Implementation of a novel peer review academy by Surgery and the Association of Women Surgeons.

BACKGROUND: A novel Peer Review Academy was developed as a collaborative effort between the Association of Women Surgeons and the journal Surgery to provide formal training in peer review. We aimed to describe the outcomes of this initiative using a mixed methods approach. METHODS: We developed a year-long curriculum with monthly online didactic sessions. Women surgical trainee mentees were paired 1:1 with rotating women surgical faculty mentors for 3 formal peer review opportunities. We analyzed pre-course and post-course surveys to evaluate mentee perceptions of the academy and assessed changes in mentee review quality over time with blinded scoring of unedited reviews. Semi-structured interviews were conducted upon course completion. RESULTS: Ten women surgical faculty mentors and 10 women surgical trainees from across the United States and Canada successfully completed the Peer Review Academy. There were improvements in the mentees' confidence for all domains of peer review evaluated, including overall confidence in peer review, study novelty, study design, analytic approach, and review formatting (all, P ≤ .02). The mean score of peer review quality increased over time (59.2 ± 10.8 vs 76.5 ± 9.4; P = .02). In semi-structured interviews, important elements were emphasized across the Innovation, Implementation Process, and Individuals Domains, including the values of (1) a comprehensive approach to formal peer review education; (2) mentoring relationships between women faculty and resident surgeons; and (3) increasing diversity in the scientific peer review process. CONCLUSION: Our novel Peer Review Academy was feasible on a national scale, resulting in significant qualitative and quantitative improvements in women surgical trainee skillsets, and has the potential to grow and diversify the existing peer review pool.

Consensus minimum core data elements adapted to peripheral vascular intervention in the drug-eluting era: Consensus report from the Registry Assessment of Peripheral Interventional Devices (RAPID) Pathways "LEAN" working group.

Registry Assessment of Peripheral Interventional Devices (RAPID) initiated the Pathways Program to provide a transparent, collaborative forum in which to pursue insights into multiple unresolved questions on benefit-risk of paclitaxel-coated devices, including understanding the basis of the mortality signal, without a demonstrable potential biological mechanism, and whether the late mortality signal could be artifact intrinsic to multiple independent prospective randomized data sources that did not prespecify death as a long-term end point. In response to the directive, the LEAN-Case Report Form working group focused on enhancements to the RAPID Phase I Minimum Core Data set through the addition of key clinical modifiers that would be more strongly linked to longer-term mortality outcomes after peripheral arterial disease intervention in the drug-eluting device era, with the goal to have future mortality signals more accurately examined.

Dual Antiplatelet Therapy Is Associated with Increased Risk of Bleeding and Decreased Risk of Stroke Following Carotid Endarterectomy.

BACKGROUND: Despite many patients undergoing carotid endarterectomy (CEA) being on dual antiplatelet therapy (DAPT) for cardiac or neurologic indications, the impact of such therapy on perioperative outcomes remains unclear. We aim to compare rates of postoperative bleeding, stroke and major adverse events (stroke, death or MI) among patients on Aspirin alone (ASAA) versus DAPT (Clopidogrel and Aspirin). METHODS: Patients undergoing CEA for carotid artery stenosis between 2010 and 2021 in the Vascular Quality Initiative (VQI) were included. We excluded patients undergoing concomitant or re-do operations or patients with missing antiplatelet information. Propensity score matching was performed between the 2 groups ASAA and DAPT based on age, sex, race, presenting symptoms, major comorbidities [hypertension, diabetes and coronary artery disease (CAD)], degree of ipsilateral stenosis, presence of contralateral occlusion, as well as preoperative medications. Intergroup differences between the treatment groups and differences in perioperative outcomes were tested with the McNemar's test for categorical variables and paired t-test or Wilcoxon matched-pairs signed-rank test for continuous variables where appropriate. Relative risks with 95% confidence intervals were estimated as the ratio of the probability of the outcome event in the patients treated within each treatment group. RESULTS: A total of 125,469 patients were included [ASAA n = 82,920 (66%) and DAPT n = 42,549 (34%)]. Patients on DAPT were more likely to be symptomatic, had higher rates of CAD, prior percutaneous coronary intervention or coronary artery bypass grafting, and higher rates of diabetes. After propensity score matching, the DAPT group had an increased rate of bleeding complications (RR: 1.6: 1.4-1.8, P < 0.001) as compared with those on ASAA despite being more likely to receive both drains and protamine. In addition, patients on DAPT had a slight decrease in the risk of in-hospital stroke as compared with patients on ASAA (RR: 0.80: 0.7-0.9, P = 0.001). CONCLUSIONS: This large multi-institutional study demonstrates a modest decrease in the risk of in-hospital stroke for patients on DAPT undergoing CEA as compared with those on ASAA. This small benefit is at the expense of a significant increase in the risk of perioperative bleeding events incurred by those on DAPT at the time of CEA. This analysis suggests avoiding DAPT when possible, during CEA.

