Body Mass Index, Genetic Susceptibility, and Risk of Complications Among Individuals with Crohn's Disease.

BACKGROUND: Obesity is associated with systemic and intestine-specific inflammation and alterations in gut microbiota, which in turn impact mucosal immunity. Nonetheless, a specific role of obesity and its interaction with genetics in the progression of Crohn's disease (CD) is unclear. METHODS: We conducted a cross-sectional study of patients with CD enrolled in Prospective Registry in Inflammatory Bowel Disease Study at Massachusetts General Hospital (PRISM). Information on diagnosis of CD and its complications were collected and confirmed through review of medical records. A genetic risk score was calculated using previously reported single-nucleotide polymorphisms-associated genome-wide with CD susceptibility. We used logistic regression to estimate the effect of body mass index (BMI) and its interaction with genetic risk on risk of CD complications. RESULTS: Among 846 patients with CD, 350 required surgery, 242 with penetrating disease, 182 with stricturing disease, and 226 with perianal disease. There were no associations between obesity (BMI ≥ 30 kg/m2) and risk of perianal disease, stricturing disease, or surgery. Compared with normal-weight individuals with BMI < 25 kg/m2, obesity was associated with lower risk of penetrating disease (odds ratio [OR = 0.56; 95% confidence interval [CI], 0.31-0.99). This association persists among a subgroup of participants with available BMI before development of penetrating disease (OR = 0.40; 95% CI, 0.16-0.88). There were no interactions between BMI and genetic risk score on risk of CD complications (all P interaction > 0.28). CONCLUSIONS: Our data suggest that obesity does not negatively impact long-term progression of CD, even after accounting for genetic predisposition.

Innovation or rebranding, acute care surgery diffusion will continue.

BACKGROUND: Patterns of adoption of acute care surgery (ACS) as a strategy for emergency general surgery (EGS) care are unknown. METHODS: We conducted a qualitative study comprising face-to-face interviews with senior surgeons responsible for ACS at 18 teaching hospitals chosen to ensure diversity of opinions and practice environment (three practice types [community, public or charity, and university] in each of six geographic regions [Mid-Atlantic, Midwest, New England, Northeast, South, and West]). Interviews were recorded, transcribed, and analyzed using NVivo (QSR International, Melbourne, Australia). We applied the methods of investigator triangulation using an inductive approach to develop a final taxonomy of codes organized by themes related to respondents' views on the future of ACS as a strategy for EGS. We applied our findings to a conceptual model on diffusion of innovation. RESULTS: We found a paradox between ACS viewed as a health care delivery innovation versus a rebranding of comprehensive general surgery. Optimism for the future of ACS because of increased desirability for trauma and critical care careers as well as improved EGS outcomes was tempered by fear over lack of continuity, poor institutional resources, and uncertainty regarding financial viability. Our analysis suggests that the implementation of ACS, whether a true health care delivery innovation or an innovative rebranding, fits into the Rogers' diffusion of innovation theory. CONCLUSIONS: Despite concerns over resource allocation and the definition of the specialty, from the perspective of senior surgeons deeply entrenched in executing this care delivery model, ACS represents the new face of general surgery that will likely continue to diffuse from these early adopters.

A qualitative analysis of acute care surgery in the United States: it's more than just "a competent surgeon with a sharp knife and a willing attitude".

BACKGROUND: Since acute care surgery (ACS) was conceptualized a decade ago, the specialty has been adopted widely; however, little is known about the structure and function of ACS teams. METHODS: We conducted 18 open-ended interviews with ACS leaders (representing geographic [New England, Northeast, Mid-Atlantic, South, West, Midwest] and practice [Public/Charity, Community, University] diversity). Two independent reviewers analyzed transcribed interviews using an inductive approach (NVivo qualitative analysis software). RESULTS: All respondents described ACS as a specialty treating "time-sensitive surgical disease" including trauma, emergency general surgery (EGS), and surgical critical care (SCC); 11 of 18 combined trauma and EGS into a single clinical team; 9 of 18 included elective general surgery. Emergency orthopedics, emergency neurosurgery, and surgical subspecialty triage were rare (1/18 each). Eight of 18 ACS teams had scheduled EGS operating room time. All had a core group of trauma and SCC surgeons; 13 of 18 shared EGS due to volume, human resources, or competition for revenue. Only 12 of 18 had formal signout rounds; only 2 of 18 had prospective EGS data registries. Streamlined access to EGS, evidence-based protocols, and improved education were considered strengths of ACS. ACS was described as the "last great surgical service" reinvigorated to provide "timely," cost-effective EGS by experts in "resuscitation and critical care" and to attract "young, talented, eager surgeons" to trauma/SCC; however, there was concern that ACS might become the "wastebasket for everything that happens at inconvenient times." CONCLUSION: Despite rapid adoption of ACS, its implementation varies widely. Standardization of scope of practice, continuity of care, and registry development may improve EGS outcomes and allow the specialty to thrive.

Utilization of morning report by acute care surgery teams: results from a qualitative study.

BACKGROUND: The rigor of handoffs is increasingly scrutinized in the era of shift-based patient care. Acute care surgery (ACS) embraced such a model of care; however, little is known about handoffs in ACS programs. METHODS: Eighteen open-ended interviews were conducted with ACS leaders representing diverse geographic and practice settings. Two independent reviewers analyzed interviews using an inductive approach to elucidate themes regarding use of morning report (using NVivo qualitative analysis software). RESULTS: Twelve of 18 respondents reported using morning report, but only 6 of 12 included attending surgeon-to-attending surgeon handoffs. One of 12 incentivized attending surgeons to participate, 2 of 12 included nursing staff members, and 2 of 12 included physician extenders. Cited benefits of morning report were safe and effective information exchange (2 of 12), quality improvement (2 of 12), multidisciplinary discussion (1 of 12), and resident education (2 of 12). Three of 12 respondents cited time commitment as the main limitation of morning report. CONCLUSIONS: Morning report is underused among ACS programs; however, if implemented strategically, it may improve patient care and resident education.