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OBJECTIVE: To determine differences in plasma sex hormone levels in male and female coronavirus disease 2019 (COVID-19) patients and healthy volunteers (HVs) because cell entry of severe acute respiratory syndrome coronavirus 2 occurs via the angiotensin-converting enzyme 2 receptor which is downregulated by 17ß-estradiol. PATIENTS AND METHODS: Citrated plasma samples were collected from 101 patients with COVID-19 upon presentation to the emergency department and from 40 HVs between November 1, 2020, and May 30, 2021. Plasma 17ß-estradiol and 5α-dihydrotestosterone (DHT) levels were measured using enzyme-linked immunosorbent assay (pg/mL). Data are presented as median and quartiles (IQR). Wilcoxon rank sum test with a P value less than .05 was considered significant. RESULTS: Patients with COVID-19 (median age, 49 years) included 51 males and 50 females (25 postmenopausal). Hospital admission was required for 58.8% of male patients (n = 30) and 48.0% of female patients (n = 24) (66.7% postmenopausal, n = 16) Healthy volunteers (median age, 41 years) included 20 males and 20 females (9 postmenopausal). Female patients with COVID-19 were found to have decreased 17ß-estradiol levels (18.5 [IQR, 10.5-32.3] pg/mL; 41.4 [IQR, 15.5-111.0] pg/mL, P=.025), and lower 17ß-estradiol to DHT ratios (0.073 [IQR, 0.052-0.159] pg/mL; 0.207 [IQR, 0.104-0.538] pg/mL, P=.015) than female HVs. Male patients with COVID-19 were found to have decreased DHT levels (302.8 [IQR, 249.9-470.8] pg/mL; 457.2 [IQR, 368.7-844.3] pg/mL, P=.005), compared with male HVs. Levels of DHT did not differ between female patients with COVID-19 and female HVs, whereas 17ß-estradiol levels did not differ between male patients with COVID-19 and male HVs. CONCLUSION: Sex hormone levels differ between patients with COVID-19 and HVs, with sex-specific patterns of hypogonadism in males and females. These alterations may be associated with disease development and severity.
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COVID-19 , Estradiol , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Adulto , Di-Hidrotestosterona , TestosteronaRESUMO
BACKGROUND: Small bowel obstruction management has evolved to incorporate the Gastrografin challenge. We expanded its use to the emergency department observation unit, potentially avoiding hospital admission for highly select small bowel obstruction patients. We hypothesized that the emergency department observation unit small bowel obstruction protocol would reduce admissions, costs, and the total time spent in the hospital without compromising outcomes. METHODS: We reviewed patients who presented with small bowel obstruction from January 2015 to December 2018. Patients deemed to require urgent surgical intervention were admitted directly and excluded. The emergency department observation unit small bowel obstruction guidelines were introduced in November 2016. Patients were divided into pre and postintervention groups based on this date. The postintervention group was further subclassified to examine the emergency department observation unit patients. Cost analysis for each patient was performed looking at number of charges, direct costs, indirect cost, and total costs during their admission. RESULTS: In total, 125 patients were included (mean age 69 ± 14.3 years). The preintervention group (n = 62) and postintervention group (n = 63) had no significant difference in demographics. The postintervention group had a 51% (36.7 hours, P < .001) reduction in median duration of stay and a total cost reduction of 49% (P < .001). The emergency department observation unit subgroup (n = 46) median length of stay was 23.6 hours. The readmission rate was 16% preintervention compared to 8% in the postintervention group (P = .18). CONCLUSION: Management of highly selected small bowel obstruction patients with the emergency department observation unit small bowel obstruction protocol was associated with decreased length of stay and total cost, without an increase in complications, surgical intervention, or readmissions.