A Least Absolute Shrinkage and Selection Operator-Derived Predictive Model for Postoperative Respiratory Failure in a Heterogeneous Adult Elective Surgery Patient Population.

BACKGROUND: Postoperative respiratory failure (PRF) is associated with increased hospital charges and worse patient outcomes. Reliable prediction models can help to guide postoperative planning to optimize care, to guide resource allocation, and to foster shared decision-making with patients. RESEARCH QUESTION: Can a predictive model be developed to accurately identify patients at high risk of PRF? STUDY DESIGN AND METHODS: In this single-site proof-of-concept study, we used structured query language to extract, transform, and load electronic health record data from 23,999 consecutive adult patients admitted for elective surgery (2014-2021). Our primary outcome was PRF, defined as mechanical ventilation after surgery of > 48 h. Predictors of interest included demographics, comorbidities, and intraoperative factors. We used logistic regression to build a predictive model and the least absolute shrinkage and selection operator procedure to select variables and to estimate model coefficients. We evaluated model performance using optimism-corrected area under the receiver operating curve and area under the precision-recall curve and calculated sensitivity, specificity, positive and negative predictive values, and Brier scores. RESULTS: Two hundred twenty-five patients (0.94%) demonstrated PRF. The 18-variable predictive model included: operations on the cardiovascular, nervous, digestive, urinary, or musculoskeletal system; surgical specialty orthopedic (nonspine); Medicare or Medicaid (as the primary payer); race unknown; American Society of Anesthesiologists class ≥ III; BMI of 30 to 34.9 kg/m2; anesthesia duration (per hour); net fluid at end of the operation (per liter); median intraoperative FIO2, end title CO2, heart rate, and tidal volume; and intraoperative vasopressor medications. The optimism-corrected area under the receiver operating curve was 0.835 (95% CI,0.808-0.862) and the area under the precision-recall curve was 0.156 (95% CI, 0.105-0.203). INTERPRETATION: This single-center proof-of-concept study demonstrated that a structured query language extract, transform, and load process, based on readily available patient and intraoperative variables, can be used to develop a prediction model for PRF. This PRF prediction model is scalable for multicenter research. Clinical applications include decision support to guide postoperative level of care admission and treatment decisions.

Multi-institutional patterns of clopidogrel response among patients undergoing transcarotid artery revascularization.

OBJECTIVE: Current guidelines recommend dual antiplatelet therapy (DAPT) in patients undergoing carotid artery stenting. The most common DAPT regimen is aspirin and clopidogrel, a P2Y12 receptor antagonist; however, the prevalence of clopidogrel resistance (CR) in patients undergoing percutaneous coronary interventions may exceed 60%. Few studies have investigated the prevalence and impact of CR in patients undergoing extracranial carotid artery stenting, particularly transcarotid artery revascularization (TCAR). METHODS: Consecutive high-risk patients ≥ 18 years who underwent TCAR for high grade (≥70%) and/or symptomatic (≥50%) carotid stenosis with preoperative P2Y12 testing between August 2019 and December 2021 were identified across five institutions. Preoperative platelet reactivity was measured with the VerifyNow P2Y12 Reaction Unit (PRU) Test (Instrumentation Laboratory, Bedford, MA), with CR defined as PRU ≥ 194 and hyper-response as PRU <70. Patients without preoperative P2Y12 testing within 30 days prior to TCAR or those on a non-clopidogrel P2Y12 inhibitor preoperatively were excluded. The primary outcome of interest was prevalence of CR. Secondary outcomes of interest included the incidence of ischemic and hemorrhagic complications. RESULTS: Of 92 patients identified, the majority were male (59%) and Caucasian (75%) with a mean age of 75 years (±8, range 56-92). Preoperatively, 93% of patients were on aspirin, 100% on clopidogrel, and 13% on therapeutic anticoagulation. At presentation, 36% were symptomatic. The mean preoperative P2Y12 was 156 PRU (±76, range 6-349). In total, 30 (33%) patients met criteria for CR (mean PRU 240 ± 37; range 197-349), and 15 (16%) met criteria for hyper-responder (mean PRU 38 ± 20; range 6-68). There was no significant difference by clopidogrel response phenotype in terms of sex (p = 0.246), race (p = 0.384), or symptomatic presentation (p = 0.956). Postoperatively, the cumulative incidence of stroke and MI was 2.1%, with no statistically significant difference in the incidence of in-hospital stroke (PRU 238, p = 0.489) or MI (PRU 168, p = 1) between clopidogrel phenotypes. Three (3.3%) patients, one CR (PRU 240) and two responders (PRU 119 and PRU 189), experienced postoperative access site hematomas that required no subsequent intervention. No other index hospitalization hemorrhagic complications occurred. CONCLUSIONS: Using preoperative P2Y12 testing with a threshold PRU ≥ 194 to define CR, we identified a high prevalence of CR in patients undergoing TCAR similar to that in the pre-existing coronary literature. We found no significant differences in postoperative ischemic or hemorrhagic complications by clopidogrel response phenotype, although complication rates in the overall study cohort were low. CR may be a spectrum from responder to partial responder to complete non-responder, and this may account for the differences in our CR cohort compared to the ROADSTER 2 protocol deviation cohort. Further investigation is warranted to determine if a quantitative assessment of CR is sufficient to identify patients at risk of developing secondary cerebrovascular ischemic events in this patient population.

