Anaphylaxis-a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis.

Anaphylaxis is an acute, potential life-threatening systemic allergic reaction that may have a wide range of clinical manifestations. Severe anaphylaxis and/or the need for repeated doses of epinephrine to treat anaphylaxis are risk factors for biphasic anaphylaxis. Antihistamines and/or glucocorticoids are not reliable interventions to prevent biphasic anaphylaxis, although evidence supports a role for antihistamine and/or glucocorticoid premedication in specific chemotherapy protocols and rush aeroallergen immunotherapy. Evidence is lacking to support the role of antihistamines and/or glucocorticoid routine premedication in patients receiving low- or iso-osmolar contrast material to prevent recurrent radiocontrast media anaphylaxis. Epinephrine is the first-line pharmacotherapy for uniphasic and/or biphasic anaphylaxis. After diagnosis and treatment of anaphylaxis, all patients should be kept under observation until symptoms have fully resolved. All patients with anaphylaxis should receive education on anaphylaxis and risk of recurrence, trigger avoidance, self-injectable epinephrine education, referral to an allergist, and be educated about thresholds for further care.

Failure on a Vascular Surgery Board-American Board of Surgery Examination does not predict cardiovascular outcomes in the Society for Vascular Surgery Vascular Quality Initiative.

OBJECTIVE: The Vascular Surgery Board of the American Board of Surgery (VSB-ABS) Qualifying and Certifying examinations are meant to assess qualifications to independently practice vascular surgery, but it is unclear whether examination performance correlates with clinical outcomes. We assessed this relationship using clinical outcomes data for VSB-ABS diplomates from the Society for Vascular Surgery Vascular Quality Initiative (SVS-VQI). METHODS: VSB-ABS examination performance for vascular surgeons participating in the SVS-VQI registry was characterized according to pass/fail status. Surgical experience was measured by number of years since completion of training. Examination performance and experience were compared with a composite clinical outcome (in-patient major adverse cardiac events or postoperative death [MACE+POD]) after arterial reconstructions (carotid stenting or endarterectomy, aortic aneurysm repair, open peripheral surgical bypasses) registered in the SVS-VQI. Multivariate mixed effects regression was performed adjusting for sex and surgery type, as well as clustering by surgeon and by hospital. RESULTS: From 2003 to 2017, complete data were available for 776 vascular surgeons who performed 124,171 arterial reconstructions (carotid n = 56,650; aortic n = 34,764; peripheral n = 32,757) registered in the SVS-VQI. Patient characteristics associated with higher odds of MACE+POD were female sex (odds ratio [OR] 1.07; 95% confidence interval [CI], 1.03-1.12; P = .006) and advancing age (OR, 1.04; 95% CI, 1.03-1.04; P < .001). Of the 776 surgeons, 149 (17%) had failed at least one VSB-ABS examination (group F). The unadjusted primary composite outcome of MACE+POD was marginally higher after operations performed by surgeons who never failed an examination (group P; 7% vs 6%; P = .03). This difference seems to be driven by higher rates of postoperative congestive heart failure in the aortic and lower extremity bypass cohorts as well as more postoperative myocardial infarctions after lower extremity bypass by group P surgeons. Following multivariable analyses, examination pass status was not associated with MACE+POD (OR, 0.98; 95% CI, 0.89-1.50; P = .517). However, increasing surgical experience correlated with significantly lower odds of MACE+POD (2% lower odds/year of experience since training [OR, 0.98; 95% CI, 0.98-0.99; P < .001]). CONCLUSIONS: VSB-ABS examination performance by SVS-VQI surgeons does not correlate with registry-reported mortality or cardiovascular complications. Increasing surgical experience is strongly associated with lower odds of cardiovascular morbidity and death.

Patient Opinion on the Affordable Care Act in an Otolaryngology Practice: the Ideological Divide.