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Obstrução Intestinal , Idoso , Idoso de 80 Anos ou mais , Diatrizoato de Meglumina , Serviço Hospitalar de Emergência , Hospitais , Humanos , Obstrução Intestinal/etiologia , Obstrução Intestinal/cirurgia , Tempo de Internação , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
Background: Diversity within the healthcare workforce is essential to improve quality of care, although evaluation of diversity within surgical training remains limited. This study analyzed diversity in recruitment of residents into surgical subspecialties at a large academic medical institution and national trends. Methods: A 21-year cross-sectional study of medical school graduates accepted into all surgical subspecialty training programs was performed. The institutional cohort was divided into two groups (1997-2006, 2007-2017). Subspecialty acceptance rates were determined between 2011 and 2018. Data on candidate demographics including gender, race, ethnicity, citizenship, and origin of medical education at a single institution and nationally were extracted. Results: Two thousand found hundred seventy-two residents were included in this study. From 1997 to 2018, female acceptances increased from 21.1% to 29.7% (p < 0.01), non-White increased from 27.9% to 31.8% (p = 0.01), and international medical graduates decreased from 28.8% to 25.5% (p = 0.02). There was no significant change in accepted Hispanic and Non-US candidates. Female subspecialty rates for subspecialties increased nationally and was comparable to our cohort, except in general surgery. Hispanic subspecialty acceptance rates were less than 10% and Black/African American acceptance rates remained less than 5% across subspecialties nationally and at our institution. Conclusion: Diversity in surgical training has modestly progressed over the last two decades, but the degree of positive change has not been universal and highlights the critical need for improvement and action. Continued institution driven and collaborative strategies are essential to promote diversity in recruitment across all surgical specialties that has implications on our future workforce and surgical leadership.
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BACKGROUND: International medical graduates (IMGs) are often relegated to preliminary positions in general surgery (GS) owing to uncertainties about the candidate's performance in the American healthcare setting. We aimed to determine the comparative performance of IMGs and American medical graduates (AMGs) at baseline and assess these trends over the course of their GS internship. METHODS: Evaluations of all IMG preliminary and AMG categorical interns from 2013 to 2017 at our GS residency program were obtained from three faculty members to score overall performance, technical skills, interpersonal communication, and medical knowledge on a 10-point Likert scale. Scores on the American Board of Surgery In-Training Exam, an in-house preparation test, United States Medical Licensing Exam, and performance during the biannual multistation objective assessments were compared between the two resident groups. RESULTS: Seventy-two interns (28 [39%] AMG categorical and 44 [61%] IMG preliminary) met inclusion criteria. The AMG group had significantly higher median Step 1 and Step 2 scores compared with our IMG group (243 versus 231, P = 0.002, and 250 versus 246, P = 0.03, respectively).Although in-house preparation test scores were higher among IMGs (median [interquartile range] of 36 [33-40] among AMGs and 38 [34-45] among IMGs; P = 0.002), there were no statistically significant differences between the American Board of Surgery In-Training Exam scores of the two groups. The median scores for the four faculty evaluation components were similar between the AMG (7, 8, 7, 7) and IMG resident groups (7, 7, 7, 7; P = nonsignificant). IMGs scored significantly higher in both biannual multistation objective assessments than AMGs (median [interquartile range] July: 59 [47-91] versus 55 [37-62], P = 0.005; January: 103 [86-116] versus 91 [87-104], P = 0.03). CONCLUSIONS: It is reassuring to confirm that no matter where they are from, great candidates can perform well as surgical interns in a GS training program.
