Integrating Quality Improvement Education into the Nephrology Curricular Milestones Framework and the Clinical Learning Environment Review.

The Accreditation Council for Graduate Medical Education requires that trainees show progressive milestone attainment in the practice-based learning and systems-based practice competencies. As part of the Clinical Learning Environment Review, sponsoring hospitals must educate trainees in health care quality improvement, provide them with specialty-specific quality data, and ensure trainee participation in quality improvement activities and committees. Subspecialty-specific quality improvement curricula in nephrology training programs have not been reported, although considerable curricular and assessment material exists for specialty residencies, including tools for assessing trainee and faculty competence. Nephrology-specific didactic material exists to assist nephrology fellows and faculty mentors in designing and implementing quality improvement projects. Nephrology is notable among internal medicine subspecialties for the emphasis placed on adherence to quality thresholds-specifically for chronic RRT shown by the Centers for Medicare and Medicaid Services Quality Incentive Program. We have developed a nephrology-specific curriculum that meets Accreditation Council for Graduate Medical Education and Clinical Learning Environment Review requirements, acknowledges regulatory quality improvement requirements, integrates with ongoing divisional quality improvement activities, and has improved clinical care and the training program. In addition to didactic training in quality improvement, we track trainee compliance with Kidney Disease Improving Global Outcomes CKD and ESRD quality indicators (emphasizing Quality Improvement Program indicators), and fellows collaborate on a yearly multidisciplinary quality improvement project. Over the past 6 years, each fellowship class has, on the basis of a successful quality improvement project, shown milestone achievement in Systems-Based Practice and Practice-Based Learning. Fellow quality improvement projects have improved nephrology clinical care within the institution and introduced new educational and assessment tools to the training program. All have been opportunities for quality improvement scholarship. The curriculum prepares fellows to apply quality improvement principals in independent clinical practice-while showing milestone advancement and divisional compliance with Clinical Learning Environment Review requirements.

Trends and risk factors for transfusion in hepatopancreatobiliary surgery.

INTRODUCTION: Patient-specific factors impacting the need for possible perioperative blood transfusions have not been examined in patients undergoing hepatopancreatobiliary (HPB) procedures. We sought to define the overall utilization of blood transfusions for HPB surgery stratified by procedure type, as well as identify patient-level risk factors for transfusion. METHODS: Hepatic and pancreatic resections were selected from the 2005-2011 American College of Surgeons National Surgical Quality Improvement Program's public use files. Transfusion utilization, risk factors, temporal trends, and outcomes were assessed using regression models. Missing data were addressed using multiple imputation. RESULTS: Twenty-six thousand eight hundred twenty-seven patients met the inclusion criteria. There were 16,953 pancreas cases (distal pancreatectomy (31.2%), pancreaticoduodenectomy (65.8%), total pancreatectomy (3.0%)), and 9,874 liver cases (wedge resection (60.0%), hemi-hepatectomy (30.1%), trisegmentectomy (9.9%)). Overall, 25.7% patients received a perioperative transfusion. Transfusion rates varied by operation type (hepatic wedge resection 18.7%, lobectomy 31.3%, trisegmentectomy 39.8%, distal pancreatectomy 19.8%, Whipple 28.7%, total pancreatectomy 43.6%, p < 0.001). On multivariate analysis, several patient-level factors were strongly associated with the risk of transfusion: preoperative hematocrit <36% (risk ratios (RR) 1.99, 95% CI 1.91-2.08), preoperative albumin <3.0 g/dL (RR 1.25, 95% CI 1.19-1.31), American Society of Anesthesiologists (ASA) class IV (RR 1.24, 95% CI 1.16-1.33), and anticoagulation/bleeding disorder (RR 1.26, 95% CI 1.15-1.38) (all p < 0.001). Patients with any one of these high-risk factors had an over twofold increased risk of perioperative transfusion (RR 2.31, 95% CI 2.21-2.40, p < 0.001). CONCLUSION: There are large differences in the incidence of transfusion among patients undergoing HPB procedures. While the type of HPB procedure was associated with the risk of transfusion, patient-level factors-including preoperative hematocrit and albumin, ASA classification, and history of anticoagulation/bleeding disorder-were as important.

Thrombocytopenia in dengue fever.

Dengue is probably the most important arthropod-borne viral disease in terms of human morbidity and mortality. We review the pathophysiology of thrombocytopenia and clinical bleeding in dengue across the spectrum of disease. The mechanisms of thrombocytopenia and coagulopathy are complex, involving platelet activation, procoagulant and anticoagulant arms of the coagulation system, complement, cytokines, and endothelial cells. Platelet counts do not correlate well with clinical bleeding. Although serious bleeding is rare, patients should be monitored closely for hemorrhagic manifestations and thrombocytopenia. Symptomatic thrombocytopenia may require platelet transfusion.

Fibrin sealants in surgical or traumatic hemorrhage.

PURPOSE OF REVIEW: Fibrin sealants have been used to control surgical hemorrhage for three decades, and numerous articles have reported their use in a variety of surgical procedures in both animal models and humans. This article reviews the recent literature on fibrin sealants with the specific aim of highlighting the use of fibrin sealants in planned and simulated trauma to provide background for clinicians who may consider using fibrin sealants in specific cases. An overview of the mechanisms of action of fibrin sealants, their indications, and current commercial formulations is also provided. RECENT FINDINGS: Recent studies have evaluated the use of fibrin sealants in vascular surgery, including aortic anastomosis in an animal model, gastrointestinal anastomoses, plastic surgery, urologic procedures including heminephrectomy, and other procedures. SUMMARY: Fibrin sealants continue to be used and evaluated in animal models and surgery. Their use in military settings and in civilian trauma centers, explored for several years, is not reported extensively in the literature. Recent events and the current tempo of military operations dictate that many potential scenarios exist for using fibrin sealants to control traumatic hemorrhage.