Colectomy in patients with liver disease: albumin-bilirubin score accurately predicts outcomes.

BACKGROUND: Patients with liver disease undergoing colectomy have higher rates of complications and mortality. The Albumin-Bilirubin score is a recently developed system, established to predict outcomes after hepatectomy, that accounts for liver dysfunction. METHODS: All patients undergoing colectomy were identified in the 2015-2018 American College of Surgeons National Surgical Quality Improvement Program colectomy-targeted database. Demographics and outcomes were compared between patients with Albumin-Bilirubin Grade 1 vs. 2/3. Multivariable regression was performed for outcomes including colorectal-specific complications. Areas under the receiver operative characteristic curves were calculated to determine accuracy of the Albumin-Bilirubin score. RESULTS: Of 86,273 patients identified, 48% (N = 41,624) were Albumin-Bilirubin Grade 1, 45% (N = 38,370) Grade 2 and 7% (N = 6,279) Grade 3. Patents with Grade 2/3 compared to Grade 1 had significantly increased mortality (7.2% vs. 0.9%, p < 0.001) and serious morbidity (31% vs. 12%, p < 0.001). Colorectal-specific complications including anastomotic leak (3.7% vs. 2.8%, p < 0.001) and prolonged ileus (26% vs. 14%, p < 0.001) were higher in patients with Grade 2/3. Grade 2/3 had increased risk of mortality (odds ratio 3.07, p < 0.001) and serious morbidity (1.78, p < 0.001). Albumin-Bilirubin had excellent accuracy in predicting mortality (area under the curve 0.81, p < 0.001) and serious morbidity (0.70, p < 0.001). CONCLUSION: Albumin-Bilirubin is easily calculated using only serum albumin and total bilirubin values. Grade 2/3 is associated with increased rates of mortality and morbidity following colectomy. Albumin-Bilirubin can be applied to risk-stratify patients prior to colectomy.

Stage IV Colorectal Cancer at Initial Presentation versus Progression during and after Treatment, Differences in Management: Management Differences for Initial Presentation versus Progression of Disease after Initial Treatment.

Stage IV colorectal cancer is a prevalent disease and understanding the appropriate treatment options is important. Medical oncologic treatment remains the mainstay of treatment in cases where curative resection is not possible. Surgical intervention is indicated if the primary tumor and associated metastases are amenable to curative resection or if obstructive, bleeding, or perforative complications arise from the tumor. New endoscopic techniques can provide palliation and benefit for patients who cannot undergo surgery and may speed time to chemotherapy initiation. Recently, immunotherapy has shown promise at managing, controlling, and regressing advanced disease, in some cases converting it to curative with resection. For patients that progress while on treatment, continued medical therapy remains the mainstay of treatment. Further research into the benefits of asymptomatic primary tumor resection without curative intent needs to be performed. Colorectal cancer, and more specifically metastatic colorectal cancer, continues to have improved 1- and 5-year survival rates and likely will continue to do so over the coming months and years.

Professional Internet Presence Amongst Endocrine Surgeons in the United States.

BACKGROUND: There is a wide range of social media adoption within medical specialties. The use of social media by endocrine surgeons has not been investigated. We undertook this study to describe the use of social media and other platforms by endocrine surgeons. MATERIALS AND METHODS: The American Association of Endocrine Surgeons' publicly available website was used to identify practicing endocrine surgeons in the United States. Surgeon demographics and practice characteristics were collected via internet query. Five social media platforms (Facebook, Instagram, Twitter, LinkedIn, YouTube) were investigated for professional accounts. The presence of a non-institutional professional website, an active Healthgrades account, and presence in non-institutional YouTube videos were also queried. One point was assigned for presence on each of the eight platforms. A professional internet presence (PIP) score was calculated. Descriptive statistics were performed on PIP scores to evaluate the relationship between surgeon and practice characteristics and PIP score. RESULTS: A total of 417 endocrine surgeons were studied. LinkedIn (222, 53.2%) and Twitter (110, 26.4%) were the most commonly used platforms. PIP scores were categorized into zero, one, two, and three or more accounts; 26.9% of surgeons had no professional internet presence. Academic surgeons had a significantly different PIP score than community-based surgeons (P < 0.01). There was no significant association between PIP score and surgeon sex, geographic regions, rural versus urban settings, and years of experience. CONCLUSIONS: Self-identified US endocrine surgeons have low professional internet presence. Endocrine surgeons may consider bolstering their professional internet presence to disseminate medical information.

A History of Health Policy and Health Disparity.

Civil Rights legislation and court decisions influenced health care policy, which attempted to provide health care to elderly and low-income populations. Passing Medicaid and Medicare was monumental in increasing access to health insurance. The Affordable Care Act aimed to increase access to and affordability of health care to alleviate some disparities in health care. The Affordable Care Act established the National Institute of Minority and Health Disparity and Offices of Minority Health. However, disparities of access, care, morbidity, and mortality among marginalized populations persist. We in the thoracic community must leverage all means to mitigate the injustice of health disparities.