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Competência Clínica/estatística & dados numéricos , Médicos Graduados Estrangeiros/estatística & dados numéricos , Cirurgia Geral , Internato e Residência , Feminino , Humanos , MasculinoRESUMO
OBJECTIVE: The nondesignated preliminary (NDP) position in general surgery (GS) offers a 1-year surgical training opportunity for medical school graduates prior to obtaining categorical residency positions. Given that there is little long-term follow-up on the experiences of NDP residents, we sought to determine how NDPs felt about their intern year in GS. DESIGN: A cross-sectional survey of all NDP GS interns from 1993 to 2018. SETTING: Academic, tertiary care center with a large GS residency program (Mayo Clinic, Rochester, MN). PARTICIPANTS: NDP GS interns (nâ¯=â¯151). RESULTS: Two-hundred and four surveys were emailed and 151 (62%) former NDP residents responded. Exposure to diverse pathology (85%), opportunity to work with experts (85%) and operative experience (72%) were the top 3 positive experiences from the NDP year. The uncertainty of being an NDP resident (78%) and experience compared to categorical counterparts (32%) were cited as the top 2 negative experiences. While 73% (nâ¯=â¯110) considered their NDP year to have laid a "strong" foundation for their future career, most respondents felt that the year was stressful and suggested improving mentoring and support for preliminary residents. Eighty-two percent (nâ¯=â¯124) of respondents stated that, they would be willing to redo their preliminary year. Fifty-four percent (nâ¯=â¯82) of respondents stated that they might have preferred a categorical position at a smaller institution versus a preliminary year. Forty percent of respondents (nâ¯=â¯60) reported fewer interviews and 24% (nâ¯=â¯36) reported a similar number of interviews offered when applying to the Match as a PGY1 prelim resident. CONCLUSIONS: Pursuing the NDP year is difficult, given the uncertainty that looms and the immense pressure to perform well. While the vast majority of our NDPs obtained categorical residency spots following their 1 year of training, feedback from this survey using 25 years of experience suggests that we can and should do more to mentor, support, and assist these residents.
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Cirurgia Geral , Internato e Residência , Estudos Transversais , Cirurgia Geral/educação , Humanos , Mentores , Inquéritos e Questionários , Centros de Atenção TerciáriaRESUMO
OBJECTIVE: With advancements in surgical equipment and procedures, human-system interactions in operating rooms affect surgeon workload and performance. Workload was measured across surgical specialties using surveys to identify potential predictors of high workload for future performance improvement. SUMMARY BACKGROUND DATA: Surgical instrumentation and technique advancements have implications for surgeon workload and human-systems interactions. To understand and improve the interaction of components in the work system, NASA-Task Load Index can measure workload across various fields. Baseline workload measurements provide a broad overview of the field and identify areas most in need of improvement. METHODS: Surgeons were administered a modified NASA-Task Load Index survey (0â=âlow, 20â=âhigh) following each procedure. Patient and procedural factors were retrieved retrospectively. RESULTS: Thirty-four surgeons (41% female) completed 662 surgery surveys (M = 14.85, SD = 7.94), of which 506 (76%) have associated patient and procedural data. Mental demand (M = 7.7, SD = 5.56), physical demand (M = 7.0, SD = 5.66), and effort (M = 7.8, SD = 5.77) were the highest rated workload subscales. Surgeons reported difficulty levels higher than expected for 22% of procedures, during which workload was significantly higher (P < 0.05) and procedural durations were significantly longer (P > 0.001). Surgeons reported poorer perceived performance during cases with unexpectedly high difficulty (P < 0.001). CONCLUSIONS: When procedural difficulty is greater than expected, there are negative implications for mental and physical demand that result in poorer perceived performance. Investigations are underway to identify patient and surgical variables associated with unexpected difficulty and high workload. Future efforts will focus on re-engineering the surgical planning process and procedural environment to optimize workload and performance for improved surgical care.
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Cirurgiões , Carga de Trabalho , Adulto , Feminino , Humanos , Pessoa de Meia-Idade , Minnesota , Estudos Prospectivos , Estudos Retrospectivos , Inquéritos e Questionários , Análise e Desempenho de Tarefas , Estados UnidosRESUMO
BACKGROUND: The aim of the study was to evaluate the outcomes of 100 consecutive patients undergoing reconstructive operation for enteric and colonic fistulas. These fistulas cause dramatic morbidity and profoundly diminish quality of life. Fistula takedown has been associated with high rates of recurrence. METHODS: Consecutive patients undergoing definitive fistula reconstruction by a single surgeon were reviewed retrospectively. Major adverse outcomes included bowel leak, fistula recurrence, death, total parenteral nutrition dependence, and incidence of new stomas. RESULTS: Among the 100 patients, median follow-up was 2.7 years. A total of 11 patients had postoperative leaks that evolved to 5 fistula recurrences. Of these patients 3 underwent successful secondary or tertiary takedown. The 30-day mortality rate was 1%, and the combined postoperative and fistula-related mortality rate at follow-up was 3%. New postoperative total parenteral nutrition dependence occurred in 2 patients (2%), and 9 (9%) had placement of a new stoma. Leaks were more frequent for patients who had a history of open abdomen than for patients who did not. CONCLUSIONS: With minimal patient selection and a methodic approach to evaluation and management, we achieved a 96% fistula-free survival rate. Few patients acquired new total parenteral nutrition dependence or a new stoma. These results compare favorably with outcomes published elsewhere.