The art of peer review: Guidelines to become a credible and constructive peer reviewer.

Peer review is a learned skill set that requires knowledge of study design, review construct, ethical considerations, and general expertise in a field of study. Participating in peer review is a rewarding and valuable experience in which all academic physicians are encouraged to partake. However, formal training opportunities in peer review are limited. In 2021, the Association of Women Surgeons and the journal Surgery collaborated to develop a Peer Review Academy. This academy is a 1-year longitudinal course that offers a select group of young women surgical trainees across all specialties a curriculum of monthly lectures and multiple formal mentored peer review opportunities to assist them in developing the foundation necessary to transition to independent peer review. The trainees and faculty mentors participating in the Association of Women Surgeons-Surgery Peer Review Academy compiled a summary of best peer review practices, which is intended to outline the elements of the skill set necessary to become a proficient peer reviewer.

Outcomes and risk factors for delayed-onset postoperative respiratory failure: a multi-center case-control study by the University of California Critical Care Research Collaborative (UC3RC).

BACKGROUND: Few interventions are known to reduce the incidence of respiratory failure that occurs following elective surgery (postoperative respiratory failure; PRF). We previously reported risk factors associated with PRF that occurs within the first 5 days after elective surgery (early PRF; E-PRF); however, PRF that occurs six or more days after elective surgery (late PRF; L-PRF) likely represents a different entity. We hypothesized that L-PRF would be associated with worse outcomes and different risk factors than E-PRF. METHODS: This was a retrospective matched case-control study of 59,073 consecutive adult patients admitted for elective non-cardiac and non-pulmonary surgical procedures at one of five University of California academic medical centers between October 2012 and September 2015. We identified patients with L-PRF, confirmed by surgeon and intensivist subject matter expert review, and matched them 1:1 to patients who did not develop PRF (No-PRF) based on hospital, age, and surgical procedure. We then analyzed risk factors and outcomes associated with L-PRF compared to E-PRF and No-PRF. RESULTS: Among 95 patients with L-PRF, 50.5% were female, 71.6% white, 27.4% Hispanic, and 53.7% Medicare recipients; the median age was 63 years (IQR 56, 70). Compared to 95 matched patients with No-PRF and 319 patients who developed E-PRF, L-PRF was associated with higher morbidity and mortality, longer hospital and intensive care unit length of stay, and increased costs. Compared to No-PRF, factors associated with L-PRF included: preexisiting neurologic disease (OR 4.36, 95% CI 1.81-10.46), anesthesia duration per hour (OR 1.22, 95% CI 1.04-1.44), and maximum intraoperative peak inspiratory pressure per cm H20 (OR 1.14, 95% CI 1.06-1.22). CONCLUSIONS: We identified that pre-existing neurologic disease, longer duration of anesthesia, and greater maximum intraoperative peak inspiratory pressures were associated with respiratory failure that developed six or more days after elective surgery in adult patients (L-PRF). Interventions targeting these factors may be worthy of future evaluation.

Performance of Carotid Revascularization Procedures as Modified by Sex.