Assessment of Accuracy of a Physician Ratings Website in One Metropolitan Area.

BACKGROUND: Patients frequently use online physician ratings websites (PRWs) to identify physicians for care. PRWs provide physician information and reviews. However, the accuracy of PRWs is uncertain. We investigated the accuracy and validity of Healthgrades with respect to endocrine surgery. We identified factors associated with reported board certification inaccuracy, higher ratings, greater quantity of ratings. MATERIALS AND METHODS: The search term "endocrine surgery specialist" was used and the search was limited to a 25-mile radius around Philadelphia, PA. Data was collected on physician sex, age, board certification, surgical specialty, quantity of ratings, average rating, response to comments, and provision of a self-description. Descriptive statistics were performed to examine surgeon characteristics, ratings, and reported board certifications. Board certification accuracy was determined by searching the corresponding American Board website and calculating a kappa statistic. Logistic regression was performed to identify factors associated with board certification inaccuracy, higher average ratings, and higher quantity of ratings. RESULTS: A total of 300 physicians were identified. Eighty-four percent of listed board certifications were accurate; the kappa statistic for accuracy of board certification was 0.634. Providing a response to comments and greater quantity of ratings were associated with higher average ratings. Provision of a self-description, male sex, and younger age were identified as factors associated with higher quantity of ratings. CONCLUSIONS: A wide range of specialties are identified as endocrine surgery specialists. The reliability of board certification reporting was moderate. Increased surgeon involvement with the Healthgrades site was inconsistently associated with higher average ratings and higher quantity of ratings but lower accuracy.

Physiologic Mechanisms of Type II Diabetes Mellitus Remission Following Bariatric Surgery: a Meta-analysis and Clinical Implications.

INTRODUCTION: As obesity prevalence grows in the USA, metabolic syndrome is becoming increasingly more common. Current theories propose that insulin resistance is responsible for the hypertension, dyslipidemia, type II diabetes mellitus (T2DM), and low HDL that comprise metabolic syndrome. Bariatric surgery is one potential treatment, and its effects include permanently altering the patient's physiology and glucose regulation. Consequently, patients with T2DM who undergo bariatric surgery often experience tighter glucose control or remission of their T2DM altogether. This meta-analysis aims to explore the physiologic mechanisms underlying T2DM remission following bariatric surgery, which demonstrates effects that could lead to expansion of the NIH criteria for bariatric surgery candidates. METHODS: A comprehensive search was conducted in PubMed and Scopus. Two independent reviewers conducted title, abstract, and full text review of papers that met inclusion criteria. Papers that measured hormone levels before and after bariatric surgery were included in the meta-analysis. Weighted means and standard deviations were calculated for preoperative and postoperative GLP-1, GIP, ghrelin, and glucagon. RESULTS: Total postprandial GLP-1 increased following bariatric surgery, which correlated with improvements in measures of glycemic control. Fasting GLP-1, fasting GIP, total postprandial GIP, total fasting ghrelin, and fasting glucagon all decreased, but all changes in hormones evaluated failed to reach statistical significance. Studies also demonstrated changes in hepatic and peripancreatic fat, inflammatory markers, miRNA, and gut microbiota following bariatric surgery. CONCLUSION: While this meta-analysis sheds light on possible mechanisms, further studies are necessary to determine the dominant mechanism underlying remission of T2DM following bariatric surgery.

A rare case report of vulvar necrotizing fasciitis in a healthy patient.

INTRODUCTION: Necrotizing fasciitis (NF), a necrotizing infection of the soft tissue, is a medical emergency usually occurring in the lower extremities and abdominal regions and often difficult to diagnose promptly. PRESENTATION OF CASE: This case report looks at one atypical presentation of NF with the unusual location of the vulva and no known associated comorbidities or risk factors. DISCUSSION: Diagnosing this patient was particularly difficult due to the inconsistent clinical, laboratory and imaging findings. The CT scans and WBC count were indicative of NF, but the LRINEC score was not high enough to make the diagnosis of NF. As a result, we relied on the hemodynamic instability and clinical findings of the physical exam to be strong indicators of NF, and acted on that indication. CONCLUSION: Acting quickly on the hemodynamic findings and suspicion as opposed to waiting for a confirmed diagnosis resulted in a good prognosis since immediate surgical debridement is imperative to surviving this acute condition. Despite major advancements in the imaging modalities and the introduction of a laboratory score, our case suggests that the diagnosis still heavily relies on clinical findings, such as hemodynamic instability. Furthermore, our case suggests that NF should be included in the differential regardless of atypical location and lack of common clinical associations.