Environmental Benefits of Electronic Table of Contents of Journals Over Print.

Recent discussion has driven debate on the best format for journals to deliver content to their readers. Traditional dogma necessitated a physical print copy, which was sent to subscribers automatically and came with the benefits of ease of use and familiarity. With the passage of time, electronic tables of contents, with or without the option for a print copy, have been used in lieu to save cost and environmental concerns and to allow content to be consumed in a more convenient, tidier way.

Pancreatic Exocrine Secretion and Weight Gain After Pancreas Transplantation.

INTRODUCTION: Weight gain after pancreas transplant is a poorly understood phenomenon thought to be related to increased posttransplant insulin production, immunosuppressive medications, and appetite changes. No study has investigated the effect of increased exocrine secretion posttransplant. AIMS AND HYPOTHESIS: We hypothesized that exocrine function, measured by fecal elastase-1 (FE-1), was normal posttransplant and not correlated with weight gain. Our primary aim was to investigate changes in FE-1 levels with pancreas transplantation and to correlate this with weight gain. Establishing weight trends and identifying additional correlating factors were secondary aims. DESIGN: Forty-two patients that underwent simultaneous pancreas and kidney or pancreas after kidney transplant at a single center between 2013 and 2021 were included. Fecal elastase was measured prospectively in each patient at a single time point, with >500 µg/g categorized as high. Weight and C-peptide values were obtained. All the patients were on steroid-free immunosuppression. RESULTS: Nineteen patients (45%) had fecal elastase levels >500 µg/g, with a maximum of 3910 µg/g; 43% had levels greater than twice the upper limit of normal. The biggest increase in weight occurred between years 1 and 2, which continued to a median weight gain of 14% at 3 years. There was no correlation between weight gain and FE-1, pretransplant C-peptide levels, or duration of diabetes. CONCLUSION: This study demonstrated supranormal fecal elastase levels and weight gain posttransplant; however, there was no correlation. Future study with serial FE-1 before and after transplant is needed to better assess its correlation with weight gain.

Measuring Impact of Simulation-Based Informed Consent Training on Surgical Intern's Long-Term Confidence.

OBJECTIVE: Our objective was to evaluate the outcome of a training program on long-term confidence of interns and attending physicians. DESIGN: In this prospective cohort study, general surgery interns underwent a training program on informed consent that involved didactics, standardized patient encounters, and supplemental procedure specific guides at the start of the academic year. At the end of the academic year, we surveyed interns from the classes of 2020 (trained) and 2019 (untrained) about their experience and confidence in obtaining an informed consent. Further, we queried attending physicians on their experience and confidence in the interns at the end of each academic year. SETTING: Single academic general surgery residency program based at 2 urban tertiary hospitals. PARTICIPANTS: General surgery interns including unmatched preliminary residents and categorical interns from general surgery, interventional radiology, and urology. RESULTS: Twenty-four incoming interns participated in the training program. Intern confidence discussing operation benefits improved from a median score of 4 to 5 (p = 0.03), and total confidence improved from a median score of 15 to 17.5 (p = 0.08). There was no difference in median total confidence scores (15 vs. 17.5; p = 0.21) between classes. Attending physicians had similar median total confidence scores following intervention (10 vs. 11; p = 0.87). Intern satisfaction was 80% with the didactic session, and 90% with standardized patient encounters. Twenty percent of learners used the supplemental procedure specific guides. CONCLUSIONS: Implementation of an intern targeted program on informed consent that incorporated didactics and standardized patient encounters was viewed as useful and may contribute to long-term improvements in confidence.

Effects of race and test preparation resources on standardized test scores, a pilot study.

BACKGROUND: Little research exists on the relationship between pre-examination resources, race, and standardized test outcomes. This study aimed to determine the effect of test preparation resources and race on test scores. METHODS: We surveyed medical students at an allopathic institution on the use of test preparation materials and their test scores. Students were grouped by self-identified race. Underrepresented in Medicine (URiM) students were defined as Black/African American (AA), Hispanic/Latino (HL), Native American (NA) and multiple races. Univariate analysis and linear regression were used for statistical analysis. RESULTS: 192 students completed the survey (response rate = 33%). URiM students reported more MCAT attempts than other students. No differences between scores existed between races. There was no association between scores and the use of test preparation resources. CONCLUSIONS: We found that URiM students took the MCAT more times than their peers; however, we found no racial/ethnic differences in examination preparation resources or scores.

End-to-end anastomosis as a superior repair type to prevent recurrence of arteriovenous fistula aneurysms and improve patency outcomes.

