Effects of oropharyngeal administration of own mother's milk on oral microbial colonization in very low birth weight infants fed by gastric tube: A randomized controlled trial.

AIMS: The aim of the present study was to explore the effect of oropharyngeal mother's milk administration on oral microbial colonization in infants fed by gastric tube at different time points. METHODS: Infants (n = 116) with birth weight <1500 g were randomly allocated into two groups which both received breast milk for enteral nutrition. The control group (n = 51) accepted oropharyngeal normal saline administration. The experimental group (n = 53) accepted oropharyngeal mother's milk administration before fed by gastric tube once every 3 h over 21 days after birth. We analyzed the oral microbiota at initiation and 7 and 14 and 21 days later using 16S DNA amplicon sequencing. RESULTS: There were no difference in oral microbial diversity between the two groups at any time point, but diversity decreased significantly over time in both groups. On the first day of life, the oral microbiota of the infant in the experimental and control groups consisted mainly of Firmicutes (7.75%, 6.18%) and Proteobacteria (68.65%, 68.69%), respectively. As time increases to 21 days after birth, Firmicutes (77.67%, 77.66%) had replaced Proteobacteria (68.65%, 68.69%) as the predominant phylum. DISCUSSION: From birth to 21 days after birth, oropharyngeal mother's milk administration did not change the diversity and structural composition of the oral microbiota. The oral microbial diversity of infants declined significantly over time. Firmicutes had replaced Proteobacteria as the predominant phylum.

Poor accessibility to consumer pricing exists for elective hernia repair surgery.

BACKGROUND: Hospital price transparency is federally mandated to improve consumer accessibility. We aimed to evaluate how hospitals were complying with these regulations for elective hernia repairs. METHODS: Searches were performed for different hospital systems in attempt to find a price for the procedure using author's own health insurance. Data collected included time to reach the cost estimate tool, time to obtain price estimates, and price ranges. With prices for inguinal and ventral hernia repairs varying across the state's medical centers. RESULTS: Fourteen medical centers across the country were included, all had a cost estimate calculator. The average success rate of obtaining a cost for inguinal hernia was 48%. Comparatively, the average success rate of obtaining a cost for ventral hernia was 12%. Of the successful searches for price, significant variation exists amongst the accessed hernia procedure cost. CONCLUSION: Despite federal mandates for hospital price transparency, online cost-estimate calculators are underperforming, thus exposing a need for more accessible cost-estimates for patients undergoing elective hernia repair.

Assessment of Conflicts of Interest in the Transcarotid Artery Revascularization Literature.

INTRODUCTION: To systematically review the accuracy of self-reported conflicts of interest (COIs) among transcarotid artery revascularization (TCAR) studies and evaluate factors associated with increased discrepancies. MATERIALS AND METHODS: A literature search identified all TCAR-related studies with at least one American author published between January 2017 and December 2020. Industry payments from Silk Road Medical, Inc. were collected using the Centers for Medicare and Medicaid Open Payments database. COI discrepancies were identified by comparing author declaration statements with payments found for the year of publication and year prior (24-mo period). Risk factors for COI discrepancy were evaluated at both the study and author level. RESULTS: A total of 79 studies (472 authors) were identified. Sixty four studies (81%) had at least one author who received payments from Silk Road Medical, Inc. Fifty eight (73%) studies had at least one author who received an undeclared payment. Consulting fees represented the majority of general payment subtype (60%). Authors who accurately disclosed payments received significantly higher median payments compared to authors who did not accurately disclose payments ($37,222 [interquartile range: $28,203-$132,589] versus $1748 [interquartile range $257-$35,041], P < 0.0001). Senior authors were significantly more likely to have a COI discrepancy compared to first authors (P = 0.0219). CONCLUSIONS: The majority of TCAR-related studies did not accurately declare COI. A multivariate analysis demonstrated no effect of sponsorship on study recommendations or impact factor. This study highlights the need for increased efforts in accountability to improve the transparency of industry sponsorship, especially when consulting authors are reporting their results on patient outcomes.

Oropharyngeal administration of mother's own milk influences levels of salivary sIgA in preterm infants fed by gastric tube.