BACKGROUND: Current recommendations on carotid revascularization postulate that women have both increased perioperative risks, such as stroke and death, as well as reduced benefit from intervention. These recommendations do not include data on transcarotid artery revascularization (TCAR). This study strives to compare safety and benefits of TCAR, TFCAS (Transfemoral Carotid Artery Stenting), and CEA (Carotid Endarterectomy) with regard to patient sex. METHODS: We performed retrospective analysis of the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) CEA and stenting registries, as well as TCAR Surveillance Project data. We compared outcomes after TCAR, TFCAS, and CEA based on sex. The primary outcome was the rate of in-hospital stroke or death. Secondary outcomes included in-hospital stroke, death, transient ischemic attack (TIA), myocardial infarction (MI), stroke/death/MI, stroke/TIA, and recurrent ipsilateral stroke and/or death at 1-year of follow-up. RESULTS:  A total of 75,538 patients were included, of which 28,960 (38.3%) were female and 46,578 (61.7%) were male. TFCAS females had more than 2 times higher odds of stroke/death (OR:2.85, 95%CI: 2.21-3.67, P < 0.001) and stroke/death/MI (OR:2.23, 95%CI:1.75-2.83, P < 0.001) when compared to CEA females. Odds of TIA were also higher in both TFCAS females (OR:2.01, 95%CI:1.19-3.42, P = 0.010) and TCAR females (OR:1.91, 95%CI:1.09-3.35, P = .023) when compared to CEA females. However, only TFCAS females experienced increased odds of stroke/TIA (OR:1.96, 95%CI:1.45-2.65, P < 0.001) when compared to CEA females. TFCAS males had almost twice the odds of stroke/death (OR:1.74, 95%CI:1.39-2.16, P < 0.001) and 44% higher odds of stroke/death/MI (OR:1.44, 95%CI:1.19-1.75, P < 0.001), and more than 3-times increased odds of death (OR:3.45, 95%CI:2.53-4.71, P < 0.001) when compared to CEA males. Odds of in-hospital stroke were comparable between TFCAS and CEA after adjusting for covariates. TCAR males have half the odds of MI when compared to CEA males (OR:0.52, 95%CI:0.34-0.80, P = 0.003). At 1-year TCAR had comparable risk of stroke/death while TFCAS had increased risk of stroke/death when compared to CEA among both males and females. CONCLUSION: TCAR performed similarly to CEA in both sexes regardless of symptomatic status. Stroke/death and stroke/death/MI rates were similar in symptomatic and asymptomatic males and females treated by CEA or TCAR. The 1-year outcomes of TCAR were also comparable to CEA in both sexes. It seems that TCAR may be a safe alternative to CEA particularly in women when surgical risk prohibits CEA and while TFCAS is associated with substantial adverse outcomes.

Anesthetic choice during transcarotid artery revascularization and carotid endarterectomy affects the risk of myocardial infarction.

OBJECTIVE: Previous studies have shown no differences in the outcomes of transcarotid artery revascularization (TCAR) performed with general anesthesia (GA) vs local or regional anesthesia (LRA). To date, no study has specifically compared the outcomes of TCAR to those of carotid endarterectomy (CEA) stratified by anesthetic type. The aim of the present study was to identify the effect of the anesthetic type on the outcomes of TCAR vs CEA. METHODS: Patients undergoing CEA and TCAR for carotid artery stenosis from 2016 to 2019 in the Vascular Quality Initiative were included. We excluded patients who had undergone concomitant procedures, patients with more than two stented lesions, and patients who had undergone the procedure for a nonatherosclerotic indication. Propensity score matching was performed between the two procedures stratified by the anesthetic type for age, sex, race, presenting symptoms, major comorbidities (ie, hypertension, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease), previous coronary artery bypass grafting or percutaneous transluminal coronary intervention, previous CEA or carotid artery stenting, degree of ipsilateral stenosis, the presence of contralateral occlusion, and preoperative medications. Intergroup differences between the treatment groups and differences in the perioperative outcomes were tested using the McNemar test for categorical variables and the paired t test or Wilcoxon matched pairs signed rank test for continuous variables, as appropriate. The relative risk (RR) and 95% confidence intervals (CIs) were estimated as the ratio of the probability of the outcome event for the patients treated within each treatment group. RESULTS: A total of 65,337 patients were included. Of the 65,337 patients, 59,664 had undergone carotid revascularization under GA (91%). When performed with LRA, TCAR and CEA had similar rates of stroke, death, and MI. However, when performed with GA, patients undergoing TCAR had a 50% decreased risk of MI compared with those undergoing CEA under GA (0.5% vs 1.0%; RR, 0.50; 95% CI, 0.32-0.80; P < .01). When stratified by symptomatic status, patients undergoing TCAR with GA for symptomatic carotid disease had a 67% decreased risk of MI compared with those undergoing CEA with GA for symptomatic disease (0.4% vs 1.2%; RR, 0.33; 95% CI, 0.15-0.75; P < .01). In contrast, no difference was found in the risk of MI between patients undergoing CEA vs TCAR for asymptomatic carotid disease (0.6% vs 0.9%; RR, 0.64; 95% CI, 0.37-1.14; P = .13). CONCLUSIONS: The results from the present study have confirmed previous studies suggesting that TCAR confers a lower risk of MI compared with CEA. However, our findings demonstrated no differences in the MI rates between TCAR and CEA when performed with LRA. Patients undergoing TCAR under GA had lower rates of MI compared with patients undergoing CEA under GA. When stratified by symptomatic status, the benefit of TCAR persisted only for the symptomatic patients.

