Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 85
Filtrar
Mais filtros










Base de dados
Intervalo de ano de publicação
1.
Am J Surg ; 2019 Sep 10.
Artigo em Inglês | MEDLINE | ID: mdl-31526512

RESUMO

BACKGROUND: The purpose of this study was to examine the reliability and the validity of the new surgical entrustable professional activities (SEPAs) instruments. METHODS: A prospective evaluation of six procedure-specific SEPAs instruments derived from the validated OPRS evaluation tools was conducted in 2018. Each instrument includes an open-ended feedback item and a series of Likert-Scale rating items. Attending, resident and a constant 3rd surgeon-observer completed the same evaluation for the observed case within 3 days of each evaluated operation. RESULTS: 40 cases performed by 10 residents and 11 attending surgeons were observed and evaluated. The SEPAs instruments were supported by strong validity evidence. Factor analysis revealed three latent variables are consistent with the core construct of SEPAs instrument. Internal reliability was high with Cronbach's α ranging from 0.84 to 0.94 across the six procedures. Test-retest reliability varied from 0.74 to 0.93 in the study sample. CONCLUSIONS: The SEPAs instruments are reliable and valid tools for assessment of crucial aspects of resident learning and surgical entrustable professional activities that lead to entrustment and eventually surgical autonomy.

2.
Ann Surg ; 270(2): e22, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31188221
4.
Surgery ; 164(4): 726-732, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30098811

RESUMO

BACKGROUND: In 2008, we projected that a deficit in the general surgical workforce would grow to 19% by 2050. We reexamined population-based general surgical workforce projections to determine the impact of recent changes in population estimates and trends in certification and General Surgery Residency. METHODS: We reviewed the Census Bureau data and the potential pool of general surgeons defined by American Board of Surgery certificates, residents completing Accreditation Council for Graduate Medical Education-approved General Surgery Residency and combined American Board of Surgery and osteopathic certificates averaged from 2007-2016. The model included removal of 150 surgeons/year who subspecialize and 729 retirements/year. RESULTS: Updated census projections estimate a 2050 U.S. population of 439 million, a 19 million increase over prior census projections. From 2007-2016, the American Board of Surgery granted 10,173 certificates, averaging 1,017/year; General Surgery Residency graduations were 10,088, averaging 1,088/year; combined American Board of Surgery and osteopathic (American Osteopathic Association) certificates were 10,084, averaging 1,084/year. General surgical workforce shortage in 2050 is projected to be 7,047 (21%) based on American Board of Surgery certificates; 4,917(15%) based on General Surgery Residency completions; 5,037 (15%) based on combined American Board of Surgery and American Osteopathic Association certificates; and 57 (0%) based on hypothetical expansion of general surgeons training by 75 positions by 2021. CONCLUSIONS: Without increasing future general surgeons training numbers, the projected future general surgical workforce shortage will continue to grow.


Assuntos
Cirurgia Geral/educação , Internato e Residência , Cirurgiões/provisão & distribução , Certificação , Humanos , Estados Unidos , Recursos Humanos
6.
J Gastrointest Surg ; 22(10): 1688-1696, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29855870

RESUMO

OBJECTIVE: To estimate the cost of rescue and cost of failure and determine cost-effectiveness of rescue from major complications at high-volume (HV) and low-volume (LV) centers METHODS: Ninety-six thousand one hundred seven patients undergoing liver resection were identified from the Nationwide Inpatient Sample (NIS) between 2002 and 2011. The incremental cost of rescue and cost of FTR were calculated. Using propensity-matched cohorts, a cost-effectiveness analysis was performed to determine the incremental cost-effectiveness ratio (ICER) between HV and LV hospitals. RESULTS: Ninety-six thousand one hundred seven patients were identified in NIS. The overall mortality was 2.3% and was lowest in HV centers (HV 1.4% vs. MV 2.1% vs. LV 2.6%; p < 0.001). Major complications occurred in 14.9% of hepatectomies and were comparable regardless of volume (HV 14.2% vs. MV 14.3% vs. LV 15.4%; p < 0.001). The FTR rate was substantially lower among HV centers (HV 7.7%, MV 11%, LV 12%; p < 0.001). At a willingness to pay benchmark of $50,000 per year of life saved, both HV (ICER = $3296) and MV (ICER = $4182) centers were cost-effective at rescuing patients from a major complication compared to LV hospitals. CONCLUSION: Not only was FTR less common at HV hospitals, but the management of most major complications was cost-effective at higher volume centers.