The aim of the present study was to explore the effect of oropharyngeal mother's milk administration on salivary secretory immunoglobulin A (sIgA) levels in preterm infants fed by gastric tube. Infants (n = 130) with birth weight < 1500 g were randomly allocated into two groups which both received breast milk for enteral nutrition. The experimental group (n = 65) accepted oropharyngeal mother's milk administration before gastric tube feeding for 14 days after birth. The control group (n = 65) accepted oropharyngeal 0.9% normal saline administration. Saliva concentration of sIgA were assessed at the 2 h, 7th and 14th day after birth. The level of salivary sIgA in experimental group were significantly higher than those in control group on the 7th day after birth (p < 0.05), but there were no differences in salivary sIgA levels on the 14th day between the two groups. The results of quantile regression analysis showed that oropharyngeal mother's milk administration, delivery mode and gestational age had significant effects on the increase of sIgA. SIgA in experimental group and the total number of intervention had a significant positive correlation (p < 0.05). Oropharyngeal mother's milk administration can improve salivary sIgA levels of preterm infants.

Conflicts of Interest in Studies Related to Mesh Use in Ventral Hernia Repair and Abdominal Wall Reconstruction.

OBJECTIVE: To examine the accuracy of the reporting of conflicts of interest (COI) among studies related to mesh use in ventral hernia repair and abdominal wall reconstruction. SUMMARY BACKGROUND DATA: Accurate declaration of COI is integral to ensuring transparency of study results. Multiple studies have demonstrated undeclared COI are prevalent in surgical literature. METHODS: Studies with at least 1 American author accepted between 2014 and 2018 in 12 major, peer-reviewed general surgery and plastic surgery journals were included. Declared COI were compared with payments listed in the "Open Payments" database [maintained by the Centers for Medicare & Medicaid Services (CMS)] during the year of acceptance and 1 year prior. Studies and authors were considered to have a COI if they received payments from any of 8 major mesh companies totaling >$100.00 from each company. Risk factors for undeclared COI were determined at the study and author levels. RESULTS: One hundred twenty-six studies (553 authors) were included. One hundred two studies (81.0%) had one or more authors who received payments from industry and inaccurately declared their COI. Two hundred forty-eight authors (44.8%) did not declare their COI accurately. On multivariate analysis, last authors were found to be at highest risk for undeclared payments (OR 3.59, 95%CI 2.02-6.20), whereas middle authors were at significantly higher risk for undeclared payments than first authors (OR 1.64, 95%CI 1.04-2.56). CONCLUSIONS: The majority of studies investigating the use of mesh in ventral hernia repairs and abdominal wall reconstructions did not accurately declare COI. Last authors are at highest risk of undisclosed payments. Current policies on disclosing COI seem to be insufficient to ensure transparency of publications.

The prevalence of asymptomatic carriers of COVID-19 as determined by routine preoperative testing.

BACKGROUND: The coronavirus disease SARS-CoV-2 (COVID-19) has swiftly spread throughout the globe, greatly influencing all aspects of life. As in previous pandemics, concerns for limited resources and a sustainable medical workforce have been on the forefront of infrastructure modifications. Consequently, surgical specialties have needed to consider each surgical case for necessity and safety during the COVID-19 outbreak. At our institution, availability of SARS-CoV-2 assay has allowed preoperative testing of asymptomatic surgical patients. AIM/OBJECTIVE: To better define the prevalence of asymptomatic carriers in a surgical population and to better understand the impact of testing on our personal protective equipment (PPE) supply. METHODS: We began routine, preoperative testing for all asymptomatic patients coming to our academic medical centre on 30 March 2020. Scheduled surgeries were deemed urgent by the surgeon with a review for appropriateness by a novel surgical committee. A retrospective patient chart review was performed. Emergency surgeries were excluded. Asymptomatic patients with positive test results had their surgeries rescheduled at the discretion of the surgeon and patient. Patients who tested negative underwent surgery with staff using standard PPE. RESULTS: Eighty-four asymptomatic surgical patients were tested preoperatively with three (3.6%) testing positive for SARS-CoV-2. Preoperative testing saved 498 N95 respirators over this time period. DISCUSSION: This is the first report of routine COVID-19 preoperative testing in an asymptomatic surgical population. Within this population, there is a 3.6% rate of asymptomatic SARS-CoV-2 carriers. Through this practice, personnel exposure can be minimised and access to PPE can be preserved.