Endovascular Repair of Splenic Vein Aneurysm with Balloon Expandable Stent Placement.

Given the rarity of splenic vein aneurysms, it is no surprise that there are little data to help guide clinicians regarding indications and techniques for repair. Traditionally associated with hepatobiliary pathology including portal hypertension and pancreatitis, management typically involved open splenectomy. We describe the case of a patient with an incidentally found enlarging splenic vein aneurysm in the absence of significant past medical history. The patient underwent successful repair of the aneurysm utilizing a transhepatic endovascular approach with a balloon expandable stent. We offer this as minimally invasive solution allowing splenic salvage.

Risk Factors Associated With Early Postoperative Respiratory Failure: A Matched Case-Control Study.

BACKGROUND: Postoperative respiratory failure is the most common serious postoperative pulmonary complication, yet little is known about factors that can reduce its incidence. We sought to elucidate modifiable factors associated with respiratory failure that developed within the first 5 d after an elective operation. MATERIALS AND METHODS: Matched case-control study of adults who had an operation at five academic medical centers between October 1, 2012 and September 30, 2015. Cases were identified using administrative data and confirmed via chart review by critical care clinicians. Controls were matched 1:1 to cases based on hospital, age, and surgical procedure. RESULTS: Our total sample (n = 638) was 56.4% female, 71.3% white, and had a median age of 62 y (interquartile range 51, 70). Factors associated with early postoperative respiratory failure included male gender (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.12-2.63), American Society of Anesthesiologists class III or greater (OR 2.85, 95% CI 1.74-4.66), greater number of preexisting comorbidities (OR 1.14, 95% CI 1.004-1.30), increased operative duration (OR 1.14, 95% CI 1.06-1.22), increased intraoperative positive end-expiratory pressure (OR 1.23, 95% CI 1.13-1.35) and tidal volume (OR 1.13, 95% CI 1.004-1.27), and greater net fluid balance at 24 h (OR 1.17, 95% CI 1.07-1.28). CONCLUSIONS: We found greater intraoperative ventilator volume and pressure and 24-h fluid balance to be potentially modifiable factors associated with developing early postoperative respiratory failure. Further studies are warranted to independently verify these risk factors, explore their role in development of early postoperative respiratory failure, and potentially evaluate targeted interventions.

Preoperative bevacizumab does not increase complications following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

BACKGROUND: Preoperative bevacizumab has been reported to increase postoperative complication risk following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). We sought to review our experience with preoperative bevacizumab in patients undergoing CRS/HIPEC for peritoneal surface malignancy. METHODS: This is a retrospective review of patients who received neoadjuvant systemic therapy with or without bevacizumab prior to CRS/HIPEC at a high-volume academic center from 2007-2018. RESULTS: Of 499 patients, a total of 88 patients received neoadjuvant chemotherapy alone (n = 34) or in combination with bevacizumab (n = 54) within 3 months prior to CRS/HIPEC. No differences existed in 60-day major morbidity (17.6 vs. 16.7%, p = 0.81) or 60-day mortality (0 vs. 0%) between the two cohorts, and neoadjuvant bevacizumab was not associated with increased odds of overall complications (OR 0.86, 95% CI 0.35-2.09, p = 0.73) or major morbidity (OR 0.86, 95% CI 0.24-3.00, p = 0.81). Stratifying patients by primary tumor origin and post-operative complications did not reveal any significant differences between the two treatment groups. In addition, progression-free survival (PFS) and overall survival (OS) were similar in both cohorts. CONCLUSIONS: Preoperative bevacizumab is not associated with increased morbidity or mortality following CRS/HIPEC. Neoadjuvant therapy employing this biologic agent is safe and should not be a deterrent for aggressive cytoreduction with curative intent.