Assuntos
Falha da Terapia de Resgate/economia , Hepatectomia/economia , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Idoso , Análise Custo-Benefício , Bases de Dados Factuais , Falha da Terapia de Resgate/estatística & dados numéricos , Feminino , Hepatectomia/mortalidade , Mortalidade Hospitalar , Hospitais com Baixo Volume de Atendimentos/economia , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Estados Unidos/epidemiologia
7.
Surgery ; 163(3): 553-559, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29179915

RESUMO

BACKGROUND: Assessments of the future general surgery workforce continue to project substantial shortages of general surgeons. The general surgery workforce is targeted currently to maintain a surgeon/population ratio of 6.5-7.5/100,000. METHODS: We examined population and age-associated incidence of cancer to estimate the number of general surgeons needed for initial surgical treatment of the patient with cancer in the year 2035 compared with 2010. We hypothesized that the number of general surgeons needed to provide future cancer care will exceed the projections of available general surgeons based on current training numbers, as well as on population-based ratios alone. RESULTS: The total number of new patients with cancers treated by general surgeons is projected to increase 56% (511,450 in 2010 to 798,070 in 2035). To maintain the same patient census per surgeon, it is estimated that 34,698 general surgeons will be needed. This is an increase of 9,198 over that based on current training numbers and 5,300-7,400 greater than the need projected by population growth alone. CONCLUSION: The analysis supports the hypothesis that an increasing incidence of cancer in the future will exceed the potential capacity of the general surgeon workforce. Regionalization of cancer care may be one solution to projected access issues.


Assuntos
Cirurgia Geral/tendências , Necessidades e Demandas de Serviços de Saúde/tendências , Neoplasias/epidemiologia , Neoplasias/cirurgia , Crescimento Demográfico , Fatores Etários , Idoso , Feminino , Humanos , Incidência , Masculino , Estados Unidos/epidemiologia , Recursos Humanos
8.
Clin Cancer Res ; 23(2): 489-502, 2017 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-27435400

RESUMO

PURPOSE: Alternative strategies to EGFR blockage by mAbs is necessary to improve the efficacy of therapy in patients with locally advanced or metastatic pancreatic cancer. One such strategy includes the use of NK cells to clear cetuximab-coated tumor cells, as need for novel therapeutic approaches to enhance the efficacy of cetuximab is evident. We show that IL-21 enhances NK cell-mediated effector functions against cetuximab-coated pancreatic tumor cells irrespective of KRAS mutation status. EXPERIMENTAL DESIGN: NK cells from normal donors or donors with pancreatic cancer were used to assess ADCC, IFN-γ release, and T-cell chemotaxis toward human pancreatic cancer cell lines. The in vivo efficacy of IL-21 in combination with cetuximab was evaluated in a subcutaneous and intraperitoneal model of pancreatic cancer. RESULTS: NK cell lysis of cetuximab-coated wild-type and mutant kras pancreatic cancer cell lines were significantly higher following NK cell IL-21 treatment. In response to cetuximab-coated pancreatic tumor cells, IL-21-treated NK cells secreted significantly higher levels of IFN-γ and chemokines, increased chemotaxis of T cells, and enhanced NK cell signal transduction via activation of ERK and STAT1. Treatment of mice bearing subcutaneous or intraperitoneal EGFR-positive pancreatic tumor xenografts with mIL-21 and cetuximab led to significant inhibition of tumor growth, a result further enhanced by the addition of gemcitabine. CONCLUSIONS: These results suggest that cetuximab treatment in combination with IL-21 adjuvant therapy in patients with EGFR-positive pancreatic cancer results in significant NK cell activation, irrespective of KRAS mutation status, and may be a potential therapeutic strategy. Clin Cancer Res; 23(2); 489-502. ©2016 AACR.