Laparoscopic Lavage in the Management of Hinchey III/IV Diverticulitis.

Diverticulitis manifestations may cover a spectrum of mild local inflammation to diffuse feculent peritonitis. Up to 35% of patients presenting with diverticulitis will have purulent (Hinchey grade III) or feculent (Hinchey grade IV) contamination of the abdomen, with a high-associated morbidity and mortality. Surgical management may involve segmental resection with or without restoration of bowel continuity. However, emergency resection for diverticulitis can be associated with high mortality rates, as well as low stoma reversal rates at 1 year. Therefore, laparoscopic peritoneal lavage has been proposed for use in selected patients with purulent peritonitis. The topic of laparoscopic peritoneal lavage for the treatment of perforated diverticulitis in the literature has been controversial. Our review of the recent data show that laparoscopic lavage may be safe and feasible in select patients with similar rates of mortality and major morbidity. There is, however, a concern regarding an associated higher rate of postoperative abscess and early reintervention risk.

Assessment of Conflicts of Interest in Studies of Breast Implants and Breast Implant Mesh.

BACKGROUND: With increased collaboration between surgeons and industry, there has been a push towards improving transparency of conflicts of interest (COI). METHODS: A literature search identified all articles published between 2016 - 2018 involving breast implants/implantable mesh from three major United States plastic surgery journals. Industry payment data from 8 breast implant/implantable mesh companies was collected using the CMS Open Payments database. COI discrepancies were identified by comparing author declaration statements with payments >$100.00 found for the year of publication and year prior. Risk factors for discrepancy were determined at study and author levels. RESULTS: A total of 162 studies (548 authors) were identified. 126 (78%) studies had at least one author receive undisclosed payments. 295 (54%) authors received undisclosed payments. Comparative studies were significantly more likely to have COI discrepancy than non- comparative studies (83% vs 69%, p < 0.05). Multivariate analysis showed no association between COI discrepancy and final product recommendation. Authors who accurately disclosed payments received higher payments compared to authors who did not accurately disclose payments (median $40,349 IQR 7278-190,413 vs median $1300 IQR 429-11,1544, p <0.001). CONCLUSIONS: The majority of breast implant-based studies had undisclosed COIs. Comparative studies were more likely to have COI discrepancy. Authors who accurately disclosed COIs received higher payments than authors with discrepancies. This study highlights the need for increased efforts to improve the transparency of industry sponsorship for breast implant-based studies.

The MBA in Medical Education: Current MD/MBA Student Aspirations, Perceptions, and Motivations.

BACKGROUND: As combined Doctor of Medicine and Master of Business Administration (MD/MBA) programs gain popularity, it is critical to understand the motives, perceptions, and interests of MD/MBA students. The purpose of this study was to investigate career aspirations of MD/MBA students, skills they perceive to gain from the dual degree, and reasons why students enroll in MD/MBA programs. MATERIALS AND METHODS: All 73 MD/MBA programs in the United States were invited to participate in a twelve-question, online survey. Responses were collected between August 2019 and February 2020 from students enrolled during the 2019-2020 academic year. The questions were designed to examine career aspirations, program perceptions, and personal motivations. Data were aggregated into descriptive summary statistics and rank orders. RESULTS: A total of 18 MD/MBA programs agreed to participate in this study, of which 14 met criteria for final analysis. From these programs, 67 of 175 students responded (38%). Among respondents, 100% planned to pursue residency. The most common career interests included the following: clinical practice at an academic hospital (85%), executive leadership in a hospital network (76%), and clinical practice in a community hospital (65%). Students ranked "making a broader impact on health care" and "pursuing leadership in clinical practice" highest among reasons to pursue an MD/MBA. Students reported high rates of acquiring MBA-oriented skills. CONCLUSIONS: MD/MBA students in this study focused on pursuing clinical careers. Students appear satisfied with their education, reporting high rates of skill acquisition. Residency programs interested in MD/MBA students can incorporate leadership and entrepreneurial opportunities to foster students' broad interests.

Closed Incision Negative Pressure Therapy: Indications and Adherence to Protocol.