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Colo/cirurgia , Doenças do Colo/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Fístula Intestinal/cirurgia , Intestino Delgado/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica , Doenças do Colo/mortalidade , Doenças do Colo/reabilitação , Procedimentos Cirúrgicos do Sistema Digestório/reabilitação , Procedimentos Cirúrgicos do Sistema Digestório/estatística & dados numéricos , Feminino , Seguimentos , Humanos , Fístula Intestinal/mortalidade , Fístula Intestinal/reabilitação , Masculino , Pessoa de Meia-Idade , Nutrição Parenteral Total/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/terapia , Recidiva , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Surgical stabilization of rib fractures (SSRF) can be used to improve pulmonary mechanics; however, hardware infection is a morbid complication. Antibiotic impregnated beads have been used to suppress infection in orthopedic practices. We aimed to determine the efficacy of antibiotic beads for infected and at-risk SSRF hardware. METHODS: This is a single institution retrospective review of adults (18 years or older) that received SSRF between 2009 and 2017. Infected and at-risk hardware were managed with antibiotic beads. The primary outcome was bony union of rib fractures. RESULTS: There were 285 SSRF patients. Infection rate was 3.5%. Antibiotic beads were placed in 17 patients - 9 for infected hardware and 8 for prophylaxis. Increased body mass index (pâ¯=â¯0.04) and hemorrhagic shock at admission (pâ¯=â¯0.03) were risk factors for infection. There was 100% bony union post-operatively. CONCLUSION: SSRF hardware infection is morbid. Antibiotic beads can salvage SSRF hardware until bony union.
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Antibacterianos/administração & dosagem , Fixação Interna de Fraturas/instrumentação , Fixadores Internos/efeitos adversos , Infecções Relacionadas à Prótese/tratamento farmacológico , Fraturas das Costelas/cirurgia , Terapia de Salvação/métodos , Infecção da Ferida Cirúrgica/tratamento farmacológico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Feminino , Seguimentos , Humanos , Fixadores Internos/microbiologia , Masculino , Pessoa de Meia-Idade , Infecções Relacionadas à Prótese/diagnóstico , Infecções Relacionadas à Prótese/epidemiologia , Infecções Relacionadas à Prótese/prevenção & controle , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/diagnóstico , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/prevenção & controle , Resultado do Tratamento , Adulto JovemRESUMO
INTRODUCTION: Hospital discharge instructions provide critical information necessary for patients to manage their own care; however, often they are written at a substantially higher readability level than recommended (ie, 6th-grade level) by the American Medical Association and the National Institutes of Health. We hypothesize that improving the reading level of discharge instructions will decrease the number of patient telephone calls and readmissions in the posthospital setting. METHODS: We conducted a prospective observational study. Patient discharge instructions were edited and incorporated to enhance the readability level in August 2015. Return telephone call and readmissions of patients admitted before the intervention from August 1, 2014, to January 31, 2015, were compared with the prospective cohort studied from September 1, 2015, to September 30, 2016. RESULTS: A total of 1,072 patients were included (preintervention: nâ¯=â¯493, postintervention: nâ¯=â¯579). Patient demographics, injury characteristics, and education level were similar among both groups. The median discharge instruction readability level in the postintervention group was significantly lower (10.0, 95% CI 10.0-10.2 vs 8.6, 95% CI 8.8-8.9; P < .0001). The proportion of patients calling after hospital discharge was significantly reduced after the intervention (21.9% vs 9.0%; P < .0001). Monthly hospital readmissions were decreased by 50% for every 100 patients discharged after the intervention (1.9% vs 0.9%; Pâ¯=â¯.002). The proportion of patients calling and readmissions for poor pain control significantly decreased after the intervention (7.1% vs 2.59%; Pâ¯=â¯.0005 and 2.8% vs 1.0%; Pâ¯=â¯.029, respectively). CONCLUSION: Enhanced readability of discharge instructions was associated with a decrease in the number of telephone calls and readmissions in the posthospital setting, enhancing health literacy and simultaneously reducing the burden on providers. Improved patient instructions written to an appropriate level may also allow for better pain control in the posthospital setting.
