Missing the Match: A National Survey Investigating Education in Renal Donor-Recipient Matching.

PURPOSE: Clinical judgment in renal donor organ and recipient selection is gained through fellowship and mentorship in early career. We aim to understand the past and current state of organ acceptance education. METHODS: We developed and distributed an anonymous, national survey to American Society of Transplant Surgeons faculty members and transplant surgery fellows in 2022. Survey questions explored in detail the evaluation of organ offers, the extent of formal education in organ evaluation, and attitudes regarding training adequacy. FINDINGS: Ninety-eight attending surgeons (65 men, 25 women, and 3 nonbinary) and 38 fellows (25 men, 6 women, and 2 nonbinary) responded. Seventy-eight percent of attending surgeons and 6% of fellows take primary organ offers. Forty-four percent of fellows report no didactic education in donor evaluation and recipient selection. Fellows report that discussion with attending surgeons (37.2%) and independent study of the literature (35.4%) are their primary modes of learning. Fellows call for additional clinical decision-making experience (47.3%), further didactic sessions (44.7%), and additional discussions with faculty (44.7%). Sixty-four percent of fellows and 55% of attendings felt their training provided adequate education about donor selection. CONCLUSION: Our responses suggest gaps in education regarding donor and recipient selection. Increased clinical experience and standardized education at the national level represent opportunities for improvement.

What influences general surgery residents' prospective entrustment and operative time in robotic inguinal hernia repairs.

INTRODUCTION: Teaching residents robotic-assisted inguinal hernia repair (RIHR) is an increasingly common extension of contemporary surgical training. This study sought to investigate what variables would influence operative time (OT) and resident prospective entrustment in RIHR cases. METHODS: We prospectively collected 68 resident RIHR operative performance evaluations with a validated instrument. Outpatient RIHR cases performed by 11 general surgery residents during 2020-2022 were included. The overall OT of matched cases was extracted from hospital billing; matched procedural step-specific OT was obtained from Intuitive Data Recorder (IDR). Statistical analysis was performed using Pearson correlation and one-way ANOVA. RESULTS: The evaluation instrument reliably assessed residents' RIHR performance (Cronbach's α = 0.93); residents' prospective entrustment strongly correlated with overall guidance provided by attending surgeon (r = 0.86, p < 0.0001) and operative plan and judgment (r = 0.85, p < 0.0001). The overall OT was significantly associated with resident's team management (r = - 0.35, p = 0.011). Procedural step-specific OT was significantly associated with residents' step-specific skill (r = - 0.32, p = 0.014). On average, RIHR cases with the highest level of prospective entrustment (Resident can teach junior) showed the shortest step-specific OT. Entrustment level 3 (Reactive guidance needed) was the turning point of all four RIHR procedural step-specific OT. CONCLUSIONS: Our findings suggest that in RIHR, attending guidance, resident operative plan and judgment, and resident technical skill contribute to resident prospective entrustment; resident team management, technical skill, and attending guidance influence operative time, which in turn impacts attendings' determination of resident prospective entrustment. Future studies with a larger sample size are needed to further validate the findings.

Is Robotic Console Time a Surrogate for Resident Operative Autonomy?

