospital stay or after discharge (74%), and failure to prescribe/administer anticoagulation (46%). Verdict for the health care professional (i.e., the defendant) was reached in 75% of cases. The median payout for patient verdicts was 1,213,644 USD (interquartile range 1,014,100; 150,000-7,700,000). Of hemorrhagic complication cases, 42% occurred in patients receiving VTE prophylaxis. In these cases, 82% resulted in a defendant verdict. CONCLUSIONS: Reasons for in-court medical professional liability claims involving perioperative VTE were mainly failure to diagnose VTE and rescue patients from complications postoperatively. The high rate of defendant verdicts supports the notion that decisions on VTE prophylaxis should not be influenced by fear of liability.

Passing the Scalpel: Lessons on retirement planning from retired academic surgeons.

BACKGROUND: Almost half of practicing surgeons in the United States are currently older than 55, but guidelines on how to prepare for retirement are limited. We sought to identify possible facilitators for, and obstacles to, surgeons' preparations for retirement. METHODS: A qualitative study was conducted using semi-structured interviews with clinically inactive academic surgeons. Emergent themes were identified via a grounded theory approach. RESULTS: We interviewed 12 surgeons (83% male; median age 75 years). Major barriers to retirement from surgery included uncertainty about when to retire, limited identity outside of surgery, and perception of retirement as strictly individual/private. Facilitators of a successful retirement identified by the participants included early career financial planning, awareness of career trajectory, development of post-surgery goals, and utilization of collective knowledge. CONCLUSION: There are numerous barriers encountered by surgeons seeking to transition from clinical practice to retirement that could be overcome by dedicated departmental and institutional efforts.

Challenges of virtual interviewing for surgical fellowships: a qualitative analysis of applicant experiences.

BACKGROUND: The COVID-19 pandemic forced surgical fellowship programs to transition from in-person to remote applicant interviews; the virtual interviewing format presented new and unique challenges. We sought to understand applicants' perceived challenges to virtual interviewing for a surgical fellowship program. METHOD: A grounded theory-based qualitative study was performed utilizing semi-structured interviews with fellowship applicants from the 2020 fellowship match. All Fellowship Council-registered applicants were eligible. We purposefully sampled participants to balance across gender, specialty-choice, and academic versus community-program affiliation. Interviews were inductively analyzed by two researchers for prominent themes. RESULTS: Fifteen interviews were conducted. Participants were 60% male (n = 9), with 33% (n = 5) from non-academic institutions. They applied for the following fellowships: Advanced Gastrointestinal/Minimal Invasive (55%), Bariatric (30%), Hepatopancreatobiliary (10%) and Surgical Oncology (5%). Four main themes emerged to describe virtual interview process challenges: (1) perceived data deficiency, (2) superficial personal connections, (3) magnification of non-professionalism, and (4) logistical frustrations. Applicants recommend program directors provide more information about the fellowship prior to interview day and offer informal independent interactions with current and previous fellows. CONCLUSIONS: According to fellowship applicants, virtual interviews resulted in a lack of information for rank-list decision making ultimately requiring them to rely on other information avenues to base their decisions. These applicants have offered advice to fellowship program directors and future applicants to better optimize this process.

Which Patient Do I Attend to First? Night-float Simulation to Assess Surgical Intern's Clinical Prioritization Skills.

OBJECTIVE: Night-float rotations require general surgery interns to prioritize multiple competing patients' needs efficiently and accurately. Research is lacking on whether these skills can be taught and to what degree the prioritizations taught match overall attending surgeon expectations. DESIGN: A night-float situation was developed to simulate the experience of surgical interns responding to multiple patients' needs. Participants were instructed to rank order 10 patient paper-case scenarios with a variety of clinical urgencies. After completing their first ranking, the interns participated in a faculty-facilitated peer discussion (intervention) and were then instructed to re-rank their priorities. Their performance was compared pre- and post-intervention, and to the ranking of 16 surgery faculty attendings. SETTING: Massachusetts General Hospital, Department of Surgery, Boston, MA. PARTICIPANTS: Post-graduate year (PGY) 1 surgical residents. RESULTS: Two classes of general surgery interns (n = 25) completed the prioritization training simulation in the middle of their internship year, one class in 2018 and one in 2020. Agreement between interns regarding patient prioritization ranking increased after the facilitated peer discussion (pre-intervention mean standard deviation = 1.8 versus 0.9 post-intervention; p = 0.03). In the post-intervention mean rank, four cases moved by one position (p < 0.05). The facilitated discussion resulted in increased absolute agreement between individual interns and attendings' ranks (mean agreement 38 ± 17% pre-intervention Vesus mean 50 ± 20% post-intervention, p = 0.02). The scenarios with highest agreement between interns and attendings concerned patients with the most urgent conditions. Scenarios with the lowest agreement were those ranked with medium-to-low urgency. CONCLUSION: A faculty-led facilitated discussion appears to increase clinical prioritization consistency among surgical interns and better align their prioritizations with expectations of local attending surgeons.