OBJECTIVE: To assess patient opinion on the Patient Protection and Affordable Care Act (PPACA) in an Otolaryngology practice and the factors that influence those opinions. STUDY DESIGN: Observational study. METHODS: An anonymous survey assessing patient opinion on the PPACA, demographic information, political affiliation, medical diagnosis, and insurance status was distributed to patients in three separate Otolaryngology clinics (General, cancer, and Low-income/Indigent) from April to June 2014. A total of 300 surveys were distributed and 207 were used for final analysis. The primary study outcome measures were patient opinion of the PPACA and statistically significant variables affecting that opinion. The association of Support for the PPACA and variables were tested using the Chi-square test. RESULTS: The only variables that showed a significant association with support for the PPACA were Political Party (p<0.0001) and Ethnicity (p=0.0050). Specifically, a higher proportion of Democrats support the PPACA than Republicans and a higher proportion of African Americans and Hispanic/Latinos support the PPACA than Whites and Native Americans. CONCLUSION: Our survey of current Otolaryngology patients mirrors national findings of the division between Republicans and Democrats in their attitudes towards the Affordable Care Act. Political party appears to be the most significant factor in shaping patient opinion on this controversial subject regardless of insurance status or cancer diagnosis and a higher proportion of African Americans and Hispanic/Latinos support the PPACA than Whites and Native Americans. LEVEL OF EVIDENCE: IV.

General surgery workloads and practice patterns in the United States, 2007 to 2009: a 10-year update from the American Board of Surgery.

OBJECTIVE: To assess changes in general surgery workloads and practice patterns in the past decade. BACKGROUND: Nearly 80% of graduating general surgery residents pursue additional training in a surgical subspecialty. This has resulted in a shortage of general surgeons, especially in rural areas. The purpose of this study is to characterize the workloads and practice patterns of general surgeons versus certified surgical subspecialists and to compare these data with those from a previous decade. METHODS: The surgical operative logs of 4968 individuals recertifying in surgery 2007 to 2009 were reviewed. Data from 3362 (68%) certified only in Surgery (GS) were compared with 1606 (32%) with additional American Board of Medical Specialties certificates (GS+). Data from GS surgeons were also compared with data from GS surgeons recertifying 1995 to 1997. Independent variables were compared using factorial ANOVA. RESULTS: GS surgeons performed a mean of 533 ± 365 procedures annually. Women GS performed far more breast operations and fewer abdomen, alimentary tract and laparoscopic procedures compared to men GS (P < 0.001). GS surgeons recertifying at 10 years performed more abdominal, alimentary tract and laparoscopic procedures compared to those recertifying at 20 or 30 years (P < 0.001). Rural GS surgeons performed far more endoscopic procedures and fewer abdominal, alimentary tract, and laparoscopic procedures than urban counterparts (P < 0.001). The United States medical school graduates had similar workloads and distribution of operations to international medical graduates. Compared to 1995 to 1997, GS surgeons from 2007 to 2009 performed more procedures, especially endoscopic and laparoscopic. GS+ surgeons performed 15% to 33% of all general surgery procedures. CONCLUSIONS: GS practice patterns are heterogeneous; gender, age, and practice setting significantly affect operative caseloads. A substantial portion of general surgery procedures currently are performed by GS+ surgeons, whereas GS surgeons continue to perform considerable numbers of specialty operations. Reduced general surgery operative experience in GS+ residencies may negatively impact access to general surgical care. Similarly, narrowing GS residency operative experience may impair specialty operation access.

Comparison of surgical operative experience of trainees and practicing vascular surgeons: a report from the Vascular Surgery Board of the American Board of Surgery.

INTRODUCTION: The Vascular Surgery Board (VSB) of the American Board of Surgery sought to answer the following questions: what is the scope of contemporary vascular surgery practice? Do current vascular surgery residents obtain training that is appropriate for their future career expectations and for successful Board certification? How effectively do practicing vascular surgeons incorporate emerging technologies and procedures into practice? METHODS: We analyzed the operative logs submitted to the VSB by recent vascular surgery residents applying for the Vascular Surgery Qualifying Examination (QE; 2006-2009) or by practicing vascular surgeons applying for the Vascular Surgery Recertification Examination (RE; 1995-2009). The relationship between reported operative experience and performance of the QE and RE was examined. RESULTS: There has been a threefold increase in the mean number of primary cases reported by both RE and QE applicants over the past 15 years and the increase in case volume has been driven largely by an increase in the number of endovascular procedures. Endovascular procedures have been broadly incorporated into the practice of most vascular surgeons applying for recertification. The number of major open surgical cases reported by recent QE applicants has remained unchanged over the period of observation. For QE applicants, the number of endovascular aneurysm repairs (EVARs) has reached a plateau at approximately 50 cases, whereas the mean number of open infrarenal aneurysm repairs has decreased for both QE and RE applicants, reflecting national trends favoring EVAR. There was a significant association between case volume and performance on the QE but not on the RE. CONCLUSION: Over the past 15 years, there has been a significant increase in the total number of operative cases reported to the VSB by both QE and RE applicants. Contrary to popular belief, the volume of major open vascular surgery reported by recent vascular surgery residents has remained relatively stable since 1994. Over the same time period, endovascular procedures have been rapidly incorporated into clinical practice by the majority of vascular surgeons applying for recertification by the VSB. Current vascular surgery residents receive a rich operative experience in both open and endovascular procedures that is reflective of contemporary practice.