BACKGROUND: Arteriovenous fistulae (AVF) complicated by aneurysms are repaired through several mechanisms. Little is known about risk factors for aneurysm recurrence or the efficacy of subsequent repair of recurring aneurysms. METHODS: About 291 patients underwent AVF aneurysm repair between 2009 and 2019 at a large urban medical center. Patients who underwent staged repair, had a primary graft with pseudoaneurysm, were status-post kidney transplant, or using other dialysis access at the time of repair were excluded. One hundred sixty-two patients were included in the study, of which 52 developed a secondary aneurysm. Chi-square and t-test analyses were used to compare demographics. Multivariate logistic regression was used to examine independent risk factors for aneurysm recurrence. Of the 52 patients with recurrent aneurysms, 41 were repaired again. Patency was examined for each group 1 year postoperatively. RESULTS: Patients without secondary aneurysms were more likely to have a Charlson Comorbidity Index score ⩾5 (p = 0.045). Males were 2.8 times more likely to develop a secondary aneurysm compared to females (p = 0.023). Patients who underwent elective compared to emergent or urgent surgery for primary aneurysms were significantly less likely to recur (OR = 0.222; p = 0.016). Primary aneurysms repaired by end-to-end anastomosis, compared to aneurysmorrhaphy or graft, were significantly less likely to recur (OR = 0.239; p = 0.041). Among patients with secondary aneurysms, those repaired via end-to-end anastomosis had a significantly higher primary patency rate 1 year postoperatively (p = 0.024). Secondary aneurysm repairs exhibited 1-year primary and secondary patency rates of 51.2% and 82.9%, respectively. CONCLUSIONS: End-to-end anastomosis reduces risk of recurrence and demonstrates superior patency rates when repairing recurrent aneurysms. It remains unclear why some patients are prone to aneurysm recurrence, however continued attempts to repair existing vascular access are proven to be successful.

Graft repair of arteriovenous fistula aneurysms is associated with decreased long-term patency.

INTRODUCTION: Arteriovenous fistula (AVF) aneurysms are a chronic complication which can be disfiguring, painful, and can rupture. Here, we compare the outcomes between three different methods of AVF aneurysm repair. METHODS: One-way ANOVA, Chi-square, and Fisher Exact analyses were used to compare demographics. Multivariate logistic regression compared outcomes. Kaplan-Meier estimate illustrated long-term fistula patency. RESULTS: There were no differences between demographics in the aneurysmorrhaphy, end-to-end anastomosis, and synthetic graft groups. The odds of patients who received graft repair losing primary patency within one year compared to the aneurysmorrhaphy group was 3.5 (p = 0.025). Graft repair patients were 6.7 times more likely to develop an infection compared to aneurysmorrhaphy (p = 0.014). Synthetic grafts also exhibited accelerated rates of complete access loss compared to autogenous methods (p = 0.034). CONCLUSIONS: Graft repair of AVF aneurysms results in higher rates of infection and decreased primary and ultimate patency compared to autogenous repair techniques. Therefore, synthetic grafts should be avoided whenever possible.

Early Experience Using Donor-derived Cell-free DNA for Surveillance of Rejection Following Simultaneous Pancreas and Kidney Transplantation.

Background: Allograft biopsy is the gold standard for diagnosing graft rejection following simultaneous pancreas and kidney (SPK) transplant. Intraperitoneal biopsies are technically challenging and can be burdensome to patients and the healthcare system. Donor-derived cell-free DNA (dd-cfDNA) is well-studied in kidney transplant recipients; however, it has not yet been studied in the SPK population. Methods: We hypothesized that dd-cfDNA could be utilized for rejection surveillance following SPK transplant. We prospectively collected dd-cfDNA in 46 SPK patients at a single institution. Results: There were 10 rejection events, 5 of which were confirmed with biopsy. The other 5 were treated based on dd-cfDNA and clinical data alone with favorable outcomes. Among all patients who did not have rejection, 97% had dd-cfDNA <0.5%. Dd-cfDNA may also help differentiate rejection from graft injury (ie, pancreatitis) with median values in rejection 2.25%, injury 0.36%, and quiescence 0.18% (P = 0.0006). Conclusions: Similar to kidneys, dd-cfDNA shows promise for rejection surveillance in SPK transplant recipients.

Surgical Management of Bronchobiliary Fistula After Thoracoabdominal Trauma.