Assuntos
Interleucinas/imunologia , Células Matadoras Naturais/imunologia , Neoplasias Pancreáticas/terapia , Proteínas Proto-Oncogênicas p21(ras)/genética , Linfócitos T/imunologia , Animais , Citotoxicidade Celular Dependente de Anticorpos/efeitos dos fármacos , Linhagem Celular Tumoral , Cetuximab/administração & dosagem , Quimiotaxia/efeitos dos fármacos , Quimiotaxia/imunologia , Citometria de Fluxo , Humanos , Interferon gama/biossíntese , Interferon gama/imunologia , Interleucinas/metabolismo , Ativação Linfocitária/efeitos dos fármacos , Ativação Linfocitária/imunologia , Camundongos , Neoplasias Pancreáticas/genética , Neoplasias Pancreáticas/imunologia , Neoplasias Pancreáticas/patologia , Linfócitos T/efeitos dos fármacos , Ensaios Antitumorais Modelo de Xenoenxerto
9.
J Gastrointest Surg ; 20(9): 1581-5, 2016 09.
Artigo em Inglês | MEDLINE | ID: mdl-27230996

RESUMO

BACKGROUND: The work-up of cystic lesions of the pancreas often involves endoscopic ultrasound (EUS) with fine needle aspiration (FNA). In addition to CEA and amylase measurement, fluid is routinely sent for cytologic examination. We evaluated the utility of cytologic findings in clinical decision-making. MATERIALS AND METHODS: Records of patients who underwent EUS-guided pancreatic cyst aspiration were reviewed. Findings from axial imaging and EUS were compared to cyst fluid cytology as well as fluid amylase and CEA. All results were then compared to final diagnosis, determined by clinical analysis for those patients not resected, and surgical pathology report for those who underwent resection. RESULTS: A total of 167 patients were reviewed. Of 48 patients with suspicious findings on imaging, cytology yielded diagnostic information in 89.6 % of cases (43 patients). However, in the 119 patients where no suspicious components were revealed on imaging, fluid cytology yielded no significant diagnostic results in any case. In all cases where mucin was noted on cytologic review, thick fluid was also seen at the time of aspiration. DISCUSSION: In our cohort of patients with cystic pancreatic lesions, cytologic analysis of pancreatic cyst fluid yielded no diagnostic benefit over radiologic findings alone. In such cases where fluid is to be aspirated, specimens that would otherwise be sent for cytologic evaluation would be better served for other purposes, such as molecular analysis or banking for future research.


Assuntos
Líquido Cístico/citologia , Cisto Pancreático/diagnóstico , Cisto Pancreático/patologia , Neoplasias Pancreáticas/diagnóstico , Neoplasias Pancreáticas/patologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Amilases/metabolismo , Antígeno Carcinoembrionário/metabolismo , Tomada de Decisão Clínica , Líquido Cístico/metabolismo , Citodiagnóstico , Aspiração por Agulha Fina Guiada por Ultrassom Endoscópico , Feminino , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Mucinas/metabolismo , Pâncreas/patologia , Cisto Pancreático/metabolismo , Cisto Pancreático/cirurgia , Neoplasias Pancreáticas/metabolismo , Neoplasias Pancreáticas/cirurgia , Tomografia Computadorizada por Raios X , Adulto Jovem
10.
J Am Coll Surg ; 221(2): 300-8, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26206636

RESUMO

BACKGROUND: Surgical management of Zollinger-Ellison syndrome (ZES) relies on localization and resection of all tumor foci. We describe the benefit of combined intraoperative use of a portable large field of view gamma camera (LFOVGC) and a handheld gamma detection probe (HGDP) for indium-111 ((111)In)-pentetreotide radioguided localization and confirmation of gastrinoma resection in ZES. STUDY DESIGN: Five patients (6 cases) with (111)In-pentetreotide-avid ZES were evaluated. Patients were injected with (111)In-pentetreotide for diagnostic imaging the day before surgery. Intraoperatively, an HGDP and LFOVGC were used to localize (111)In-pentetreotide-avid lesions, guide resection, assess specimens for (111)In-pentetreotide activity, and to verify lack of abnormal post-resection surgical field activity. RESULTS: Large field of view gamma camera imaging and HGDP-assisted detection were helpful for localization and guided resection of tumor and removal of (111)In-pentetreotide-avid tumor foci in all cases. In 3 of 5 patients (3 of 6 cases), these techniques led to detection and resection of additional tumor foci beyond those detected by standard surgical techniques. The (111)In-pentetreotide-positive or-negative specimens correlated with neuroendocrine tumors or benign pathology, respectively. In one patient with mild residual focal activity on post-resection portable LFOVGC imaging, thought to be artifact, had recurrence of disease in the same area 5 months after surgery. CONCLUSIONS: Real-time LFOVGC imaging and HGDP use for surgical management of gastrinoma improve success of localizing and resecting all neuroendocrine tumor-positive tumor foci, providing instantaneous navigational feedback. This approach holds potential for improving long-term patient outcomes in patients with ZES.