Thromboembolism risk of COVID-19 is high and associated with a higher risk of mortality: A systematic review and meta-analysis.

BACKGROUND: Studies have suggested that there is increased risk of thromboembolism (TE) associated with coronavirus disease 2019 (COVID-19). However, overall arterial and venous TE rates of COVID-19 and effect of TE on COVID-19 mortality is unknown. METHODS: We did a systematic review and meta-analysis of studies evaluating TE in COVID-19. We searched PubMed, Cochrane, and Embase for studies published up to June 12, 2020. Random effects models were used to produce summary TE rates and odds ratios (OR) of mortality in COVID-19 patients with TE compared to those without TE. Heterogeneity was quantified with I 2 . FINDINGS: Of 425 studies identified, 42 studies enrolling 8271 patients were included in the meta-analysis. Overall venous TE rate was 21% (95% CI:17-26%): ICU, 31% (95% CI: 23-39%). Overall deep vein thrombosis rate was 20% (95% CI: 13-28%): ICU, 28% (95% CI: 16-41%); postmortem, 35% (95% CI:15-57%). Overall pulmonary embolism rate was 13% (95% CI: 11-16%): ICU, 19% (95% CI:14-25%); postmortem, 22% (95% CI:16-28%). Overall arterial TE rate was 2% (95% CI: 1-4%): ICU, 5% (95%CI: 3-7%). Pooled mortality rate among patients with TE was 23% (95%CI:14-32%) and 13% (95% CI:6-22%) among patients without TE. The pooled odds of mortality were 74% higher among patients who developed TE compared to those who did not (OR, 1.74; 95%CI, 1.01-2.98; P = 0.04). INTERPRETATION: TE rates of COVID-19 are high and associated with higher risk of death. Robust evidence from ongoing clinical trials is needed to determine the impact of thromboprophylaxis on TE and mortality risk of COVID-19. FUNDING: None.

Monitored Anesthesia Care Is Associated With a Decrease in Morbidity After Endovascular Angioplasty in Aortoiliac Disease.

OBJECTIVES: Few studies have evaluated the association between anesthesia type and outcomes after endovascular angioplasty/stents for aortoiliac occlusive disease. The aim of the present study was to evaluate the association between primary anesthesia type and postprocedural complications for endovascular angioplasty of aortoiliac occlusion. DESIGN: Retrospective cohort study. SETTING: Multi-institutional. PARTICIPANTS: The study comprised 3,110 patients undergoing endovascular angioplasty of aortoiliac occlusive disease, with 1,974 and 1,136 patients who underwent monitored anesthesia care (MAC) and general anesthesia (GA), respectively. The American College of Surgeons National Surgical Quality Improvement Program database for the years 2012 to 2016 was used for the present study. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The final analysis included 3,110 patients, 63% of whom received MAC and 37% of whom received GA. The mean age was 64 years among the GA group, of whom 57.2% were male. The mean age among that MAC group was 65 years, 55.8% of whom were male. After adjusting for demographic factors and preoperative comorbidities, there was a statistically significant lower odds of postoperative complications (ie, pulmonary complications, infection, intraoperative/postoperative transfusion, reoperation, and amputation) and shorter length of stay in the MAC group compared with the GA group (p < 0.05). CONCLUSIONS: Although larger observational studies and randomized controlled trials are needed to further evaluate the potential effect of MAC versus GA, MAC anesthesia should be considered for patients undergoing endovascular angioplasty for aortoiliac occlusion.

Postoperative respiratory failure: An update on the validity of the Agency for Healthcare Research and Quality Patient Safety Indicator 11 in an era of clinical documentation improvement programs.

BACKGROUND: Administrative data can be used to identify cases of postoperative respiratory failure (PRF). We aimed to determine if recent changes to the Agency for Healthcare Research and Quality Patient Safety Indicator 11 (PSI 11) and adoption of clinical documentation improvement programs have improved the validity of PSI 11. We also analyzed reasons why PSI 11 was falsely triggered. STUDY DESIGN: Cross-sectional study of all eligible discharges using health record data from five academic medical centers between October 1, 2012 and September 30, 2015. RESULTS: Of 437 flagged records, 434 (99.3%) were accurately coded and 414 (94.7%) represented true clinical PRF. None of the false positive records involved respiratory failure present on admission. Most (78.3%) false positive records required airway protection but did not have respiratory failure. CONCLUSION: The validity of PSI 11 has improved with recent changes to the code criterion and adoption of clinical documentation improvement programs.