Bronchobiliary fistulas are exceedingly rare pathological connections between the biliary and the bronchial systems, which result from hepatobiliary neoplasms, abscesses, or thoracoabdominal trauma. Prompt recognition, diagnosis, and intervention is essential in order to prevent the high morbidity and mortality associated with this disease process. Multiple management strategies have been described in the literature; however, the optimal course has not been well defined. We present a case of a 31-year-old male who developed a bronchobiliary fistula 1 month after thoracoabdominal trauma. After conservative management with biliary stenting failed, he successfully underwent latissimus sparing right posterolateral thoracotomy, complete fistulectomy, right lower lobe wedge resection, and diaphragmatic reconstruction with subsequent resolution of his symptoms.

Postoperative Mortality in Patients With Cirrhosis: Reconsidering Expectations.

BACKGROUND: A diagnosis of cirrhosis increases a patient's risk of postoperative mortality. Surgeons are reticent to operate when cirrhosis is known unless no option is available. This study aimed to identify the modern perioperative risk in cirrhotic patients undergoing intervention under general anesthesia for non-transplant operations. METHODS: A retrospective chart review was conducted utilizing the Rush Medical Center electronic medical record. All patients over 18 years of age with a diagnosis of cirrhosis undergoing intervention between 2009 and 2019 were reviewed. 90-day mortality rates in patients grouped by Child's score, Model for End-Stage Liver Disease (MELD), and Model for End-Stage Liver Disease with sodium incorporated (MELDNa) were compared to previously accepted rates. RESULTS: 93 patients (46% women) aged 22-72 years of all Child-Turcot-Pugh (CTP) (40% A, 36% B, and 25% C) classifications and MELD/MELDNa ranging 6-40 were analyzed. 90-day mortality of the entire population was 16%, significantly lower than expected based on CTP score (16% vs. 32%; P = .0005), MELD (16% vs. 41%; P < .0001), and MELDNa (16% vs. 46.8%; P < .0001). This was also true for CTP-B patients (12% vs. 30%; P = .025), CTP-C patients (35% vs. 70%; P = .0002), patients with MELD >14 (27% vs. 70%; P < .001), and patients with MELDNa >14 (23% vs. 70%; P < .0001). CONCLUSION: Data indicate that perioperative mortality is lower than widely accepted. This suggests the need for a national database study using a representative population to determine the risk of mortality for patients with cirrhosis having surgery in recent times. Accurate estimation of this risk allows for meaningful discussion between physicians and patients when deciding to proceed with elective, necessary operations.

Can Donor-Derived Cell-Free DNA Detect Graft-Versus-Host Disease in Solid Organ Transplantation: A Case Report.

Graft-versus-host disease (GVHD) is a rare complication after solid organ transplant. We present a case of GVHD after simultaneous pancreas kidney transplant. The patient was diagnosed with a cutaneous biopsy after developing the classic symptoms of maculopapular rash, diarrhea, and pancytopenia. However, this patient had unexplained elevations in donor-derived cell-free DNA (dd-cfDNA) for months before the onset of GVHD symptoms. We hypothesize that GVHD may be associated with elevated dd-cfDNA as a result of massive donor lymphocyte proliferation and turnover. Further investigation is warranted because earlier diagnosis and treatment could improve outcomes in an otherwise lethal disease.

Outcomes following percutaneous endoscopic gastrostomy versus fluoroscopic procedures in the Medicare population.

BACKGROUND: In the United States, few high-quality manuscripts have directly compared the complication profiles of percutaneous endoscopic versus fluoroscopic gastrostomy. Thus, it is our goal to compare these 2 common procedures to better understand their efficacy and complication profiles. MATERIALS AND METHODS: A retrospective analysis of patient records from Medicare parts A/B from 2007 to 2012 was used to identify percutaneous fluoroscopic gastrostomy and percutaneous endoscopic gastrostomy procedures. Patient demographics were stratified by age, sex, comorbidities, and complications. RESULTS: A total of 258,641 patients were found to have either percutaneous fluoroscopic gastrostomy (26,477, 10.2%) or percutaneous endoscopic gastrostomy (232,164, 89.8%). Percutaneous fluoroscopic gastrostomy experienced greater rates for all complications queried. Multivariate analysis revealed that the percutaneous fluoroscopic gastrostomy cohort had statistically significant increased odds for short-term complications, such as ileus (odds ratio 1.4, 95% confidence interval 1.22-1.54), mechanical (odds ratio 2.4, 95% confidence interval 2.28-2.58), wound infection (odds ratio 1.4, 95% confidence interval 1.24-1.52), persistent fistula after tube removal (odds ratio 1.9, 95% confidence interval 1.78-2.12), and other complications (odds ratio 2.2, 95% confidence interval 2.03-2.37), and long-term complications, including abdominal wall pain (odds ratio 1.4, 95% confidence interval 1.33-1.44), wound infection (odds ratio 1.1, 95% confidence interval 1.01-1.15), and persistent fistula after tube removal (odds ratio 1.8, 95% confidence interval 1.72-1.87). CONCLUSION: Gastrostomy tubes are more frequently being placed via percutaneous endoscopic and fluoroscopic methods. This study suggests that those undergoing fluoroscopic placement have higher odds of developing short- and long-term postoperative complications.