Assuntos
Câmaras gama , Gastrinoma/cirurgia , Pancreatectomia/métodos , Compostos Radiofarmacêuticos , Somatostatina/análogos & derivados , Síndrome de Zollinger-Ellison/cirurgia , Adolescente , Adulto , Idoso , Feminino , Gastrinoma/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Cintilografia , Resultado do Tratamento , Síndrome de Zollinger-Ellison/diagnóstico por imagem
11.
Ann Surg Oncol ; 22(4): 1153-9, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25358667

RESUMO

BACKGROUND: For patients with metastatic pancreatic cancer, FOLFIRINOX (fluorouracil [5-FU], leucovorin [LV], irinotecan [IRI], and oxaliplatin) has shown improved survival rates compared with gemcitabine but with significant toxicity, particularly in patients with a high tumor burden. Because of reported response rates exceeding 30 %, the authors began to use a modified (m) FOLFIRINOX regimen for patients with advanced nonmetastatic disease aimed at downstaging for resection. This report describes their experience with mFOLFIRINOX and aggressive surgical resection. METHODS: Between January 2011 and August of 2013, 43 patients with borderline resectable pancreatic cancer (BRPC, n = 18) or locally advanced pancreatic cancer (LAPC, n = 25) were treated with mFOLFIRINOX (no bolus 5-FU, no LV, and decreased IRI). Radiation was used based on response and intended surgery. Charts were retrospectively reviewed to assess response, toxicities, and extent of resection when possible. RESULTS: The most common grade 3/4 toxicity was diarrhea in six patients (14 %) with no grade 3/4 neutropenia or thrombocytopenia. Resection was attempted in 31 cases (72 %) and accomplished in 22 cases (51.1 %) including 11 of 25 LAPC cases (44 %). Vascular resection was required in 4 cases (18 %), with R0 resection in 86.4 % of the resections. Complications occurred in 6 cases (27 %), with no perioperative deaths. The median progression-free survival period was 18 months if the resection was achieved compared with 8 months if no resection was performed (p < 0.001). CONCLUSION: Neoadjuvant mFOLFIRINOX is an effective, well-tolerated regimen for patients with advanced nonmetastatic pancreatic cancer. When mFOLFIRINOX is coupled with aggressive surgery, high resection rates are possible even when the initial imaging shows locally advanced disease. Although data are still maturing, resection appears to offer at least a progression-free survival advantage.


Assuntos
Adenocarcinoma/tratamento farmacológico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Terapia Neoadjuvante , Neoplasias Pancreáticas/tratamento farmacológico , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Camptotecina/administração & dosagem , Camptotecina/análogos & derivados , Desoxicitidina/administração & dosagem , Desoxicitidina/análogos & derivados , Feminino , Fluoruracila/administração & dosagem , Seguimentos , Humanos , Irinotecano , Leucovorina/administração & dosagem , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Compostos Organoplatínicos/administração & dosagem , Oxaliplatina , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/patologia , Prognóstico , Estudos Prospectivos , Estudos Retrospectivos , Taxa de Sobrevida
12.
Biomed Res Int ; 2014: 468959, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25050350

RESUMO

Pancreatic ductal adenocarcinoma (PDA) is the fourth most common cancer causing death in the United States. Early tumor recurrence is an important contributor to the dismal prognosis. The availability of an accurate prognostic biomarker for predicting disease recurrence following curative resection will be beneficial for patient care. Most of the currently studied biomarkers remain in the investigational phase, with CA 19-9 being the only biomarker currently approved by the FDA. Herein, we review the utility of CA 19-9 and other investigational cellular, gene, and molecular tumor markers for predicting PDA recurrence following curative surgical resection.