OBJECTIVE: Robotic-assisted surgery is an increasing part of general surgery training, but resident autonomy on the robotic platform can be hard to quantify. Robotic console time (RCT), the percentage of time the resident controls the console, may be an appropriate measure of resident operative autonomy. This study aims to characterize the correlation between objective resident RCT and subjectively scored operative autonomy. METHODS: Using a validated resident performance evaluation instrument, we collected resident operative autonomy ratings from residents and attendings performing robotic cholecystectomy (RC) and robotic inguinal hernia repair (IH) at a university-based general surgery program between 9/2020-6/2021. We then extracted RCT data from the Intuitive surgical system. Descriptive statistics, t-tests and ANOVA were performed. RESULTS: A total of 31 robotic operations (13 RC, 18 IH) performed by 4 attending surgeons and 8 residents (4 junior, 4 senior) were matched and included. 83.9% of cases were scored by both attending and resident. The average RCT per case was 35.6%(95% CI 13.0%,58.3%) for junior residents (PGY 2-3) and 59.7%(CI 51.1%,68.3%) for senior residents (PGY 4-5). The mean autonomy evaluated by residents was 3.29(CI 2.85,3.73) out of a maximum score of 5, while the mean autonomy evaluated by attendings was 4.12(CI 3.68,4.55). RCT significantly correlated with subjective evaluations of resident autonomy (r=0.61, p=0.0003). RCT also moderately correlated with resident training level (r=0.5306, p<0.0001). Neither attending robotic experience nor operation type significantly correlated with RCT or autonomy evaluation scores. CONCLUSIONS: Our study suggests that resident console time is a valid surrogate for resident operative autonomy in robotic cholecystectomy and inguinal hernia repair. RCT may be a valuable measure in objective assessment of residents' operative autonomy and training efficiency. Future investigation into how RCT correlates with subjective and objective autonomy metrics such as verbal guidance or distinguishing critical operative steps is needed to validate the study findings further.

Patients are pragmatic and physicians are perfectionists? Comparing success after liver transplantation among patients and physicians.

Although both patients and physicians are key stakeholders in health care outcomes, patients and physicians often define success differently. The purpose of this study was to compare patient and physician perceptions of success 1 year after liver transplantation. This was a single-institution, qualitative study. We conducted in-person, semi-structured interviews with liver transplant recipients 1 year after transplantation and virtual interviews with transplant surgeons and hepatologists. Transcripts were coded and iteratively analyzed for themes using the principles of phenomenology. Twenty patients, 8 caregivers, 5 transplant surgeons, and 4 hepatologists were interviewed. Subject interviews averaged 57 (patient) and 27 (physician) minutes. Overall, patients and physicians had significant agreement in their definitions of success, which included avoidance of death, restoration of physical and mental function, return to society, acquisition of new health care knowledge, and open communication between the patient and the physician. Patients highlighted relief from worry about their future health status, and physicians highlighted decreased health care costs. Patients noted that a liver transplant did not have to be perfect, that is free from complications, to be successful. Physicians had a more stringent view and felt that any deviation from an ideal course reduced the relative success of a transplant. Detailed assessment of patient and physician responses reveals similar overall goals of regaining physical, mental, and emotional function. Complications are perceived differently by patients and physicians. Awareness of this discordance may serve to enhance relationships between transplant patients and their providers.

Distortions in the Balance Between Teaching and Efficiency in the Operating Room.

INTRODUCTION: The balance between teaching and operative efficiency (i.e., continuing operative case progression) is difficult for even the most experienced master surgeon educators. The purpose of this study was to explore influencing factors behind attending surgeons' decisions to break the balance between operative efficiency and teaching in the operating room. METHODS: Semistructured interviews were conducted with surgeons across the United States via Web-based video conferencing. The interviews were audio-recorded and transcribed. Qualitative analysis using the framework method was utilized, and emergent themes were identified. RESULTS: Twenty-three attending surgeons from 8 academic institutions and 11 surgical specialties completed interviews (14 men and 9 women). Attending surgeons consider a variety of factors associated with their dual roles (surgeon versus teacher) when balancing operative efficiency and providing appropriate independence for residents with oversight to promote autonomy. These were divided into surgeon-role-related factors (patient safety, financial factors, scheduling factors, preservation of faculty reputation for efficiency, and mode of operation) as well as teacher-role-related factors (preparation, level, and technical skill of the resident). These factors then informed attending surgeons' determinations about how the case was progressing, which prompted them to intervene and reduce resident autonomy or allow the resident to continue. CONCLUSIONS: Surgeons consider numerous factors when deciding how to balance resident teaching and autonomy while preserving operative efficiency. These findings provide helpful insights for surgical departments to consider inclusion in faculty-development programs, resident education, and systematic improvements.

Relationship Between Gender, Training Level and Goal Orientation Achievement Motivation: Implications for Learners and Faculty.