Determining who trains vascular surgery fellows in endovascular techniques.

OBJECTIVES: Vascular surgery training has evolved from a single clinical year after general surgery training to a multi-year training program to encompass such entities as noninvasive vascular laboratory, office-based procedures, and endovascular techniques. Simultaneously, members of the vascular surgery community have had to undergo significant training to become facile with endovascular techniques. We surveyed vascular surgery trainees on the online Vascular Surgery In-Training Examination (VSITE) in 2008 and 2009 to assess who trained them in percutaneous techniques. METHODS: Vascular surgery trainees in the Independent (2-year) and Integrated (5-year) training programs were asked to participate in a survey upon completion of the VSITE in 2008 and 2009. Examinees were asked to select whether vascular surgeons, cardiologists, or interventional radiologists trained them in carotid angioplasty and stenting (CAS), thoracic endografts (TEVAR), endovascular abdominal aortic aneurysm repair (EVAR), renal artery intervention, iliac stenting, superficial femoral artery (SFA), and tibial artery percutaneous interventions. RESULTS: Survey response rate was 79.6% (191 of 240). Results of the survey are shown in Table I. In 2009, vascular surgeons provided more than 84% of the training to vascular surgery residents. Only six respondents had >50% of their percutaneous training with interventional radiology and two with cardiologists. CONCLUSION: Vascular surgeons involved in resident education have been able to retrain themselves in endovascular techniques such that they are now able to provide greater than 80% of the endovascular experience to vascular surgery residents.

Verbal and visuospatial memory in lateral onset Parkinson disease: time is of the essence.

OBJECTIVE: This investigation sought to study immediate and delayed verbal and visuospatial recall in Parkinson disease (PD) patients with left hemibody (LHO) and right hemibody (RHO) onset of motor symptoms and to examine the role of mental processing speed in recall of this information. BACKGROUND: Research is mixed regarding material specific memory impairments in LHO and RHO PD. However, earlier research has not used a factorial approach in investigating material specific memory in LHO and RHO PD. We hypothesized that LHO PD patients would exhibit an increase in performance following the delayed verbal free recall trial and either decline or stability in performance on the delayed visuospatial free recall trial. The opposite pattern was hypothesized for RHO PD patients. METHOD: The Hopkins Verbal Learning Test-revised (HVLT-R) and the Brief Visuospatial Memory Test-revised (BVMT-R) were administered to a sample of 28 LHO PD patients and 36 RHO PD patients. The Stroop Color-word Test was administered as a measure of mental processing speed. RESULTS: The results indicated that the RHO group experienced a significant decline in performance on verbal free recall from the immediate to the delayed trials and a significant improvement in performance from the immediate to the delayed visuospatial free recall trials. Additionally, a significant negative correlation was found between mental processing speed and changes in recall from the immediate to the delayed conditions for the RHO group. CONCLUSIONS: These results indicate that the RHO PD group experienced a significant decline in verbal free recall and a significant improvement in visuospatial free recall from the immediate to the delayed trials and that the LHO PD patients experienced no significant changes. Further, mental processing speed appears to influence the recall of information from the immediate to the delayed conditions.

Anxiety affects working memory only in left hemibody onset Parkinson disease patients.