Assuntos
Adenocarcinoma/cirurgia , Biomarcadores Tumorais/metabolismo , Carcinoma Ductal Pancreático/cirurgia , Recidiva Local de Neoplasia/diagnóstico , Recidiva Local de Neoplasia/cirurgia , Neoplasias Pancreáticas/cirurgia , Humanos
14.
Ann Surg Oncol ; 21(3): 862-867, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24046122

RESUMO

BACKGROUND: Pancreas cancer is highly lethal even at early stages. Adjuvant therapy with chemotherapy (CT) or chemoradiation (CRT) is standard following surgery to delay recurrence and improve survival. There is no consensus on the added value of radiotherapy (RT). We conducted a retrospective analysis of clinical outcomes in pancreas cancer patients treated with CT or CRT following surgery. METHODS: Patients with resected pancreas adenocarcinoma were identified in our institutional database. Relevant clinicopathologic and demographic data were collected. Patients were grouped according to adjuvant treatment: group A: no treatment; group B: CT; group C: CRT. The primary endpoint of overall survival was compared between groups B vs. C. Univariate and multivariate analyses of potential prognostic factors were conducted including all patients. RESULTS: A total of 146 evaluable patients were included (group A: n = 33; group B: n = 45; group C: n = 68). Demographics and pathologic characteristics were comparable. There was no significant survival benefit for CRT compared with CT (mOS 16.8 months vs. 21.5 months, respectively, p = 0.76). Local recurrence rates were similar in all three groups. Univariate analyses identified absence of lymph node involvement (hazards ratio [HR] 1.43, p = 0.0082) and administration of adjuvant therapy (HR 0.496, p = 0.0008) as significant predictors for improved survival. Multivariate analyses suggested that patients without nodal involvement derived the most benefit from adjuvant treatment. CONCLUSIONS: The addition of RT to CT did not improve survival over CT. Lymph node involvement predicts inferior clinical outcome.


Assuntos
Adenocarcinoma/terapia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Quimiorradioterapia/mortalidade , Quimioterapia Adjuvante/mortalidade , Recidiva Local de Neoplasia/terapia , Neoplasias Pancreáticas/terapia , Radioterapia Adjuvante/mortalidade , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/patologia , Estadiamento de Neoplasias , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/patologia , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida
15.
J Vasc Surg ; 59(2): 542-6, 2014 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-24360239

RESUMO

Talent management and leadership development is becoming a necessity for health care organizations. These leaders will be needed to manage the change in the delivery of health care and payment systems. Appointment of clinically skilled physicians as leaders without specific training in the areas described in our program could lead to failure. A comprehensive program such as the one described is also needed for succession planning and retaining high-potential individuals in an era of shortage of surgeons.


Assuntos
Educação Médica , Liderança , Diretores Médicos/educação , Papel do Médico , Administração da Prática Médica , Certificação , Currículo , Educação Médica/normas , Humanos , Diretores Médicos/organização & administração , Diretores Médicos/normas , Diretores Médicos/provisão & distribução , Administração da Prática Médica/organização & administração , Administração da Prática Médica/normas , Desenvolvimento de Programas , Desenvolvimento de Pessoal
16.
Ann Surg ; 259(4): 605-12, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24374513