PURPOSE: Achievement goal orientation (GO) theory describes Mastery (M), one's intrinsic drive for competency for the sake of competency, and performance approach (PAP), a drive for competency by displaying competency, which are both adaptive. In learners motivated by performance avoid (PAV), showing competency by avoiding appearing incompetent dominates (maladaptive). The aim of this study was to determine differences in GO by gender and training (PGY) level. METHODS: A prospective, multi-institutional cohort of general surgery trainees participated in a cross-sectional study (2020-2021). Participants completed a 10-item instrument (the Goal Orientation in Surgical Trainees, GO-ST) measured on a 5-pointLikert scale (1 = never,3 = weekly,5 = daily). Student's t-tests and ANOVA F-test were used as appropriate. RESULTS: A total of 144/164 trainees participated (87.8%). The sample was 40.0%(n = 56) female and 57.9%(n = 81) male; 21.3%(n = 30) were PGY1, 22.0%(n = 31) PGY2, 24.8%(n = 35) PGY3, 18.4%(n = 26) PGY4, 13.5%(n = 19) PGY5. There were no significant differences in mean scale scores by gender for Mastery (3.3 vs 3.5; p = 0.17), or PAP (3.7 vs 3.5; p = 0.10), but mean PAV scores were significantly higher for females (3.6 vs 3.3; p = 0.04). While there were no significant differences in mean Mastery and PAP scale scores by training level (p = 0.44; p = 0.31), there was a significant difference in PAV scores (p < 0.01). The frequency of PAV feelings decreased over 5 years. CONCLUSIONS: Only PAV motivation differed by gender and training level. Understanding the psychology of motivation with this framework can aid both residents and programs in re-focusing on more adaptive learning strategies and supporting trainees in their transition to master surgeons.

Length of stay and surgical site complications are not increased after elective incisional hernia in patients with a history of solid organ transplantation.

BACKGROUND: The incidence of ventral hernia development after solid organ transplantation has been reported to be up to 30%. We aim to determine the impact of previous solid organ transplant on post-operative length of stay (LOS) and surgical site complications in elective ventral hernia repairs. METHODS: A retrospective review of prospectively collected data from the Abdominal Core Health Quality Collaborative (ACHQC) was conducted to include all patients age 18 years or older who underwent elective incisional hernia repair. Those with and without a history of solid organ transplantation were compared. The primary outcome was in-hospital LOS. Secondary outcomes included 30-day surgical site infection (SSI) rate, 30-day surgical site occurrence requiring procedural intervention (SSOPI) rate, 30-day overall post-operative complications and recurrence. The association between transplant and the LOS was tested with a negative binomial regression model adjusted for the demographic characteristics, comorbidities and hernia characteristics in the model. RESULTS: The population analyzed included 13,452 (98.79%) patients without a history of organ transplantation and 165 (1.21%) patients who had a history of organ transplantation. After adjusting for age, hernia width, BMI, gender, race, insurance type, ASA class, hypertension, dyspnea, OR time > 2 h, abdominal wall SSI history, recurrent hernia, operative approach the median LOS was not significantly different between patients with a history of solid organ transplant [2.8 (2.6, 2.9) days] and those without [2.6 days (2.2, 3.1)] (p = 0.5). The proportion of SSI (2.4% vs 4.04%; p = 0.42), SSOPI (4.2% vs 5.8%; p = 0.38) and recurrence (0.6% vs 0.4%, p = 0.51) was similar between both groups. Other remaining 30-day post-operative were negligible in our sample. CONCLUSIONS: There were no significant differences in LOS or infection rates between patients with and without a history of solid organ transplantation despite known risks of immunosuppression and chronic steroid use. Therefore, although these patients have many classic risk factors for poor outcomes, the data suggest that their history of solid organ transplantation should not preclude them from surgery.

The long game: Evolution of clinical decision making throughout residency and fellowship.