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Compreensão , Alta do Paciente , Readmissão do Paciente , Telefone , Adulto , Idoso , Feminino , Pessoal de Saúde , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
OBJECTIVE: Faculty evaluations, ABSITE scores, and operative case volumes often tell little about true resident performance. We developed an objective structured clinical examination called the Surgical X-Games (5 rooms, 15 minutes each, 12-15 tests total, different for each postgraduate [PGY] level). We hypothesized that performance in X-Games will prove more useful in identifying areas of strength or weakness among general surgery (GS) residents than faculty evaluations, ABSITE scores, or operative cases volumes. DESIGN: PGY 2 to 5 GS residents (n = 35) were tested in a semiannual X-Games assessment using multiple simulation tasks: laparoscopic skills, bowel anastomosis, CT/CXR analysis, chest tube placement, etc. over 1 academic year. Resident scores were compared to their ABSITE, in-training evaluation reports, and operating room case numbers. SETTING: Academic medical center. PARTICIPANTS: PGY-2, 3, 4, and 5 GS residents at Mayo Clinic in Rochester, MN. RESULTS: Results varied greatly within each class except for staff evaluations: in-training evaluation reports medians for PGY-2s were 5.3 (range: 5.0-6.0), PGY-3s 5.9 (5.5-6.3), PGY-4s 5.6 (5.0-6.0), and PGY-5s were 6.1 (5.6-6.9). Although ABSITE and operating room case volumes fluctated greatly with each PGY class, only X-Games scores (median: PGY-2 = 82, PGY-3 = 61, PGY-4 = 76, and PGY-5 = 60) correlated positively (p < 0.05) with operative case volume and negatively (p < 0.05) with staff evaluations. CONCLUSIONS: X-Games assessment generated wide differentiation of resident performance quickly, inexpensively, and objectively. Although "Minnesota-nice" surgical staff may feel all GS trainees are "above average," objective assessment tells us otherwise.
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Competência Clínica , Cirurgia Geral/educação , Internato e Residência/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Correlação de DadosRESUMO
OBJECTIVE: To assess if the Accreditation Council for Graduate Medical Education (ACGME) case log system accurately captures operative experience of our postgraduate year 1 (PGY-1) residents. DESIGN: ACGME case log information was retrospectively obtained for 5 cohorts of PGY-1 residents (2011-2015) and compared to the number of operative cases captured by an institutional automated operative case report system, Surgical Access Utility System (SAUS). SAUS automatically captures all surgical team members who are listed in the operative dictation for a given case, including interns. A paired t-test analysis was used to compare number of cases coded between the 2 systems. SETTING: Academic, tertiary care referral center with a large general surgery training program. PARTICIPANTS: PGY-1 general surgery trainees (interns) from the years 2011-2015. RESULTS: Forty-nine PGY-1 general surgery residents were identified over a 5-year period. Mean operative case volume per intern, per year, captured by the automated SAUS was 176.5 ± 28.1 (SD) compared to 126.3 ± 58.0 ACGME cases logged (mean difference = 50.2 cases, p < 0.001). CONCLUSIONS: ACGME case log data may not accurately reflect the actual operative experience of our PGY-1 residents. If such data holds true for other general surgery training programs, the true impact of duty hour regulations on operative volume may be unclear when using the ACGME case log data. This current standard approach for using ACGME case logs as a representation of operative experience requires further scrutiny and potential revision to more accurately determine operative experience for accreditation purposes.
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Competência Clínica , Cirurgia Geral/educação , Internato e Residência/estatística & dados numéricos , Sistemas Computadorizados de Registros Médicos/normas , Carga de Trabalho/estatística & dados numéricos , Centros Médicos Acadêmicos/organização & administração , Acreditação , Adulto , Bases de Dados Factuais , Educação de Pós-Graduação em Medicina/estatística & dados numéricos , Feminino , Cirurgia Geral/estatística & dados numéricos , Humanos , Masculino , Controle de Qualidade , Estudos Retrospectivos , Sociedades Médicas/normas , Estados UnidosRESUMO
OBJECTIVE: To compare objective assessment scores between international medical graduates (IMGs) and United States Medical Graduates. Scores of residents who completed a preliminary year, who later matched into a categorical position, were compared to those who matched directly into a categorical position at the Mayo Clinic, Rochester. DESIGN: Postgraduate year (PGY) 1 to 5 residents participate in a biannual multistation, OSCE-style assessment event as part of our surgical training program. Assessment data were, retrospectively, reviewed and analyzed from 2008 to 2016 for PGY-1 and from 2013 to 2016 for PGY 2 to 5 categorical residents. SETTING: Academic medical center. PARTICIPANTS: Categorical PGY 1 to 5 General Surgery (GS) residents at Mayo Clinic Rochester, MN. RESULTS: A total of 86 GS residents were identified. Twenty-one residents (1 United States Medical Graduates [USMG] and 20 IMGs) completed a preliminary GS year, before matching into a categorical position and 68 (58 USMGs and 10 IMGs) residents, who matched directly into a categorical position, were compared. Mean scores (%) for the summer and winter multistation assessments were higher for PGY-1 trainees with a preliminary year than those without (summer: 59 vs. 37, p < 0.001; winter: 69 vs. 61, p = 0.05). Summer and winter PGY-2 scores followed the same pattern (74 vs. 64, p < 0.01; 85 vs. 71, p < 0.01). For the PGY 3 to 5 assessments, differences in scores between these groups were not observed. IMGs and USMGs scored equivalently on all assessments. Overall, junior residents showed greater score improvement between tests than their senior colleagues (mean score increase: PGY 1-2 = 18 vs. PGY 3-5 = 3, p < 0.001). CONCLUSIONS: Residents with a previous preliminary GS year at our institution scored higher on initial assessments compared to trainees with no prior GS training at our institution. The scoring advantage of an added preliminary year decreased as trainees progressed through residency.
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Competência Clínica , Educação de Pós-Graduação em Medicina/métodos , Médicos Graduados Estrangeiros/educação , Cirurgia Geral/educação , Internato e Residência/métodos , Centros Médicos Acadêmicos , Estudos de Coortes , Avaliação Educacional , Feminino , Humanos , Masculino , Estudos Retrospectivos , Treinamento por Simulação/métodos , Estados UnidosRESUMO
OBJECTIVE: To create a novel "at-home" preresidency preparatory adjunct for medical students entering surgical residency. DESIGN: Preparatory resources were mailed to match medical students before residency matriculation in 2015. This included "how-to" videos, low-cost models, and surgical instruments for 5 "stations" (arterial blood gas analysis, anatomy and imaging knowledge, knot tying ability, and suturing dexterity) of our program's biannual general surgery intern objective assessment activity (Surgical Olympics: total 13 stations, 10 points each). Scores from 2015 were compared with 2014 historical controls in a retrospective manner using the Student's t-test. SETTING: Academic, tertiary care referral center with a large general surgery training program. PARTICIPANTS: Postgraduate year 1 general surgery trainees (interns) from the years 2014 and 2015. RESULTS: Twenty-six interns participated in the 2015 assessment and were compared to thirty-two 2014 interns. Overall mean scores were low, but higher (19.7 vs. 15.4, p = 0.04) in the 2015 class. The largest increase was noted in the anatomy knowledge station (mean = 5.0 vs. 1.9, p < 0.01). Scores in stations assessing technical competence were similar to controls. The number of perfect scores among the 5 stations was higher (10 vs. 5) in the 2015 group. Mean scores from the other 8 stations, for which no resources were mailed, showed no difference (29.3 vs. 28.3, p = 0.75). CONCLUSIONS: Enacting a simple, home-based curriculum for medical students before surgical residency, improved performance on early knowledge assessments.