RESUMO

OBJECTIVE: To test by randomized prospective multicenter trial the hypothesis that pancreaticoduodenectomy (PD) without the use of intraperitoneal drainage does not increase the frequency or severity of complications. BACKGROUND: Some surgeons have abandoned the use of drains placed during pancreas resection. METHODS: We randomized 137 patients to PD with (n = 68, drain group) and without (n = 69, no-drain group) the use of intraperitoneal drainage and compared the safety of this approach and spectrum of complications between the 2 groups. RESULTS: There were no differences between drain and no-drain cohorts in demographics, comorbidities, pathology, pancreatic duct size, pancreas texture, baseline quality of life, or operative technique. PD without intraperitoneal drainage was associated with an increase in the number of complications per patient [1 (0-2) vs 2 (1-4), P = 0.029]; an increase in the number of patients who had at least 1 ≥grade 2 complication [35 (52%) vs 47 (68%), P = 0.047]; and a higher average complication severity [2 (0-2) vs 2 (1-3), P = 0.027]. PD without intraperitoneal drainage was associated with a higher incidence of gastroparesis, intra-abdominal fluid collection, intra-abdominal abscess (10% vs 25%, P = 0.027), severe (≥grade 2) diarrhea, need for a postoperative percutaneous drain, and a prolonged length of stay. The Data Safety Monitoring Board stopped the study early because of an increase in mortality from 3% to 12% in the patients undergoing PD without intraperitoneal drainage. CONCLUSIONS: This study provides level 1 data, suggesting that elimination of intraperitoneal drainage in all cases of PD increases the frequency and severity of complications.


Assuntos
Drenagem/métodos , Pancreaticoduodenectomia , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias/prevenção & controle , Adulto , Idoso , Término Precoce de Ensaios Clínicos , Feminino , Seguimentos , Humanos , Incidência , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Fístula Pancreática/epidemiologia , Fístula Pancreática/etiologia , Fístula Pancreática/prevenção & controle , Pancreaticoduodenectomia/mortalidade , Cuidados Pós-Operatórios/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Índice de Gravidade de Doença , Resultado do Tratamento
17.
J Gastrointest Surg ; 18(3): 491-6, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24234246

RESUMO

BACKGROUND: The role of gastrectomy in the face of incurable gastric cancer is evolving. We sought to evaluate our experience with incomplete (i.e., R2) gastrectomy in advanced gastric cancer. METHODS: We reviewed 210 locally advanced or metastatic gastric cancers (1992-2008). Patient characteristics and outcomes were compared between three groups: gastrectomy (N = 99), exploration without resection (N = 66), and no surgery (N = 45). RESULTS: Clinicopathologic characteristics were similar between groups. Symptoms successfully resolved after gastrectomy in 48 % with a complication rate of 32 % and mortality of 6 %. Overall median survival for all patients was 6.2 months: 10.0 months after gastrectomy, 4.1 months after exploration without resection, and 5.3 months for no surgery (p < 0.001). Perioperative complications were the only predictor of symptom resolution following resection (OR = 0.175). Resolution of symptoms (p < 0.001, Hazards Ratio (HR) = 0.09) and preoperative nausea/vomiting (p = 0.017, HR = 0.55) improved survival, while linitis plastica (p = 0.035, HR = 4.05) and spindle cell morphology (p = 0.011, HR = 1.98) were predictors of poor survival in patients undergoing resection. CONCLUSIONS: Gastrectomy in the setting of advanced gastric cancer may be useful in up to half of patients with an acceptable perioperative mortality rate. Symptom resolution offers a potential survival advantage but is dependent upon a complication-free course, so should only be considered selectively.


Assuntos
Gastrectomia , Cuidados Paliativos , Neoplasias Gástricas , Dor Abdominal/etiologia , Dor Abdominal/cirurgia , Fístula Anastomótica/etiologia , Feminino , Gastrectomia/efeitos adversos , Gastrectomia/mortalidade , Obstrução da Saída Gástrica/etiologia , Obstrução da Saída Gástrica/cirurgia , Humanos , Masculino , Náusea/etiologia , Náusea/cirurgia , Metástase Neoplásica , Estadiamento de Neoplasias , Neoplasias Gástricas/complicações , Neoplasias Gástricas/mortalidade , Neoplasias Gástricas/patologia , Neoplasias Gástricas/cirurgia , Taxa de Sobrevida , Vômito/etiologia , Vômito/cirurgia , Perda de Peso
19.
JAMA Surg ; 148(5): 413-7, 2013 May.
Artigo em Inglês | MEDLINE | ID: mdl-23677403