BACKGROUND: The purpose of this study was to explore the trajectory of autonomy in clinical decision making. METHODS: We conducted a qualitative secondary analysis of interviews with 45 residents and fellows from the General Surgery and Obstetrics & Gynecology departments across all clinical postgraduate years (PGY) using convenience sampling. Each interview was recorded, transcribed and iteratively analyzed using a framework method. RESULTS: A total of 16 junior residents, 22 senior residents and 7 fellows participated in 12 original interviews. Early in training residents take their abstract ideas about disease processes and make them concrete in their applications to patient care. A transitional stage follows in which residents apply concepts to concrete patient care. Chief residents re-abstract their concrete technical and clinical knowledge to prepare for future surgical practice. CONCLUSIONS: Understanding where each learner is on this pathway will assist development of curriculum that fosters resident readiness for practice at each PGY level.

All Politics Are Local: A Single Institution Investigation of the Educational Impact of Residents and Fellows Working Together.

BACKGROUND: Most general surgery residents pursue fellowship; there is limited understanding of the impact residents and fellows have on each other's education. The goal of this exploratory survey was to identify these impacts. MATERIALS AND METHODS: Surgical residents and fellows at a single academic institution were surveyed regarding areas (OR assignments, the educational focus of the team, roles and responsibilities on the team, interpersonal communication, call, "other") hypothesized to be impacted by other learners. Impact was defined as "something that persistently affects the clinical learning environment and a trainee's education or ability to perform their job". Narrative responses were reviewed until dominant themes were identified. RESULTS: Twenty-three residents (23/45, 51%) and 12 fellows (12/21, 57%) responded. Responses were well distributed among resident year (PGY-1:17% [4/23], PGY-2, 35% [8/23], PGY-3 26% [6/23], PGY-4 9% [2/23%], PGY-5 13% [3/23]). Most residents reported OR assignment (14/23, 61%) as the area of primary impact, fellows broadly reported organizational categories (Roles and responsibilities 33%, educational focus 16%, interpersonal communication 16%). Senior residents reported missing out on operations to fellows while junior residents reported positive impacts of operating directly with fellows. Residents of all levels reported that fellows positively contributed to their education. Fellows, senior residents, and junior residents reported positive experiences when residents and fellows operated together as primary surgeon and assistant. CONCLUSIONS: Residents and fellows impact one another's education both positively and negatively. Case allocation concerns senior residents, operating together may alleviate this, providing a positive experience for all trainees. Defining a unique educational role for fellows and delineating team expectations may maximize the positive impacts in this relationship.

Education Morbidity and Mortality: Reviving Intraoperative Teaching and Learning.

BACKGROUND: Using the platform of morbidity and mortality conference, we developed and executed a combined faculty-resident intervention called "Education M&M" to discuss challenges faced by both parties in the operating room (OR), identify realistic solutions, and implement action plans. This study aimed to investigate the impact of this intervention on resident OR training. MATERIALS AND METHODS: Two resident case presentations were followed by audience discussion and recommendations regarding actionable solutions aimed at improving resident OR training from an expert faculty panel. Postintervention surveys were completed by participants immediately and 2 mo later to assess perceived short and long-term impact on OR teaching and/or learning and the execution of two recommended solutions. Descriptive statistical analysis was applied. RESULTS: Immediate post-intervention surveys (n = 44) indicated that 81.8% of participants enjoyed the M&M "a lot"; 90.1% said they would use some or a lot of the ideas presented. Awareness of OR teaching/learning challenges before and after the M&M improved from 3.0 to 3.7 (P = 0.00001) for faculty and 3.0 to 3.9 for trainees (P = 0.00004). Understanding of OR teaching and/or learning approaches improved from 3.1 to 3.7 for faculty (P = 0.00004) and 2.7 to 3.9 for trainees (P = 0.00001). In 2-mo post-intervention surveys, most residents had experienced two recommended solutions (71% and 88%) in the OR, but self-reported changes to faculty behavior did not reach statistical significance. CONCLUSIONS: A department-wide education M&M could be an effective approach to enhance mutual communication between faculty members and residents around OR teaching/learning by identifying program-specific challenges and potential actionable solutions.

Resident Self-Entrustment and Expectations of Autonomy: OB > GYN?