Obstruction-Free Survival Following Operative Intervention for Malignant Bowel Obstruction in Appendiceal Cancer.

BACKGROUND: Patients with peritoneal metastases from appendiceal cancer are at high risk of malignant bowel obstruction (MBO), which is associated with significant morbidity and mortality. There are no definitive treatment guidelines regarding operative intervention for MBO. We sought to evaluate the efficacy and safety of operative intervention in this population. METHODS: We identified patients with peritoneal metastases from appendiceal cancer who underwent surgery for MBO at our institution between 2011 and 2018. Baseline characteristics, postoperative complications, and follow-up data were collected. The primary endpoint was obstruction-free survival (OFS). Other endpoints were postoperative recovery of bowel function, 60-day Clavien-Dindo (CD) morbidity, and overall survival (OS). RESULTS: Twenty-six patients underwent operative treatment for MBO, of whom 14 had high-grade (HG) histology and 12 had low-grade (LG) histology. Seven (25.9%) patients had severe (CD grade 3 or higher) 60-day complications, including one (3.8%) postoperative death. All remaining patients had return of bowel function and resumed oral intake during hospitalization. Six (23.1%) patients had repeat admissions for MBO after surgery. Median OFS was 17.0 months (95% confidence interval [CI] 2.3-31.8), and median OS was 18.5 months (95% CI 3.6-33.3) following surgery. CONCLUSION: In this carefully selected group of patients with peritoneal metastases from appendiceal cancer, surgery for MBO provided durable palliation with acceptable morbidity.

The Use of Solicited Publishing by Academic Surgeons.

BACKGROUND: Few details are known about open-access surgery journals that solicit manuscripts via E-mail. The objectives of this cross-sectional study are to compare solicitant surgery journals with established journals and to characterize the academic credentials and reasons for publication of their authorship. METHODS: We identified publishers who contacted the senior author and compared their surgery journals with 10 top-tier surgical journals and open-access medical journals. We assessed the senior authorship of articles published January 2017-March 2017 and utilized a blinded survey to determine motivations for publication. RESULTS: Throughout a 6-week period, 110 E-mails were received from 29 publishers distributing 113 surgery journals. Compared with established journals, these journals offered lesser publication fees, but also had lesser PubMed indexing rates and impact factors (all P < .002). Professors, division chiefs, and department chairs were the senior authors of nearly half of US-published papers and spent ≈$83,000 to publish 117 articles in journals with a median impact factor of 0.12 and a 33% PubMed indexing rate. Survey responses revealed a dichotomy as 43% and 57% of authors published in these journals with and without knowledge of their solicitant nature, respectively. The most commonly reported reasons for submission included waived publication fees (50%), invitation (38%), and difficulty publishing elsewhere (12%). CONCLUSION: Despite their sparse PubMed indexing and low impact factors, many senior academic faculty publish in solicitant surgery journals. This study highlights the importance for the academic surgical community to be cognizant of the quality of a journal when reviewing the literature for research and evidence-based practice.

Academic Surgical Oncologists' Productivity Correlates with Gender, Grant Funding, and Institutional NCI Comprehensive Cancer Center Affiliation.

BACKGROUND: A scholar's h-index is defined as the number of h papers published, each of which has been cited at least h times. We hypothesized that the h-index strongly correlates with the academic rank of surgical oncologists. METHODS: We utilized the National Cancer Institute (NCI) website to identify NCI-designated Comprehensive Cancer Centers (CCC) and Doximity to identify the 50 highest-ranked general surgery residency programs with surgical oncology divisions. Demographic data of respective academic surgical oncologists were collected from departmental websites and Grantome. Bibliometric data were obtained from Web of Science. RESULTS: We identified 544 surgical oncologists from 64 programs. Increased h-index was associated with academic rank (p < 0.001), male gender (p < 0.001), number of National Institutes of Health (NIH) grants (p < 0.001), and affiliation with an NCI CCC (p = 0.018) but not number of additional degrees (p = 0.661) or Doximity ranking (p = 0.102). H-index was a stronger predictor of academic rank (r = 0.648) than total publications (r = 0.585) or citations (r = 0.450). CONCLUSIONS: This is the first report to assess the h-index within academic surgical oncology. H-index is a bibliometric predictor of academic rank that correlates with NIH grant funding and NCI CCC affiliation. We also highlight a previously unexpected and unappreciated gender disparity in the academic productivity of US surgical oncologists. When academic rank was accounted for, female surgical oncologists had lower h-indices compared with their male colleagues. Evaluation of the etiologies of this gender disparity is needed to address barriers to academic productivity faced by female surgical oncologists as they progress through their careers.