RESUMO

IMPORTANCE: With duty hour debates, specialization, and sex distribution changes in the applicant pool, the relative competitiveness for general surgery residency (GSR) is undefined. OBJECTIVE: To determine the modern attributes of top-ranked applicants to GSR. DESIGN Validation cohort, survey. SETTING: National sample of university and community-based GSR programs. PARTICIPANTS: Data were abstracted from Electronic Residency Application Service files of the top 20-ranked applicants to 22 GSR programs. We ranked program competitiveness and blinded review of personal statements. MAIN OUTCOMES AND MEASURES: Characteristics associated with applicant ranking by the GSR program (top 5 vs 6-20) and ranking by highly competitive programs were identified using t and χ2 tests and modified Poisson regression. RESULTS: There were 333 unique applicants among the 440 Electronic Residency Application Service files. Most applicants had research experience (93.0%) and publications (76.8%), and 28.4% had Alpha Omega Alpha membership. Nearly half were women (45.2%), with wide variation by program (20.0%-75.0%) and a trend toward fewer women at programs in the South and West (38.0% and 37.5%, respectively). Men had higher United States Medical Licensing Examination Step 1 scores (238.0 vs 230.1; P < .001) but similar Step 2 scores (245.3 vs 244.5; P = .54). Using bivariate analysis, highly competitive programs were more likely to rank applicants with publications, research experience, Alpha Omega Alpha membership, higher Step 1 scores, and excellent personal statements and those who were male or Asian. However, the only significant predictors were Step 1 scores (relative risk [RR], 1.36 for every 10-U increase), publications (RR, 2.20), personal statements (RR, 1.62), and Asian race (RR, 1.70 vs white). Alpha Omega Alpha membership (RR, 1.62) and Step 1 scores (RR, 1.01) were the only variables predictive of ranking in the top 5. CONCLUSIONS AND RELEVANCE: This national sample shows GSR is a highly competitive, sex-neutral discipline in which academic performance is the most important factor for ranking, especially in the most competitive programs. This study will inform applicants and program directors about applicants to the GSR program.


Assuntos
Avaliação Educacional , Cirurgia Geral/educação , Internato e Residência , Estudantes de Medicina , Adulto , Escolha da Profissão , Estudos de Coortes , Feminino , Humanos , Masculino , Fatores Sexuais , Estados Unidos , Adulto Jovem
20.
J Am Coll Surg ; 216(5): 944-53; discussion 953-4, 2013 May.
Artigo em Inglês | MEDLINE | ID: mdl-23522787

RESUMO

BACKGROUND: Our aim was to compare trends in retention of academic surgeons by reviewing surgical faculty attrition rates (leaving academic surgery for any reason) of 3 cohorts at 5-year intervals between 1996 and 2011. STUDY DESIGN: The Association of American Medical Colleges' Faculty Administrative Management On-Line User System database was queried for a retention report of all tenure/clinical track full-time MD faculty within our academic medical center on July 1, 1996 (group 1), July 1, 2001 (group 2), and July 1, 2006 (group 3). Retention was tracked for 5 years post snapshot. The individual 5-year cohort attrition rates (observed frequencies) were compared with combined attrition rates for all 3 groups (expected frequencies). RESULTS: Overall, attrition trends for groups 2 (lower) and 3 (higher) were significantly different than the trends for all groups combined. Minorities and professors at the full or associate rank in group 3 contributed to this difference. Faculty in group 3 leaving our academic medical center were significantly more likely to transition into nonacademic practice compared with the other 2 groups. CONCLUSIONS: Greater attrition in the last 5-year cohort, despite the increase in faculty positions, is worrisome. A continuous retention life cycle is critical if academic medical centers hope to compete for talent. Retention planning should include on-boarding programs for enculturation, monitoring of professional satisfaction, formalized mentoring of younger surgeons, retaining academic couples and a part-time workforce, leadership and talent management, exit interviews, and competitive financial packages.


Assuntos
Mobilidade Ocupacional , Docentes de Medicina/estatística & dados numéricos , Cirurgia Geral/educação , Reorganização de Recursos Humanos/estatística & dados numéricos , Reorganização de Recursos Humanos/tendências , Faculdades de Medicina/estatística & dados numéricos , Adulto , Distribuição de Qui-Quadrado , Estudos de Coortes , Feminino , Humanos , Liderança , Masculino , Mentores , Pessoa de Meia-Idade , Ohio , Salários e Benefícios , Faculdades de Medicina/tendências
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA