Giovanni Battista Morgagni and the Morgagni Hernia.

Giovanni Morgagni remains an eminent figure in the field of pathological anatomy. Born in Forli, Italy, he excelled as a child. He entered medical school at the age of 16 years old in Bologna. By the age of 31 he held the chair position at the University of Padua. During his tenure, he discovered many anatomical and pathological findings, with the most widely known discovery being the Morgagni Hernia. Morgagni first described this eponymic hernia in an adult stonecutter during an autopsy. In addition to his many discoveries, his most esteemed written contribution to the field of medicine came in the form of a five-volume book titled De Sedibus et Causis Morborum per Anatomen Indagatis, in which he correlated cadaveric anatomy and symptomatology revealed upon autopsy. He remained on faculty at the University of Padua for over five decades until his death in 1771.

Reassessing career pathways of surgical leaders: An examination of surgical leaders' early accomplishments.

BACKGROUND: The American College of Surgeon (ACS), American Surgical Association (ASA), Association of Women Surgeons (AWS), and Society of Black Academic Surgeons (SBAS) partnered to gain insight into whether inequities found in surgical society presidents may be present earlier. METHODS: ACS, ASA, AWS, and SBAS presidents' CVs were assessed for demographics and scholastic achievements at the time of first faculty appointment. Regression analyses controlling for age were performed to determine relative differences across societies. RESULTS: 66 of the 68 presidents' CVs were received and assessed (97% response rate). 50% of AWS future presidents were hired as Instructors rather than Assistant professors, compared to 29.4% of SBAS, 25% of ASA and 29.4% of ACS. The future ACS, ASA, and SBAS presidents had more total publications than the AWS presidents, but similar numbers of 1st and Sr. author publications. CONCLUSION: Gender inequities in academic surgeon hiring practices and perceived scholastic success may be present at first hire.

Colectomy among Fee-for-Service Medicare Enrollees Coded as DRG 330: A Potential Platform to Allow Consumer Cost Transparency?

The use of Centers for Medicare and Medicaid Services Diagnosis Related Group (CMS-DRG) codes define hospital reimbursement for Medicare beneficiaries. Our objective was to assess all patients with comorbidities on admission who were discharged in the DRG 330 category to determine the impact of postoperative complications on Medicare costs. The 5% Medicare Database was used to evaluate patients who underwent a colectomy and were coded as CMS-DRG 330. Patients were divided into two groups: No surgical complications (NSC) and surgical complications (SC). Length of stay (LOS), complications, hospital charges, CMS reimbursement, discharge destination, and inpatient mortality were assessed. Statistical significance was set at p < 0.05. In total, 13,072 patients were identified. The SC group had higher inpatient mortality, a longer LOS (p < 0.0001) and was more likely to be discharged with post-acute care support (p = 0.0005). The use of CMS-DRG coding has the potential to provide Medicare fiscal intermediaries, beneficiaries, and providers with a more accurate understanding of the relative impact of their baseline health. The data further suggest that providers may benefit by more fully understanding the cost of preventive measures as a means of reducing total cost of care for this population.

One Size Does Not Fit All: Sociodemographic Factors Affecting Weight Loss in Adolescents.

Successful lifestyle changes for weight reduction are heavily dependent on recognizing the importance of societal and cultural factors. Patients 13-19 years of age with a BMI ≥95th percentile are eligible for our multidisciplinary adolescent weight loss clinic. A behavioral questionnaire was administered at the initial visit. Patients were seen every 4-6 weeks. Bivariate analysis was used to identify sociodemographic factors associated with differences in weight loss. Overall, receiving reduced cost meals was associated with a lower likelihood of losing weight (kg) (p < 0.01). When stratified by race, White adolescents were more likely to lose weight if caretakers reported having enough money to buy healthy food (p < 0.05); in contrast, Black adolescents were less likely to lose weight (p < 0.05). However, Black patients were more likely to lose weight if they reported eating fruits and vegetables (p < 0.05). Female adolescents were more likely to lose weight if they felt unhappy about their appearance (p < 0.05). Interestingly, male adolescents were less likely to lose weight if they felt unhappy about their appearance (p < 0.05). Social and cultural norms influence weight loss in adolescents in unique and differing ways. Culturally competent individualized interventions could increase weight loss in diverse groups of adolescents with obesity.