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Escolha da Profissão , Competência Clínica , Educação a Distância/métodos , Cirurgia Geral/educação , Internato e Residência/métodos , Estudantes de Medicina , Centros Médicos Acadêmicos , Adulto , Currículo , Avaliação Educacional , Feminino , Humanos , Masculino , Projetos Piloto , Estudos Retrospectivos , Gravação em VídeoAssuntos
Anfotericina B/farmacologia , Dissecção Aórtica/cirurgia , Isquemia Mesentérica/cirurgia , Mucormicose/terapia , Polimetil Metacrilato , Infecções dos Tecidos Moles/terapia , Dissecção Aórtica/complicações , Dissecção Aórtica/diagnóstico por imagem , Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Progressão da Doença , Evolução Fatal , Feminino , Humanos , Síndrome de Marfan/complicações , Síndrome de Marfan/cirurgia , Isquemia Mesentérica/etiologia , Pessoa de Meia-Idade , Mucormicose/etiologia , Insuficiência de Múltiplos Órgãos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/terapia , Medição de Risco , Infecções dos Tecidos Moles/etiologiaRESUMO
BACKGROUND: Tube thoracostomy (TT) can be an effective therapy for thoracic pathologies. Ineffective placement of TT is common and associated with significant complications. Complications require additional interventions to repair damaged tissues or replace dysfunctional TT. We hypothesize that complicated TT insertion increases cost to the hospital system. METHODS: Adult trauma patients requiring TT at a level 1 trauma center (2012-2013) were reviewed. Intraoperative or image-guided TT placements were excluded. Baseline demographics and TT insertion cost (normalized and assigned by hospital billing records) were recorded. Costs included initial TT equipment, radiographs, and subsequent operative or radiologic intervention to correct TT complications. Complications were categorized using previously validated method. Secondary outcomes included: number of TT inserted, number of chest radiographs performed, and TT dwell time utilizing a standardized TT discontinuation protocol. RESULTS: A total of 154 patients with 246 TT were included. Ninety TT (37%) had complication. Complication categories are postremoval (n = 15, 16.7%), insertional (n = 13, 14.4%), positional (n = 62, 68.9%). Overall median complicated TT cost was 9 times greater than uncomplicated TT insertion, p = 0.001. Insertional complications median cost 21 times greater than an uncomplicated, due to operative and radiologic interventions (p = 0.0001). Positional and postremoval complication rates increased median cost by 3 times compared to uncomplicated TT (p = 0.03). Operative or radiologic interventions (n = 10) were performed for organ injury or uncontrolled hemo-/pneumothorax. Increased dwell time median [IQR] was associated with complicated TT compared to uncomplicated 3 [1-5] versus 2 [1-3], p = 0.01. CONCLUSION: TT is a common procedure. TT complications are often considered benign. However, patients with a complicated TT insertion, especially related to insertional subtypes, have markedly increased hospitalization costs due to need for operative or radiologic repair. LEVEL OF EVIDENCE: Level V-retrospective study. STUDY TYPE: This is a retrospective single-institution study.