BACKGROUND: Complications associated with wound management not only increase the morbidity and mortality of surgical interventions but they also increase the cost and decrease the quality of care. Closed incision negative pressure therapy (CINPT) has been proposed as a superior method of wound care compared to the more traditional wound management methods. Since the Food and Drug Administration indications for using CINPT are broad and generally nonspecific, it is unclear whether patients are appropriately screened for and receive this treatment modality. MATERIAL AND METHODS: To identify common clinical indications for CINPT, we conducted a literature review to define a consensus for CINPT candidates and used the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to indicate if certain patient demographics impact decision-making. RESULTS: Based on the literature review, encompassing 57 articles, and the National Surgical Quality Improvement Program (NSQIP) database, over 11,000 patients received CINPT. Both the NSQIP data and the literature review commonly reported BMI >30 (47.1% and 39.6%), smoking (22.7% and 29.2%), and diabetes mellitus (22.7% and 47.9) as the most common clinical indications for using CINPT. DISCUSSION: The most common indications for using CINPT according to the literature review and the NSQIP database are BMI > 30, smoking status, and diabetes mellitus. Besides identifying patients who potentially benefit the most from CINPT, the results of this study suggest clinical adherence to the practice guidelines reported in the literature regarding wound management using this treatment modality.

The Adoption of Oncoplastic Surgery Using Breast Reduction or Mastopexy Techniques in an Academic Breast Cancer Center Program Can Increase Breast Conservation Rates.

BACKGROUND: Interest in oncoplastic surgery (OPS), a form of breast conservation surgery (BCS), has grown in the United States over the last decade. Oncoplastic surgery allows for the removal of larger tumors without compromising esthetic outcome or oncologic safety. One of the quality measures on which breast cancer centers in the United States are evaluated is rate of BCS. The purpose of this study was to investigate whether the adoption of OPS increases BCS rates and decreases mastectomy rates at the institutional level. METHODS: Clinicopathologic data were retrospectively collected for breast cancer patients in a single institution database. Rates of BCS vs mastectomy and partial mastectomy versus OPS were measured between 2012 and 2018 to capture 3 years before and 3 years after the hiring of an oncoplastic surgeon in 2015 with subsequent practice adoption of oncoplastic techniques. We compared the 2 periods using χ and Fisher exact test for categorical variables. Rates of breast conservation and mastectomy were further stratified by tumor stage. RESULTS: Four hundred sixty-eight patients underwent breast cancer surgery at Tufts Medical Center between 2012 and 2018.Patients who underwent surgery between 2012-2015 and 2016-2018 were similar in terms of age, histological type, tumor size, receipt of neoadjuvant therapy, receptor status, and Charlson Comorbidity Index. There was a statistically significant (P < 0.0001) increase in BCS rate after 2015 attributable to the practice adoption of OPS. The proportion of patients who were recommended reexcision did not significantly increase with the introduction of OPS suggesting an appropriate and safe patient selection process for patients undergoing these breast conservation techniques. When stratified by T stage (tumor size), rates of mastectomy for T2 tumors (greater than 2 cm but less than 5 cm) decreased precipitously after 2015 and BCS increased proportionately. The rate of BCS for T1 tumors also increased but less drastically. CONCLUSIONS: The adoption of OPS in an academic breast cancer center can result in significantly higher rates of BCS, particularly for those with larger tumors (T2). Academic breast cancer centers should strongly consider incorporating OPS to their treatment paradigm to provide patients with the option to avoid mastectomy.

Analysis of Surgical Trends for Axillary Lymph Node Management in Patients with Ductal Carcinoma In Situ Using the NSQIP Database: Are We Following National Guidelines?