Pediatric firearm injuries: Racial disparities and predictors of healthcare outcomes.

BACKGROUND/PURPOSE: The U.S. has an alarming rate of firearm injuries. Racial disparities among victims and predictors of outcomes are not well established. Our objective was to assess costs, length of stay (LOS), and inpatient mortality among nonfatal and fatal pediatric firearm injuries that required hospitalization. METHODS: Pediatric (≤18 years of age) hospitalizations with a firearm injury discharge diagnosis were identified from the national Kids' Inpatient Databases (KID) for 2006 through 2012. Firearm injury intent, weapon type, and hospitalization rates by racial groups were examined. Inpatient mortality, costs, and length of stay were examined using regression models. RESULTS: Of 15,211 hospitalizations, the majority of injuries were due to assault (60%) and the intentions of firearm injury differed by race (p < 0.001). The median cost per hospitalization was $10,159 (interquartile range: $5071 to $20,565), totaling more than a quarter of a billion dollars. On regression analysis, Black (OR: 0.41; CI: 0.30-0.55) and Hispanic (OR: 0.47; CI: 0.34-0.66) patients were less likely to die than White patients. CONCLUSION: Pediatric firearm injury circumstances and survival vary by race with Whites being more likely to experience unintentional injury and suicide, while Blacks and Hispanics are more likely to experience inflicted injury. LEVEL OF EVIDENCE: Level II. TYPE OF STUDY: Clinical Research Study.

The Society of Black Academic Surgeons CV benchmarking initiative: Early career trends of academic surgical leaders.

BACKGROUND: Surgeons from under-represented backgrounds are less likely to receive academic tenure and obtain leadership positions. Our objective was to query the curriculum vitaes (CVs) of SBAS leadership to develop a benchmarking tool to promote and guide careers in academic surgery. METHODS: CVs from academic leaders were reviewed for academic productivity at early career stages-the first 5-and 10-years. Variables queried: peer-reviewed publications, grant funding, surgical societal involvement, invited lectureships and visiting professorships. RESULTS: Of 20 CVs, 41 leadership positions including 13 SBAS Presidents were identified. At 5- and 10-years, respectively, the academic productivity increased: 20.6 and 52.3 publications; 4.7 and 9.7 grants; 18 and 42.6 lectures/professorships. CONCLUSION: The CV benchmarking tool may be a useful framework for aspiring academic surgeons to track their progress relative to successful SBAS members. Creative strategies like these, paired with faculty mentorship and sponsorship are necessary to improve the ethnic diversity in academic surgery.

Development of comorbidity score for patients undergoing major surgery.

OBJECTIVE: To develop and validate a claims-based comorbidity score for patients undergoing major surgery, and compare its performance with established comorbidity scores. DATA SOURCE: Five percent Medicare data from 2007 to 2014. STUDY DESIGN: Retrospective cohort study of patients aged ≥65 years undergoing six major operations (N = 99 250). DATA COLLECTION: One-year mortality was the primary outcome. Secondary outcomes were hospital mortality, 30-day mortality, 30-day readmission, and length of stay. The comorbidity score was developed in the derivation cohort (70 percent sample) using logistic regression model. The comorbidity score was calibrated and validated in the validation cohort (30 percent sample), and compared against the Charlson, Elixhauser, and Centers for Medicare and Medicaid Services Hierarchical Condition Categories (CMS-HCC) comorbidity scores using c-statistic, net reclassification improvement, and integrated discrimination improvement. PRINCIPAL FINDINGS: In the validation cohort, the surgery-specific comorbidity score was well calibrated and performed better than the Charlson, Elixhauser, and CMS-HCC comorbidity scores for all outcomes; the performance was comparable to the CMS-HCC for 30-day readmission. For example, the surgery-specific comorbidity score (c-statistic = 0.792; 95% CI, 0.785-0.799) had greater discrimination than the Charlson (c-statistic = 0.747; 95% CI, 0.739-0.755), Elixhauser (c-statistic = 0.747; 95% CI, 0.735-0.755), or CMS-HCC (c-statistic = 0.755; 95% CI, 0.747-0.763) scores in predicting 1-year mortality. The net reclassification improvement and integrated discrimination improvement were greater for surgery-specific comorbidity score compared to the Charlson, Elixhauser, and CMS-HCC scores. CONCLUSIONS: Compared to commonly used comorbidity measures, a surgery-specific comorbidity score better predicted outcomes in the surgical population.