OBJECTIVE: This investigation sought to examine the potential moderating influence of heightened anxiety on working memory in Parkinson disease (PD) patients. Further, we wanted to determine whether this moderating influence of anxiety differentially affects PD patients with left hemibody (LBH) versus right hemibody (RHB) onset of motor symptoms. BACKGROUND: Research has examined the neurocognitive effects of depression in PD. However, a paucity of research has examined the effects of heightened anxiety in PD. We predicted that LHB PD patients with heightened anxiety would perform worse on a measure of working memory than RHB PD patients. METHOD: A total of 59 PD patients completed the state-trait anxiety inventory and were also administered the digit span subtest of the Wechsler Memory Scale-III. RESULTS: The results supported the hypotheses, indicating that the LHB PD patients with heightened anxiety performed significantly worse than the RHB PD patients with heightened anxiety and the LHB PD patients with low anxiety. CONCLUSIONS: These findings suggest that left hemibody onset PD patients may experience more disability in their activities of daily living. Future research should explore whether differences also exist between PD patients with and without the diagnosed anxiety disorders.

Walking at work: Maximum gait speed is related to work ability in hospital nursing staff.

OBJECTIVES: Like the concept of work ability in occupational health, gait speed is a measure of general fitness and can predict functional decline and morbidity. This is especially important when our care-takers, i.e. nurses, show decline in fitness and become care-receivers. The study aims to describe the demographics of hospital nurses in the context of gait speed and work ability as well as to determine the association between them. METHODS: Three-hundred and twelve inpatient nurses and nursing assistants were sampled from a level 1 trauma and teaching hospital from several service lines and acuity levels. Spearman correlation tests were utilized to determine the relationship of gait speed and ratings of item 1 on the Work Ability Index (WAI) as well as Cochran-Armitage test for linear trend of gait speed. RESULTS: Maximum gait speed has a significant positive association with work ability with a Rho coefficient of 0.217 (P < .0001). Additionally, the linear trend test of gait speed tertiles was significant (P < .001) for work ability categories of Moderate to Poor (0-7) and Good to Excellent (8-10). CONCLUSIONS: Gait speed is correlated with the item 1 self-rating of the WAI in hospital nursing staff. The 10-m walk test is a practical and easy measure that can be utilized in occupational health. More research is required to validate gait speed in other occupational health populations and investigate gait speed changes and its interaction with the work environment longitudinally.

Operative experience of residents in US general surgery programs: a gap between expectation and experience.

OBJECTIVE: The purpose of the study was to identify a group of operations which general surgery residency program directors believed residents should be competent to perform by the end of 5 years of training and then ascertain actual resident experience with these procedures during their training. SUMMARY BACKGROUND DATA: There is concern about the adequacy of training of general surgeons in the United States. The American Board of Surgery and the Association of Program Directors in Surgery undertook a study to determine what operative procedures residency program directors consider to be essential to the practice of general surgery and then we measured the actual operative experience of graduating residents in those procedures, as reported to the Residency Review Committee for Surgery (RRC). METHODS: An electronic survey was sent to residency program directors at the 254 general surgery programs in the US accredited by the RRC as of spring 2006. The program directors were presented with a list of 300 types of operations. Program directors graded the 300 procedures "A," "B," or "C" using the following criteria: A--graduating general surgery residents should be competent to perform the procedure independently; B--graduating residents should be familiar with the procedure, but not necessarily competent to perform it; and C--graduating residents neither need to be familiar with nor competent to perform the procedure. After ballots were tallied, the actual resident operative experience reported to the RRC by all residents finishing general surgery training in June 2005 was reviewed. RESULTS: One hundred twenty-one of the 300 operations were considered A level procedures by a majority of program directors (PDs). Graduating 2005 US residents (n = 1022) performed only 18 of the 121 A procedures, an average of more than 10 times during residency; 83 of 121 procedures were performed on an average less than 5 times and 31 procedures less than once. For 63 of the 121 procedures, the mode (most commonly reported) experience was 0. In addition, there was significant variation between residents in operative experience for specific procedures. In virtually all cases, the mean reported experience exceeded the mode, suggesting that the mean is a poor measure of typical experience. CONCLUSIONS: These data pose important problems for surgical educators. Methods will have to be developed to allow surgeons to reach a basic level of competence in procedures which they are likely to experience only rarely during residency. Even for more commonly performed procedures, the numbers of repetitions are not very robust, stressing the need to determine objectively whether residents are actually achieving basic competency in these operations. Finally, the large variations in experience between individuals in our residency system need to be explored, understood, and remedied.

Verbal learning in Alzheimer's disease: cumulative word knowledge gains across learning trials.