INTRODUCTION: Entrustment is a key component connecting to resident preparedness for surgical practice in the operating room (OR). Residents' self-entrustment of their surgical competencies closely associates with their OR training experience and granted autonomy. Some recent studies have investigated how attending surgeons entrusted residents in the OR. There is little to no data, however, in examining these issues from the resident perspective. The goal of this study was to identify the perception and expectations of autonomy from residents' perspective, as well as the self-entrustment of their surgical competencies in obstetrics (OB) and gynecologic (GYN) procedures. METHODS: Focus group interviews of OB/GYN residents were performed. Residents were selected by convenience sampling. Audio recordings of each interview were transcribed, iteratively analyzed, and emergent themes identified, using a framework method. RESULTS: A total of 123 minutes of interviews were recorded. Eight junior residents (PGY1-2) and 12 senior residents (PGY3-4) participated. Our data illustrated that (1) the perception of autonomy shifted significantly throughout residency training; (2) residents demonstrated higher expectations and self-entrustment for OB surgical procedures than for GYN surgical procedures upon graduation; and (3) case volume, modalities of OR teaching and mutual communication are 3 factors influencing resident self-entrustment of their surgical competencies. CONCLUSIONS: Residents showed disparities in their self-entrustment and expectations of autonomy between OB and GYN surgical procedures. Better understanding these differences and the 3 influencing factors could help programs develop a potential solution for improvement in resident entrustment and autonomy upon graduation.

Residents' method for gaining operative autonomy.

INTRODUCTION: The goal of this study was to explore the resident construct for their perceived successful method of actions that lead to OR autonomy during residency and the strategies they employed. METHODS: We conducted focus group interviews with residents from the General Surgery (GS) and Obstetrics & Gynecology (OBGYN) departments at a single academic institution across all clinical postgraduate years (PGY) using convenience sampling. Audio recordings of each interview were transcribed, analyzed and emergent themes were identified using a framework method. RESULTS: A total of 38 residents participated. A 3-stage resident method to gain operative autonomy emerged. This progresses from building rapport, developing mutual entrustment, and finally to obtaining autonomy. We identified 4 common strategies used by residents to construct this method: smart communication, attention to attending preferences, helpful allies and visible attributes. CONCLUSION: Our findings provide insight into resident strategies to achieve progressive autonomy in the OR helping programs improve resident's learning efficiency.

The Construction of Case-Specific Resident Learning Goals.

OBJECTIVE: Developing resident autonomy in the operating room is a complex process and resident established case specific learning goals may increase resident operating room training efficiency. However, little is understood about residents' experience identifying learning goals for a given case. The aim of this study was to explore the essential components contributing to surgery residents' identification of specific learning goals for surgical cases. DESIGN: We conducted focus group interviews with general surgery residents across all post-graduate years (PGY) through convenience sampling. Audio recordings of each interview were transcribed and iteratively analyzed. Emerging themes were identified using a framework method. SETTING: The study was conducted within the Department of General Surgery at the Ohio State University Medical Center, a tertiary academic medical center. PARTICIPANTS: Eight junior (PGY 1-2) and 10 senior (PGY 3-5) residents participated, of whom 10 were female and 8 were male. RESULTS: On average, each focus group interview lasted 57.00 (SD ± 12.99) minutes. Three essential components of residents' creation of case-specific learning goals emerged from the focus group interviews: medical knowledge, surgical experience and entrustment. Residents require baseline knowledge and surgical experience with an operation to identify the learning goal they would aim to execute. They also require entrustment of themselves and support of the attending to accomplish the case specific learning goal. Differences in the possession of these three components would likely influence differences in the ability to create learning goals between junior and senior residents. CONCLUSIONS: Medical knowledge, surgical experience and entrustment are 3 factors that are imperative to the creation of a resident's case specific learning goal. The complex combination of these three components contributes to the building of the learning goal prior to the start of the operation. Elucidating these aspects provides additional information for targeted interventions in the future.

Approaches to the Salvage of Axillary Bilateral Femoral Bypass in Patients with Claudication due to Demand Ischemia.