Correlation between air quality and lung cancer incidence: A county by county analysis.

BACKGROUND: Poor air quality has previously been associated with lung cancer development, but the risks associated with regional differences in air quality are poorly understood. We investigated the association of air quality indices with development of lung cancer in all Texas counties. METHODS: Lung cancer incidence, air quality indicators (particulate matter <2.5 µm, radon levels, oil well density), and known risk factors were obtained using data from the Texas Commission on Environmental Quality and the Texas Cancer Registry. Linear regression models were constructed to correlate air quality indicators with lung cancer incidence and advanced stage at diagnosis (stage III or IV), while controlling for other patient characteristics. RESULTS: Lung cancer incidence ranged from 27.6 to 103.4 cases per 100,000 people. In the study, 2.5 µm was associated with increased lung cancer incidence (ß = 4.38, P < .0001), but not radon levels (ß = -2.70, P = .41). Air quality indicators were not significantly associated with an advanced cancer diagnosis. CONCLUSION: There are wide differences in the incidence of lung cancer across Texas. These differences seem to be related to air quality. Identifying high-risk areas may help to guide strategies such as implementation of targeted lung cancer screening programs.

Cost of benign versus oncologic colon resection among fee-for-service Medicare enrollees.

BACKGROUND AND OBJECTIVES: Reimbursement for colonic pathology by the Centers for Medicare and Medicaid Services (CMS) are grouped in the Medicare Severity-Diagnosis Related Groups (MS-DRG). With limited available data, we sought to compare the relative impact of malignant vs benign colonic pathology on reimbursement under the MS-DRG system. METHODS: We used 5% national Medicare data from 2011 to 2014. Patients were classified as having benign disease or malignancy. Descriptive statistics and multivariate regression analysis were used to evaluate the surgical approach and health resource utilization. RESULTS: Of 10 928 patients, most were Non-Hispanic White women. The majority underwent open colectomy in both cohorts (P < .001). Colectomy for benign disease was associated with higher total charges (P < .001) and a longer length of stay (P = .0002). Despite higher charges, payments were not significantly different between the cohorts (P = .434). Both inpatient mortality and discharge to a rehab facility were higher in the oncologic group (P < .001). CONCLUSION: Payment methodology for colectomy under the CMS MS-DRG system does not appear to accurately reflect the episode cost of care. The data suggest that inpatient costs are not fully compensated. A transition to value-based payments with expanded episode duration will require a better understanding of unique costs before adoption.

Diagnosis-Related Group in Colon Surgery: Identifying Areas of Improvement to Drive High-Value Care.

Diagnosis-related group (DRG) migration is defined as the reassignment of colectomy patients from DRG 331 to 330 based exclusively on postoperative complications. Strategic and comparative application of this metric has the potential to demonstrate baseline and excessive rates of complications related directly to patient care differences across institutions. The aim of this study was to report the variability of DRG migration across United States hospitals and its impact on overall cost and length of stay (LOS). This study investigated the variability of DRG migration rates across United States hospitals polling 5 per cent of the national Medicare data. The study endpoints were total cost, LOS, and DRG migration rate. Hospitals were classified into tertiles for low (0.1-16.6%), moderate (16.7-23.0%), and high (23.1-83.3%) DRG migration rates. The study included 5120 patients from 615 hospitals. DRG migration rates for hospitals ranged from 0.1 per cent to 83.3 per cent, with 157 in the low, 183 in the moderate, and 364 in the high tertile. DRG migration resulted in a progressively increased LOS and hospital costs from the lowest to highest tertile. Several diagnoses were identified which are suggestive of failure to integrate evidence-based processes of care across the tertiles. The data confirm a wide variation in DRG migration rates from DRG 331 to 330 based only on postoperative complications. These ranges allow for the potential definition of both best practice, and opportunities for quality improvement with respect to postoperative complications, identification of hospital outliers, and the economics of care as part of a value-based care program.