Research regarding learning in Alzheimer's disease (AD) patients has been mixed. Learning capacity might be better indexed using a score that reflects the interaction between the learning slope and total recall, referred to as the Cumulative Word Learning (CWL) score. We compared a group of AD patients to normal participants using a traditional index of learning and the CWL score that were derived from the Hopkins Verbal Learning Test-Revised (HVLT-R). The HVLT-R is a supra-span, list-learning test containing 12 words from three semantic categories. The results indicated that the sample of AD patients performed within the average range, using the traditional learning z score. Although mild AD patients were not found to differ from controls in the traditional learning z score, a significant difference was noted for the CWL score. The moderate AD patients differed from the normal controls in both learning measures. Furthermore, unlike the traditional learning score, the CWL score was a significant predictor of overall cognitive functioning, as indexed using their Mini-Mental State Examination (MMSE) score. Thus, the CWL score might be a more sensitive indicator overall of total learning capacity and may be useful in staging Alzheimer's disease because of increased resilience to floor effects.

Future of Implantable Auditory Devices.

The advances in technology leading to rapid developments in implantable auditory devices are constantly evolving. Devices are becoming smaller, less visible, and more efficient. The ability to preserve hearing outcomes with cochlear implantation will continue to evolve as surgical techniques improve with the use of continuous feedback during the procedure as well as with intraoperative delivery of drugs and robot assistance. As engineering methods improve, there may one day be a totally implantable aid that is self-sustaining in hearing-impaired patients making them indistinguishable from patients without hearing loss.

Certification and maintenance of certification in surgery.

The processes that lead to certification by the American Board of Surgery (ABS) emphasize surgeons' training and qualifications. Moreover, the need for periodic recertification appears to provide strong motivation for surgeons to remain current. Such certification is regarded as having great value among patients, but concerns about quality and safety have increased pressure to assess what surgeons actually do in practice. As a result, the American Board of Medical Specialties (ABMS) member boards have recently initiated Maintenance of Certification (MOC) programs that add a requirement for assessment of practice performance to the elements of traditional certification. This article describes the current ABS certification process and the ABS MOC program in greater detail.

Graduate medical education in surgery in the United States.

Each year, approximately 1000 graduating medical students enter 5-year residency programs in general surgery. Their salaries are funded by the federal government. Following 5 years of general surgery training, approximately 70% of graduates enroll in a specialty fellowship. Surgery training currently faces a number of challenges, including the diminishing attractiveness of surgery as a career, attrition from residency programs, mandated work hour limits, extensive service requirements in the hospital environment, increasing specialization, and changing patient expectations about the role of residents in their care, among others. In the face of these challenges, the profession is beginning to respond to the need for positive change in the process of training surgeons.

Maintenance of certification.

Maintenance of Certification (MOC) is the most recent stage in the evolution of specialty board certification. Driven by increasing concerns over the quality and safety of medical care, MOC represents a change in the frequency and the nature of the requirements of existing recertification. Under MOC, the every 10-year snapshot of professionalism, participation in continuing medical education, and medical expertise that are part of current recertification will become a more continuous process. MOC adds the assessment of practice performance to these measures and represents a philosophical change as well as a requirement change. The focus of these assessments is for improvement rather than judgment. The extent to which MOC succeeds will reflect surgeons' ability to improve the quality of care through voluntary efforts.

Combined Treatment Modalities of Hyperbaric Oxygen Therapy, Bilayer Matrix Wound Dressing, and Negative Pressure Therapy in Patients with Failed Temporoparietal Fascia Flaps.

Temporoparietal fascia flaps are reported to have a 94% success rate in auricular reconstruction. Bilayer matrix (Integra™, Integra LifeSciences, Plainsboro, NJ) dermal graft alone has an average success rate of 76.6%. When combined with fibrin glue and negative pressure therapy (V.A.C.® Freedom®, KCI, San Antonio, Tex) the flaps have a success rate of up to 98% in patients with a variety of wound types and sites. Two patients are presented with failed temporoparietal fascia flaps. In addition, one also had prior failure of a split-thickness skin graft; the second also had failure of prior Integra split-thickness skin graft, and hyperbaric oxygen therapy. All 3 treatment modalities of bilayer dermal graft, negative pressure therapy, and hyperbaric oxygen used simultaneously allowed both flaps to heal.