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Custos Diretos de Serviços , Complicações Intraoperatórias/economia , Complicações Pós-Operatórias/economia , Toracostomia/economia , Adulto , Idoso , Tubos Torácicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pneumotórax/etiologia , Radiografia Torácica/economia , Análise de Regressão , Estudos Retrospectivos , Toracostomia/efeitos adversos , Centros de TraumatologiaAssuntos
Apendicite/diagnóstico , Calcinose/cirurgia , Doenças do Íleo/diagnóstico , Dor Abdominal/diagnóstico , Dor Abdominal/etiologia , Anastomose Cirúrgica/métodos , Apendicite/cirurgia , Calcinose/diagnóstico , Ceco/cirurgia , Diagnóstico Diferencial , Feminino , Humanos , Doenças do Íleo/cirurgia , Exame Físico/métodos , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento , Adulto JovemRESUMO
OBJECTIVE: A nondesignated preliminary surgery (NDPS) position encompasses 1 year of training provided by many general surgery residencies. Our aim was to assess factors predicting success and provide evidence for program directors to support career guidance to preliminary residents. METHODS: Retrospective cohort study of 221 NDPS residents who entered 5 university-based institutions were identified from 2009 to 2013. Records for trainees were reviewed. We defined primary success as obtaining a categorical position in the specialty of choice and secondary success as obtaining a categorical position in any specialty immediately after finishing their NDPS training. Statistical evaluation was performed using chi-square analysis, independent t-test and logistic regression using α <0.05. RESULTS: Of the 221 NDPS residents, 217 (98%) completed postgraduate year (PGY)-1 and 65 (29%) completed PGY-2. Totally, 90 (41%) obtained categorical general surgery positions, 89 (40%) obtained categorical positions in other specialties, and 42 (19%) failed to obtain a categorical position immediately after their NDPS years. Ultimately, 139 (63%) of residents achieved primary success and 40 (18%) additional residents obtained categorical positions in specialties other than their first choice, resulting in a total of 179 (81%) of residents obtaining categorical positions. Mean United States Medical Licensing Examination step 1 and step 2 scores for those who obtained secondary success were 227 and 234 vs. 214 and 219, respectively, for those who failed to secure a categorical position (p < 0.01). United States Medical Licensing Examination step 2 score was a significant predictor of primary (p < 0.03) and secondary success (p < 0.02). Of 65 PGY-2 NDPS residents, 32 (49%) achieved primary success, and 11 (17%) others achieved secondary success for a total of 43 (66%). For PGY-2 NDPS, American Board of Surgery In-Training Examination was the only significant predictor of primary and secondary success (p < 0.02 and p < 0.05). CONCLUSIONS: NDPS training provides a viable and successful opportunity for at least 81% of young physicians to pursue their career goals even after an unsuccessful first match.
Assuntos
Sucesso Acadêmico , Competência Clínica , Cirurgia Geral/educação , Internato e Residência/métodos , Centros Médicos Acadêmicos , Adulto , Área Sob a Curva , Estudos de Coortes , Educação de Pós-Graduação em Medicina/métodos , Feminino , Humanos , Masculino , Valor Preditivo dos Testes , Estudos Retrospectivos , Especialidades Cirúrgicas/estatística & dados numéricos , Estados UnidosRESUMO
PURPOSE: Data on laparoscopic totally extraperitoneal inguinal hernia repairs (TEP-IHRs) suggest that approximately 250 operations are needed to gain mastery, but the annual volume required to maintain high-quality outcomes is unknown. MATERIALS AND METHODS: A retrospective review was performed of every patient undergoing a TEP-IHR at the Mayo Clinic (Rochester, MN) from 1995 to 2011. Analysis focused on the annual volume of 21 staff surgeons and their specific patient outcomes broken up into three groups: Group 1 (G1) (n = 1 surgeon) performed >30 repairs per year; Group 2 (G2) (n = 3 surgeons), 15-30 repairs; and Group 3 (G3) (n = 17), <15 repairs. RESULTS: In total, 1601 patients underwent 2410 TEP-IHRs, with no significant patient demographic differences among groups. Greater annual surgeon volume (G1 > G2 > G3) was associated with improved outcomes as shown by the respective rates for intra- (1%, 2.6%, and 5.6%) and postoperative (13%, 27%, and 36%) complications, need for overnight stay (17%, 23%, and 29%), and hernia recurrence (1%, 4%, and 4.3%) (all P < .05). Surgeons with greater annual operative volumes were more likely to operate on patients with bilateral and recurrent hernias. Surgeons performing at least 15 repairs per year (G1 and G2) showed improvements in quality metrics over time. CONCLUSIONS: Annual operative volumes of >30 repairs per year are associated with the highest quality outcomes for TEP-IHR. Operative volumes of at least 15 repairs per year are associated with improvements in quality metrics over time. Mentorship and operative assistance of low-volume TEP-IHR surgeons may be useful in improving patient outcomes.