Adolescent Bariatric Surgery: Effects of Socioeconomic, Demographic, and Hospital Characteristics on Cost, Length of Stay, and Type of Procedure Performed.

BACKGROUND: Despite the efficacy of bariatric surgery in adolescents and the increasing rates of adolescent obesity, the use of bariatric surgery remains low. Treatment cost and length of stay (LOS) could be influencing the utilization of bariatric surgery. METHODS: We used the Kids' Inpatient Database (KID) from 2006, 2009, and 2012. Adolescents with a primary diagnosis of obesity who underwent bariatric surgery were included. Multinomial logistic and linear regression modeling was used to determine the association of the predictor variables with type of procedure and treatment cost and LOS, respectively. RESULTS: We identified 1799 adolescents who underwent bariatric surgery. The majority of the subjects were female (77%) and White (60%). The most commonly performed procedure was Roux-en-Y gastric bypass (56%). Race, region, hospital teaching status, and hospital ownership affected the type of procedure performed. Self-pay patients were less likely to undergo Roux-en-Y gastric bypass (RYGB) than sleeve gastrectomy (SG) when compared to patients with private insurance. Teaching hospitals were less likely to perform RYGB or AGB than SG when compared to non-teaching hospitals. Treatment cost was significantly affected by income, teaching hospital status, hospital size, and surgery type. LOS was affected by income quartile, region, and surgery type. CONCLUSION: Socioeconomic and demographic factors as well as hospital characteristics affect not only the LOS and treatment cost, but also the type of bariatric surgery performed in adolescents. Identifying and understanding the factors influencing procedure choice, treatment cost, and LOS can improve care and healthcare resource utilization.

Did we prioritize quality improvement in general surgery: Time for a focus on outcomes and enhanced recovery care plans?

BACKGROUND: In 2008, 2005-2006 National Surgical Quality Improvement Program (NSQIP) data were used to identify surgical operations contributing disproportionately to morbidity and mortality. Since then, numerous enhanced recovery programs have been utilized to augment quality improvement efforts. This study reassesses procedural complication incidence after a decade of quality improvement efforts. METHODS: Data from the 2015 NSQIP were used. The same original 36 general surgery procedure groups were created using Current Procedural Terminology codes. Ninety percent of our 409,230 patients matched into a procedure group and adverse event rates were analyzed for each. RESULTS: Ten procedure groups accounted for 80% of adverse events. Colectomy ranked the highest for adverse events (34%), readmissions (27%) and mortality rates (45.8%). For outpatient cholecystectomy, the relative percent point difference for adverse events has increased by 224% since 2005. CONCLUSION: Refocusing on colectomy and outpatient cholecystectomy represent current priorities in general surgery.

Personality Testing May Identify Applicants Who Will Become Successful in General Surgery Residency.

BACKGROUND: Identification of successful general surgical residents remains a challenging endeavor for program directors with a national attrition of approximately 20% per year. The Big 5 personality traits and the Grit Scale have been extensively studied in many industries, and certain traits are associated with professional or academic success. However, their utility in surgery resident selection is unknown. METHODS: We performed a retrospective review of all categorical surgery residents (n = 34) at the University of Texas Medical Branch from 2015 to 2017. Current residents were classified into low performing (n = 12) or non-low performing (n = 22) based on residency performance and standardized test scores. Groups were assessed for differences in both conventional metrics used for selection and Big 5 and grit scores using bivariate analysis and Pearson's correlation coefficient. Personality testing was administered to recent resident applicants (n = 81). Applicants were ranked using conventional application information. We then examined the applicants' personalities and their rank position with personality characteristics of non-low-performing residents to determine if there was any correlation. RESULTS: The Big 5 personality test identified significantly higher extroversion, conscientiousness, and emotional stability scores in those residents classified as non-low performers. There was no significant difference in conventional metrics or in grit scores between non-low performers and low performers. Our final rank does not correlate well with personality traits of non-low performers. CONCLUSIONS: The Big 5 test may prove to be a useful adjunct to the traditional residency application in identifying applicants who may become successful in general surgery residency.