Outcomes following port-a-catheter placement in the Medicare population.

BACKGROUND: We aimed to evaluate the long-term complication profile associated with port-a-catheter placement. METHODS: Patients undergoing port-a-catheter placement from 2007 to 2012 with 5-year follow up were identified. Descriptive statistics, χ2 tests, and multivariate regression models were analyzed. RESULTS: Any complication occurring within 5 years postoperatively was common (59.04%, n = 53,353). Arrhythmogenic (32.66%, n = 30,625) and thrombovascular (36.80%, n = 34,499) complications were more common than infection (17.86%, n = 16,745) and mechanical (10.31%, n = 9,670) complications. Multivariate analysis demonstrated that history of atrial fibrillation is a risk factor for developing any complication (odds ratio 7.99, 95% confidence interval 7.29-8.77). CONCLUSION: Patients with history of atrial fibrillation have increased odds of developing infectious, thrombovascular, mechanical, and arrhythmogenic complications with port-a-catheter placement. This study is the first to show that postprocedure arrhythmias occur at significant rates within the 5-year follow-up period. We caution that development of new arrhythmia should be monitored throughout a prolonged follow-up period. We hope our analysis encourages multidisciplinary coordination of patients with ports so that implants are promptly removed when they are no longer needed to avoid these complications.

Laparoscopic-Assisted Versus Mini-Open Laparotomy for Ventriculoperitoneal Shunt Placement in the Medicare Population.

BACKGROUND: Placement of the distal shunt catheter into the peritoneum during ventriculoperitoneal shunt (VPS) surgery can be done with either laparoscopic assistance or laparotomy. OBJECTIVE: To compare outcomes in laparoscopic-assisted vs laparotomy for placement of VPS in the Medicare population. METHODS: Patients undergoing VPS placement, between 2004 and 2014, were identified by International Classification of Disease, Ninth Revision and Current Procedural Terminology codes in the Medicare database. Demographic data including age, sex, comorbidities, and indications were collected. Six- and twelve-month complication rates were analyzed. RESULTS: A total of 1966 (3.2%) patients underwent laparoscopic-assisted VPS and 60 030 (96.8%) patients underwent nonlaparoscopic-assisted VPS placement. Compared with traditional open VPS placement, the laparoscopic approach was associated with decreased odds of distal revision at 6- and 12-mo postoperatively (6 mo: odds ratio [OR] = 0.41, 95% confidence interval [CI]: 0.21-0.74; 12 mo: OR = 0.60, 95% CI: 0.39-0.94). At 6- and 12-mo postoperatively, multivariable regression analysis demonstrated increased odds of distal revision in patients with a body mass index (BMI) > 30 Kg/M2, history of open abdominal surgery, and history of laparoscopic abdominal surgery. Additionally, history of prior abdominal surgery and BMI > 30 Kg/M2 were significantly associated with increase odds of shunt infection at 6 and 12-mo, respectively. CONCLUSION: In the largest retrospective analysis to date, patients with a history of abdominal surgery and obesity were found to be at increased risk of infection and distal revision after VPS placement. However, the laparoscopic approach for abdominal placement of the distal catheter was associated with reduced rates of distal revision in this population, suggesting an avenue for reducing complications in well-selected patients.

Trends in Antibiotic Duration for Complicated Intra-Abdominal Infections : Adaptation to Current Guidelines.

INTRODUCTION: The 2017 surgical infection society (SIS) guidelines recommend 4 days of antibiotic therapy after source control for complicated intra-abdominal infections (cIAIs). Inappropriate exposure to antibiotics has a negative impact on outcomes in individual patients and populations. The goal of this study was to evaluate our institution's practice patterns and adherence to current antibiotic guidelines. METHODS: Medical records from 2010 to 2018 for cIAIs were examined. Complicated appendicitis and complicated diverticulitis cases were included. Exclusion criteria included other etiologies of IAIs, pediatric cases, and cancer operations. RESULTS: Fifty-nine complicated appendicitis cases and 96 complicated diverticulitis cases were identified. For all cases, antibiotic duration prior to publication of the SIS guidelines was significantly longer than post-SIS duration (appendicitis: 12.6 ± 1.1 days pre-SIS [n = 37] vs 9.0 ± 1.1 days post-SIS [n = 22], P = .01; diverticulitis: 15.1 ± 0.8 days pre-SIS [n = 49] vs 11.2 ± 0.5 post-SIS [n = 47], P = .04). Surgical management (SM) was associated with shorter duration of postsource control antibiotic exposure compared with percutaneous drainage (PD) for both appendicitis (SM 10.0 ± 1.2 days vs PD 13.4 ± 1.0 days, P = .02) and diverticulitis (SM 12.8 ± 1.5 days vs PD 16.0 ± 1.5, P = .07). Patients with complicated appendicitis received shorter duration of antibiotics when managed by acute care surgeons compared to general surgeons (8.4 ± 1.1 vs 11.9 ± 0.8, P = .02). CONCLUSION: Despite improvements after the SIS guidelines' publication, the antibiotic duration is still longer than recommended. Surgical intervention and management by acute care specialists were associated with a shorter duration of antibiotic exposure.

Economic evaluation of suture versus clip anastomosis in arteriovenous fistula creation.

OBJECTIVE: Techniques such as the use of nonpenetrating vascular clips for arteriovenous fistula (AVF) anastomotic creation have been developed in an effort to reduce fistula-related complications. However, the outcomes data for the use of clips have remained equivocal, and the cost evaluations to support their use have been largely theoretical. Therefore, the present study aimed to determine both the clinical and the cost outcomes of AVFs created with nonpenetrating vascular clips compared with the continuous suture technique during a 10-year period at a single institution. METHODS: All patients undergoing AVF creation in the upper extremity from 2009 through 2018 were retrospectively analyzed. The patient demographics and AVF outcomes were collected and compared stratified by the surgical technique used. A cost analysis was performed of a subgroup of patients from 2013 to 2018. RESULTS: During the 10-year study period, 916 AVFs were created (79% using the continuous suture technique and 21% using nonpenetrating vascular clips). Patient demographics and comorbid conditions did not differ between the two groups, and no differences were present in maturation, primary patency, assisted primary patency, or complication rates between the two groups at 1 year. The suture group had a shorter time to maturation (4.3 months vs 5.5 months; P < .01) and improved secondary patency compared with the clip group (77.13% vs 69.59%; P = .03) The cost analysis of the procedures revealed a significant difference in direct costs (suture, $1389.26 vs clip, $1716.51; P < .01) and contribution margin (suture, $1770.19 vs clip, $1128.36; P < .01) for the two groups. CONCLUSIONS: Both suture and clip techniques in AVF creation demonstrated equivalent rates of maturation, primary patency, assisted primary patency, and complications at 1 year with higher expense associated with the use of clips. Thus, in an effort to reduce the economic burden of healthcare in the United States, the findings from the present study support the preferential use of the standard polypropylene suture technique when creating upper extremity AVFs.

Should Pre-Transplant Hemoglobin A1c Be Used to Predict Post-Transplant Compliance in End-Stage Renal Disease Patients Undergoing Kidney Transplantation?

BACKGROUND Patient compliance with immunosuppressive therapy after transplant has impacts on both graft and patient outcomes. For diabetic end-stage renal disease (ESRD) patients who are undergoing evaluation for kidney transplantation in our program, hemoglobin A1c (HbA1c) level of >10% is used as a flag that the patient may be at risk for noncompliance and that more comprehensive psychosocial screening is needed prior to transplant. We evaluated the association between pre-transplant HbA1c level and post-transplant compliance, as no study to date has looked at this in the transplant population. MATERIAL AND METHODS The charts of 392 patients who received a kidney transplant at a single institution between July 2008 and June 2012 were retrospectively reviewed. One hundred and sixty-five diabetic patients who received a kidney transplant alone were included in the final analysis. Our predictive variable was HbA1c level greater than 7.7% based on previous reports in the diabetic population. Outcome measures were graft survival, rejection episodes, unexplained low immunosuppressant levels, and documented noncompliance. RESULTS There were no statistically significant differences between the HbA1c groups of ≤7.7% and >7.7% in outcomes of failed grafts (22.0% and 17.8%, p=0.2), rejection episodes (15.0% and 6.7%, p=0.3), unexplained low immunosuppressant level (46.6% and 37.9%, p=0.3), and documented noncompliance (25.0% and 16.7%, p=0.4). CONCLUSIONS In diabetic ESRD patients selected for renal transplantation, elevated pre-transplant HbA1c levels, defined as HbA1c >7.7%, are not predictive of post-transplant medication compliance. We advocate that this group of patients should not be denied transplant solely on their elevated pre-transplant HbA1c.