BACKGROUND: For patients with ductal carcinoma in situ (DCIS), multiple national cancer organizations recommend that sentinel lymph node biopsy (SLNB) be offered when treated with mastectomy, but not when treated with breast-conserving surgery (BCS). This study analyzes national surgical trends of SLNB and axillary lymph node dissection (ALND) in DCIS patients undergoing breast surgery with the aim to quantify deviations from national guidelines. METHODS: A retrospective cohort analysis of the American College of Surgeons' National Surgical Quality Improvement Program (ACS NSQIP) database from 2005 to 2017 identified patients with DCIS. Patients were categorized by their primary method of breast surgery, i.e. mastectomy or BCS, then further categorized by their axillary lymph node (ALN) management, i.e. no intervention, SLNB, or ALND. Data analysis was conducted via linear regression and a non-parametric Mann-Kendall test to assess a temporal trend and Sen's slope. RESULTS: Overall, 43,448 patients with DCIS met the inclusion criteria: 20,504 underwent mastectomy and 22,944 underwent BCS. Analysis of DCIS patients from 2005 to 2017 revealed that ALND decreased and SLNB increased in every subgroup, regardless of surgical treatment modality. Evaluation in the mastectomy group increased overall: mastectomy alone increased from 57.1 to 65.8% (p < 0.01) and mastectomy with immediate reconstruction increased from 58.5 to 72.1% (p < 0.01). Increases also occurred in the total BCS population: partial mastectomy increased from 14.0 to 21.1% and oncoplastic surgery increased from 10.5 to 23.0% (both p < 0.01). CONCLUSIONS: Despite national guideline recommendations for the management of ALN surgery in DCIS patients, approximately 20-30% of cases continue to not follow these guidelines. This warrants further education for surgeons and patients.

Review of Surgical Education Research Trends in North America.

OBJECTIVE: The purpose of this study was to synthesize surgical education research literature over the last decade and to address the following questions: (1) What are the most common subjects studied? (2) What research designs and data-gathering strategies are commonly employed? (3) Where are these papers being published? (4) What subject and research design trends have emerged in the last decade? DESIGN: A literature review was conducted on surgical education publications from January 2008 to July 2018, using the search terms, "Graduate Medical Education," and "General Surgery." Inclusion criteria included articles published in the United States and Canada specific to general surgery and graduate medical education. RESULTS: A total of 1043 articles met inclusion criteria and were categorized according to year published, journal type, journal of publication, subject of research, research design, and data collection method. The following observations were noted: (1) curriculum/teaching remains the most common subject of surgical education research, with growing emphasis on program evaluation, well-being, duty hours, and case exposure. (2) Descriptive research is the most common, although qualitative and mixed methods research is becoming more common. (3) Online surveys are the most common data collection method as they are the quickest way to gather data but there is an increasing use of interviews as support for qualitative research grows. and (4) Surgical education papers are largely published in journals specifically designed for education, and have slowly grown in popularity in generalized surgical journals. CONCLUSIONS: As surgical education continues to develop as a field, we anticipate further acceptance of qualitative research in major peer-reviewed surgical journals, increased emphasis on resident well-being, and more effective use of interviews and mixed methods including online resources for data collection.

A cost-utility analysis comparing large volume displacement oncoplastic surgery to mastectomy with free flap reconstruction in the treatment of breast cancer.

PURPOSE: Breast cancer surgical treatment may include large volume displacement oncoplastic surgery (LVOS) or mastectomy with free flap reconstruction (MFFR). We investigated the cost-utility between LVOS versus MFFR to determine which approach was most cost-effective. METHODS: A literature review was performed to calculate probabilities for clinical outcomes for each surgical option (LVOS versus MFFR), and to obtain utility scores that were converted into quality adjusted life years (QALYs) as measures for clinical effectiveness. Average Medicare payments were surrogates for cost. A decision tree was constructed and an incremental cost-utility ratio (ICUR) was used to calculate cost-effectiveness. RESULTS: The decision tree demonstrates associated QALYs and costs with probabilities used to calculate the ICUR of $3699/QALY with gain of 2.7 QALY at an additional cost of $9987 proving that LVOS is a cost-effective surgical option. One-way sensitivity analysis showed that LVOS became cost-ineffective when its clinical effectiveness had a QALY of less than 30.187. Tornado Diagram Analysis and Monte-Carlo simulation supported our conclusion. CONCLUSION: LVOS is cost-effective when compared to MFFR for the appropriate breast cancer patient. CLINICAL QUESTION/LEVEL OF EVIDENCE: II.

Combined endo-laparoscopic surgery (CELS) for benign colon polyps: a single institution cost analysis.