Antifibrosis Effect of Novel Oridonin Analog CYD0618 Via Suppression of the NF-κB Pathway.

BACKGROUND: Liver fibrosis is characterized as excessive deposition of the extracellular matrix proteins, primarily by activated hepatic stellate cells (HSCs). NF-κB has been reported as one of the major mediators of HSC activation. Previously, our team reported that oridonin exhibited antihepatic fibrogenetic activity in vitro. In this study, we examined the effects of its novel derivative CYD0618 on HSC viability, apoptosis, and NF-κB signaling. METHODS: Cell proliferation of activated human and rat HSC lines LX-2 and HSC-T6 was measured using Alamar Blue Assay. Apoptosis was measured by a Cell Death Detection ELISA kit. Cellular proteins were determined by Western blots and immunofluorescence. RESULTS: CYD0618 significantly inhibited LX-2 and HSC-T6 cell proliferation in a dose-dependent manner. CYD0618 induced cell apoptosis in both cell lines. CYD0618 treatment increased cell cycle inhibitory protein p21, p27, and induced apoptosis marker cleaved poly (ADP-ribose) polymerase, while suppressing the expression of Collagen type 1. CYD0618 blocked lipopolysaccharide (LPS)-induced NF-κB p65 nuclear translocation and DNA binding activity and prevented LPS-induced NF-κB inhibitory protein IκBα phosphorylation and degradation. LPS-stimulated NF-κB downstream target cytokines IL-6 and MCP-1 were attenuated by CYD0618. Endogenous and LPS-stimulated NF-κB p65 S536 phosphorylation was inhibited by CYD0618 treatment. CONCLUSIONS: The potent antihepatic fibrogenetic effect of CYD0618 may be mediated via suppression of the NF-κB pathway.

Factors during training which predict future use of minimally invasive thoracic surgery.

BACKGROUND: While minimally invasive thoracic surgery (MIS) has increased nationwide over the years, most patients undergoing lung and esophageal resections still undergo an open approach. We performed a national survey to analyze factors associated with a propensity to perform MIS after completing a cardiothoracic training program. MATERIALS AND METHODS: Cardiothoracic surgery trainees in 2 or 3-year programs from 2010 to 2016 were sent an online survey regarding the numbers and types of cases performed during training and current practice patterns as attending surgeons. Comfort level with MIS was also assessed. Responses were recorded and analyzed using SPSS. RESULTS: One hundred thirty-six trainees responded, with a mean of 121 lobectomies (30-250) and 40 esophagectomies (8-110) performed during training. Mean minimally invasive lobectomy and esophagectomy rates during training were 53% and 30% respectively. A greater ratio of MIS procedures performed during training correlated with a higher rate performed as an attending (lobectomies, p = 0.04; esophagectomies, p = 0.01) and a greater comfort level with performing these procedures (lobectomies, p = 0.01 and esophagectomies, p < 0.01). CONCLUSIONS: Based on these results, performing a greater ratio of minimally invasive lobectomies and esophagectomies during fellowship training increases the likelihood of performing them as an attending.

Sociodemographic determinants of non-accidental traumatic injuries in children.

BACKGROUND: Traumatic injuries account for 18% of child abuse cases and 1680 children die from abuse annually. We set out to determine the impact of sociodemographic characteristics on resource utilization and outcomes in nonaccidental trauma (NAT). METHODS: We used the Kid's Inpatient Database to identify children with two main subgroups of child abuse diagnoses: NAT and other forms of child abuse. Income was represented by quartiles. Statistical analysis included descriptive statistics and regression analyses. RESULTS: We identified 5617 children requiring hospital admission due to NAT. Medicaid insurance payer status was associated with higher rates of traumatic injuries than private insurance. Black race, male sex, and high-income-quartile were independent factors associated with increased cost. We identified an increased risk of mortality in younger children and those with self-pay/uninsured status. CONCLUSION: NAT represents a prevalent cause of childhood mortality. This study identifies sociodemographic factors associated with increased occurrence, higher resource utilization, and increased mortality in NAT.