The axillary bilateral femoral bypass is often utilized as an alternative to in-line aortic reconstruction in patients with multiple medical comorbidities, who would be unable to tolerate open abdominal surgery with an aortic clamp, or patients with mycotic aneurysms, or infected grafts. Idealized fluid mechanics suggest that there would be equal flow in an axillary bilateral femoral bypass when compared to in-line reconstruction. However, in a non-idealized state, friction results in kinetic energy loss and decreased volume flow to the lower extremities in the longer, smaller diameter graft. Although older or less active people may tolerate the lower volume flow of a long segment extra-anatomic bypass, there is growing evidence that a subset of patients will be symptomatic from reduced flow volumes. Here we present 3 patients in whom symptomatic relief was achieved with the addition of a contralateral axillary femoral bypass and ligation of the previous femorofemoral component.

Practices and Perceptions Among Surgical Oncologists in the Perioperative Care of Obese Cancer Patients.

BACKGROUND: Obesity and cancer are two common diseases in the United States. Although there is an interaction of obesity and cancer, little is known about surgeon perceptions and practices in the care of obese cancer patients. We sought to characterize perceptions and practices of surgical oncologists regarding the perioperative care of obese patients being treated for cancer. METHODS: A cross-sectional survey was designed, pilot tested, and utilized to assess perceptions and practices of surgeons treating cancer patients. Surgical oncologists were identified using a commercially available database, and Qualtrics® was used to distribute and manage the survey. Statistical analyses were completed by using SPSS. RESULTS: Of the 1731 electronic invitations, 172 recipients initiated the survey, and 157 submitted responses (91.2%). Many surgeons (65.7%) believed that obese patients are more likely to present with more advanced cancers and were more likely than system factors to explain this delayed treatment [t(87) = 4.84; p < 0.001]. Nearly two-thirds of providers (64.5%) reported that obesity had no impact on the timing of surgery; however, one-third of respondents (34.2%) were more likely to recommend preoperative nonsurgical therapy rather than upfront surgery among obese patients. For operations of the chest/abdomen and breast/soft tissue, surgeons perceived obesity to be more related to risk of postoperative than intraoperative complications (chest/abdomen mean 4.13 vs. 3.26; breast/soft tissue 4.11 vs. 2.60; p < 0.001). CONCLUSIONS: One in three surgeons reported that patient obesity would change the timing/sequence of when resection would be offered. Many surgeons perceived that obesity was related to a wide array of intra- and postoperative adverse outcomes.

Pre-operative Sarcopenia Identifies Patients at Risk for Poor Survival After Resection of Biliary Tract Cancers.

INTRODUCTION: Biliary tract cancers (BTC) are aggressive malignancies that require complex surgical procedures. Patients with BTC can present with skeletal muscle depletion, yet the effects of muscle wasting (sarcopenia) on outcomes have not been well studied. The objective of the current study was to define the impact of sarcopenia on survival among patients undergoing resection of BTC. METHODS: Patients who underwent exploration for BTC who had a pre-operative CT scan available for review were identified. Body composition variables including total and psoas muscle area (cm2), muscle density (Hounsfield units), visceral fat area, subcutaneous fat area, and waist-to-hip ratio were analyzed at the level of L3. Outcomes were assessed according to the presence or absence of sarcopenia defined using sex- and BMI-specific threshold values for Psoas Muscle Index (PMI, cm2/m2). RESULTS: Among 117 patients with BTC, 78 (67%) underwent curative-intent resection and 39 (33%) were explored but did not undergo resection due to metastatic/locally advanced disease. Tumor type included distal cholangiocarcinoma (n = 18, 15.4%), hilar cholangiocarcinoma (n = 27, 23.1%), gallbladder carcinoma (n = 52, 44.4%), and intrahepatic cholangiocarcinoma (n = 20, 17.1%). Median patient age was 65.6 years and 43.6% were male. Mean patient BMI was 26.1 kg/m2 among men and 27.5 kg/m2 among women. Overall, 41 (35.0%) patients had sarcopenia. Sarcopenia was associated with an increased risk of death among patients who underwent resection (HR 3.52, 95%CI 1.60-7.78, p = 0.002), which was comparable to patients with unresectable metastatic disease. Other factors such as low serum albumin (HR 3.17, 95% CI 1.30-7.74, p = 0.011) and low psoas density (HR 2.96, 95% CI 1.21-7.21, p = 0.017) were also associated with increased risk of death. Survival was stratified based on sarcopenia, psoas density, and serum albumin. The presence of each variable was associated with an incremental increased risk of death (0 variables ref.; 1 variable HR 3.8, 95% CI 1.0-14, p = 0.043; 2 variables HR 13.1, 95% CI 3.0-57.7, p = 0.001; 3 variables HR 14.6, 95% CI 2.5-87.1, p = 0.003). Patients who had no adverse prognostic factors had a 3-year OS of 67% versus no survival among patients with all 3 factors. CONCLUSIONS: Sarcopenia was common among patients undergoing resection of BTC, occurring in 1 of every 3 patients. Sarcopenia was associated with poor survival after resection, particularly among patients who experienced a recurrence. Body composition metrics such as sarcopenia and low psoas muscle density in addition to low albumin level were able to stratify patients into different prognostic categories.