The Impact of Physician EHR Usage on Patient Satisfaction.

Background and Significance: The increased emphasis on patient satisfaction has coincided with the growing adoption of electronic health records (EHRs) throughout the U.S. The 2001 Institute of Medicine Report, "Crossing the Quality Chasm," identified patient-centered care as a key element of quality health care.[1] In response to this call, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey was developed to assess patients' health care experiences in the inpatient setting. Simultaneously, financial incentives have facilitated the rapid adoption of EHR applications, with 84% of hospitals maintaining at least a basic EHR in 2015 (a ninefold increase since 2008).[2]Despite the concurrent deployment of patient satisfaction surveys and EHRs, there is a poor understanding of the relationship that may exist between physician usage of the EHR and patient satisfaction. Most prior research into the impact of the EHR on physician­patient communication has been observational, describing the behaviors of physicians and patients when the clinician accesses an EHR in the exam room. Past research has shown that encounters where physicians access the EHR are often filled with long pauses,[3] and that few clinicians attempt to engage patients by sharing what they are looking at on the screen.[4] A recent meta-analysis reviewing 53 papers found that only 7 studies attempted to correlate objective observations of physician communication behaviors with patient perceptions by eliciting feedback from the patients.[5] No study used a standardized assessment tool of patient satisfaction. The authors conclude that additional work is necessary to better understand the patient perspective of the presence of an EHR during a clinical encounter.Additionally, increasing EHR adoption and emphasis on patient satisfaction have also corresponded with rising physician burnout rates.[6] [7] Prior work suggests that EHR adoption may be contributing to this trend.[8] Burnout from the EHR may be due in part to the significant amount of time physicians spend logged into systems, documenting long after clinic has ended in effort to avoid disrupting the patient­physician relationship.[9]We used existing data sources to describe the relationship between the amount of time physicians spend logged in to the EHR­both during daytime hours as well after clinic hours­and performance on a validated patient satisfaction survey. Our null hypothesis is that there is no relationship between increased time logged in to the EHR and patient satisfaction.

Increase in contralateral prophylactic mastectomy conversation online unrelated to decision-making.

BACKGROUND: The increased uptake of contralateral prophylactic mastectomy (CPM) among breast cancer patients remains poorly understood. We hypothesized that the increased rate of CPM is represented in conversations on an online breast cancer community and may contribute to patients choosing this operation. METHODS: We downloaded 328,763 posts and their dates of creation from an online breast cancer community from August 1, 2000, to May 22, 2016. We then performed a keyword search to identify posts which mentioned breast cancer surgeries: contralateral prophylactic mastectomy (n = 7095), mastectomy (n = 10,889), and lumpectomy (n = 9694). We graphed the percentage of CPM-related, lumpectomy-related, and mastectomy-related conversations over time. We also graphed the frequency of posts which mentioned multiple operations over time. Finally, we performed a qualitative study to identify factors influencing the observed trends. RESULTS: Surgically related posts (e.g., mentioning at least one operation) made up a small percentage (n = 27,678; 8.4%) of all posts on this community. The percentage of surgically related posts mentioning CPM was found to increase over time, whereas the percentage of surgically related posts mentioning mastectomy decreased over time. Among posts that mentioned more than one operation, mastectomy and lumpectomy were the procedures most commonly mentioned together, followed by mastectomy and CPM. There was no change over time in the frequency of posts that mentioned more than one operation. Our qualitative review found that most posts mentioning a single operation were unrelated to surgical decision-making; rather the operation was mentioned only in the context of the patient's cancer history. Conversely, the most posts mentioning multiple operations centered around the patients' surgical decision-making process. CONCLUSIONS: CPM-related conversation is increasing on this online breast cancer community, whereas mastectomy-related conversation is decreasing. These results appear to be primarily informed by patients reporting the types of operations they have undergone, and thus appear to correspond to the known increased uptake of CPM.