BACKGROUND: Endoscopic removal of benign colon polyps is not always possible, even with advanced endoscopic techniques. Segmental colectomy has been the traditional therapy but is associated with an increased risk of complications and may be unnecessary since fewer than 20% of these polyps harbor malignancy. Combined endo-laparoscopic surgery (CELS) has emerged as an alternative method to address these polyps. While feasibility, safety, and improved short-term patient outcomes have been demonstrated, there has never been an evaluation of cost comparing these two approaches within a single institution. METHODS: In this observational cohort study, we compared short-term outcomes and costs of 11 patients who underwent CELS for right colon polyps with 11 patients who underwent a laparoscopic right colectomy between April 2014 and November 2017. The cost analysis covered the perioperative period from operating room to hospital discharge. RESULTS: A total of 11 patients underwent an attempted CELS procedure for right colon polyps with a success rate of 90% (10/11). The median length of stay (LOS) for CELS patients was 1 day. LOS for patients who underwent a laparoscopic right colectomy at TMC was 3.82 days. The median OR time for CELS was 166.73 (± 57.88) min, compared to 204.73 (± 51.49) min for a laparoscopic right colectomy. The calculated total cost for a CELS patient was $5523.29, compared to $12,626.33 for a laparoscopic right colectomy, for a cost-savings of $7103.04 per patient. CONCLUSIONS: CELS procedures are associated with good short-term outcomes and are performed at a lower cost compared to traditional laparoscopic colectomy, with the most significant cost saver being shorter hospital LOS. This is the first study to directly compare the cost of CELS to traditional laparoscopic colectomy in the surgical management of benign colon polyps within a single institution.

Pedunculated small bowel lipoma with heterotopic pancreas causing intussusception.

Small bowel intussusception is a relatively uncommon cause of abdominal pain. The diagnosis is often delayed due to vague symptoms and limitations with current endoscopic and radiographic approaches to evaluate the small bowel lumen. Treatment often requires surgical resection, which can usually be performed in a minimally invasive fashion.

A cost-utility analysis comparing large volume displacement oncoplastic surgery to mastectomy with single stage implant reconstruction in the treatment of breast cancer.

BACKGROUND: For larger cancers in moderate to large breast sized women, breast surgical cancer treatment may include large volume displacement oncoplastic surgery (LVOS) or mastectomy with single stage implant reconstruction (SSIR). Often in the case of LVOS, reduction mammaplasty designs are used in the oncoplastic reconstructions with a contralateral symmetry operation. The goal of this study was to investigate the cost-utility between LVOS versus SSIR to determine which approach is cost-effective in the treatment of breast cancer. METHODS: A review of the literature was performed to determine baseline values and ranges. An average national Medicare payment rates using DRG and CPT codes were used for cost assessment. After constructing a decision tree, an incremental cost-utility ratio (ICUR) was calculated comparing the difference for both surgical options in costs by the difference in clinical-effectiveness. To validate our results, we performed one-way sensitivity analyses in addition to a Monte-Carlo analysis. RESULTS: An ICUR of $546.81/QALY favoring LVOS was calculated based off of its clinical-effectiveness gain of 7.67 QALY at an additional cost of $4194. One-way sensitivity analyses underscored the degree by which LVOS was cost-effective. For example, LVOS became cost-ineffective when a successful LVOS cost more than $50,000. Similarly, probabilistic sensitivity analysis using Monte-Carlo simulation showed that even with varying multiple variables at once, results tended to favor our conclusion supporting the cost-effectiveness of LVOS. CONCLUSIONS: For the appropriate patients with moderate to large sized breasts with breast cancer, large volume displacement oncoplastic surgery is cost-effective compared to mastectomy with single staged implant reconstruction.

Epiploic Appendagitis Mimicking Recurrent Diverticulitis.

Here, we report a case in which a patient with an extensive history of diverticulitis of the sigmoid colon presented with left lower quadrant abdominal pain similar to her previous episodes of diverticulitis. An initial diagnosis of diverticulitis was made based on her history and exam, intravenous antibiotics were given, and an elective surgical resection was considered. However, a subsequent CT scan revealed epiploic appendagitis with no evidence of diverticulitis. Though uncommon, in patients with a history of recurrent diverticulitis, alternative causes of left lower quadrant abdominal pain such as epiploic appendagitis should be considered as this may alter future treatment decisions.