A high burden of comorbid conditions leads to decreased survival in breast cancer.

BACKGROUND: Despite our most advanced medical and surgical treatment 40,000 women die from breast cancer each year. The aging population and their increasing burden of comorbidities may not be able to realize the full benefit of treatments due to a combination of the side effects and patient frailty. The aim of this study was to characterize the comorbidities of breast cancer patients and to determine if the number of comorbidities is a significant contributor to survival. METHODS: A database including patients from the year 2002 to 2012 was created to include health comorbidities from the electronic medical record. Patients were classified into groups according to their number of comorbidities. Disease free and overall survival was calculated for each patient. A one-way analysis of variance was then performed to determine if there was a difference in survival. RESULTS: A total of 279 patients were included: predominately African American (48.7%), female (98.6%) and late middle age (average age =56.1 years). The average number of comorbidities was 2.2 with hypertension and obesity being the most common. Significant differences were found in the number of comorbidities between African Americans (2.61) and Caucasians (1.78) (P<0.005). Disease free survival and overall survival according to number of comorbidities were both significantly different (F=2.775, P<0.008; F=3.684, P<0.001) with a threshold of decreased survival at six comorbidities. CONCLUSIONS: The population of women who face breast cancer is heterogeneous with a wide variety of comorbidities, which negatively impact their survival.

Murine model of long-term obstructive jaundice.

BACKGROUND: With the recent emergence of conjugated bile acids as signaling molecules in cancer, a murine model of obstructive jaundice by cholestasis with long-term survival is in need. Here, we investigated the characteristics of three murine models of obstructive jaundice. METHODS: C57BL/6J mice were used for total ligation of the common bile duct (tCL), partial common bile duct ligation (pCL), and ligation of left and median hepatic bile duct with gallbladder removal (LMHL) models. Survival was assessed by Kaplan-Meier method. Fibrotic change was determined by Masson-Trichrome staining and Collagen expression. RESULTS: Overall, 70% (7 of 10) of tCL mice died by day 7, whereas majority 67% (10 of 15) of pCL mice survived with loss of jaundice. A total of 19% (3 of 16) of LMHL mice died; however, jaundice continued beyond day 14, with survival of more than a month. Compensatory enlargement of the right lobe was observed in both pCL and LMHL models. The pCL model demonstrated acute inflammation due to obstructive jaundice 3 d after ligation but jaundice rapidly decreased by day 7. The LHML group developed portal hypertension and severe fibrosis by day 14 in addition to prolonged jaundice. CONCLUSIONS: The standard tCL model is too unstable with high mortality for long-term studies. pCL may be an appropriate model for acute inflammation with obstructive jaundice, but long-term survivors are no longer jaundiced. The LHML model was identified to be the most feasible model to study the effect of long-term obstructive jaundice.