The next frontier of acute care general surgery: fellowship training.

Acute care surgery (ACS) is an area of surgical specialization within general surgery and a model for clinical care delivery that has proliferated over the last 2 decades. Models of ACS in Canada exist in both academic and community settings and are used to manage patients in need of emergency general surgery (EGS) care, with or without the provision of trauma care. The implementation of the ACS model has changed the landscape of patient care, surgical education and the workforce, providing an option for some general surgeons to exclude EGS care from their regular practice. The rise of ACS as a concentration of surgical skill and content expertise has resulted in the establishment of dedicated ACS fellowship training programs. This is a landmark in the evolution of general surgery, as well as a stepping stone on the path to improving patient care, surgical education and scholarly endeavour in this field.

The call for ecological validity is right but missing perceptual idiosyncrasies is wrong.

Although psychology has long professed that perception predicts action, the strength of the evidence supporting the statement depends on the ecological validity of the technologies and paradigms used, particularly those that track eye movements, supporting Cesario's argument. While right to call for ecological validity, Cesario's model fails to account for individual differences in visual experience perceivers have when presented with the same stimulus.

Transition Home Following New Fecal Ostomy Creation: A Qualitative Study.

PURPOSE: Perioperative ostomy education is essential for patients to develop skills and comfort with self-care at home with a new ostomy, but shortened hospital length of stay (LOS) reduces time for postoperative education for patients. This study explored the initial experiences and care needs of patients who have undergone creation of a new ostomy during their transition from hospital to home. DESIGN: Qualitative interpretive description using latent content analysis. SUBJECTS AND SETTING: Thirteen patients who had undergone an elective colorectal surgery involving creation of an ostomy were interviewed. Participants were 33 to 78 years of age, 54% were female, and 62% were undergoing ostomy creation for colorectal cancer operations. Eleven participants underwent temporary ileostomy creation, and 2 patients had permanent end colostomies created. METHODS: Interviews were conducted in person and audiotaped by study investigators within 4 to 6 weeks postoperatively. Audiotapes were transcribed verbatim by trained transcriptionists, and each transcript was reviewed in duplicate by study investigators. A latent content analysis method was used to determine the implied meaning in participants' experiences of having a new ostomy. RESULTS: The transition from hospital to home with a new ostomy was illustrated by 5 major themes: (1) Having an ostomy is a life-changing and bizarre experience; (2) Adjustment and adaptation occur through acceptance and self-reliance; (3) It's a hands-on thing: with the role of WOC nurse providing support in achieving independence; (4) Improved home care infrastructure is needed; and (5) Practical advice shared from experiential learning. CONCLUSION: Patients with new ostomies are motivated and able to cope with the ostomy and regain independence over a short period after surgery. Shorter LOS does not impede ostomy education so long as adequate home care and support group programs are available. Knowledge gained through this study will assist WOC nurses in managing patients' expectations and the planning and delivery of education to patients with newly created ostomies.

Examining the transferability of colon and rectal operative experience on outcomes following laparoscopic rectal surgery.

BACKGROUND: Laparoscopic rectal surgery is technically challenging and often low volume. Alternatively, colon resections utilize similar advanced laparoscopic skills and are more common but it is unknown whether this experience affects laparoscopic rectal surgery outcomes. The purpose of this paper is to determine the volume-outcome relationship between several colorectal procedures and laparoscopic rectal surgery outcomes. METHODS: This was a population-based retrospective cohort of all colorectal surgeries with primary anastomoses performed across Canada (excluding Quebec) between April 2008 and March 2015. Patient characteristics, comorbidities, procedures, and discharge details were collected from the Canadian Institute for Health Information. Volumes for common colorectal procedures were calculated for individual surgeons. All-cause morbidity, defined as complications arising during the index admission and contributing to an increased length of stay by more than 24 h, was the primary outcome examined. RESULTS: A total of 5323 laparoscopic rectal surgery cases and 108,034 colorectal cases, between 180 hospitals and 620 surgeons, were identified. Data analysis demonstrated that high-volume laparoscopic rectal surgeons (OR 0.77, CI 0.61-0.96, p = 0.020) and high-volume open rectal surgeons (OR 0.76, CI 0.61-0.93, p = 0.009) significantly reduced all-cause morbidity. Conversely, surgeon volumes for laparoscopic and open colon cases had no effect on laparoscopic rectal outcomes. CONCLUSION: High-volume surgeon status in laparoscopic and open rectal surgery are important predictors of all-cause morbidity after laparoscopic rectal surgery, while laparoscopic colon surgery volumes did not impact outcomes. This may reflect more dissimilarity between colon and rectal cases and less transferability of advanced laparoscopic skills than previously thought.

Diagnosis and management of acute cholecystitis: a single-centre audit of guideline adherence and patient outcomes.

Background: The Tokyo Guidelines were published in 2007 and updated in 2013 and 2018, with recommendations for the diagnosis and management of acute cholecystitis. We assessed guideline adherence at our academic centre and its impact on patient outcomes. Methods: This is a retrospective chart review of patients with acute calculous cholecystitis who underwent cholecystectomy at our institution between November 2013 and March 2015. Severity of cholecystitis was graded retrospectively if it had not been documented preoperatively. Compliance with the Tokyo Guidelines' recommendations on antibiotic use and time to operation was recorded. Cholecystitis severity groups were compared statistically, and logistic regression was used to determine predictors of complications. Results: One hundred and fifty patients were included in the study. Of these, 104 patients were graded as having mild cholecystitis, 45 as having moderate cholecystitis, and 1 as having severe cholecystitis. Severity was not documented preoperatively for any patient. Compliance with antibiotic recommendations was poor (18.0%) and did not differ by cholecystitis severity (p = 0.90). Compliance with the recommendation on time to operation was 86.0%, with no between-group differences (p = 0.63); it improved when an acute care surgery team was involved (91.0% v. 76.0%, p = 0.025). On multivariable analysis, comorbidities (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.19-1.85, p < 0.001) and conversion to laparotomy (OR 13.45, 95% CI 2.16-125.49, p = 0.01) predicted postoperative complications, while severity of cholecystitis, antibiotic compliance and time to operation had no effect. Conclusion: In this study, compliance with the Tokyo Guidelines was acceptable only for time to operation. Although the poor compliance with recommendations relating to documentation of severity grading and antibiotic use did not have a negative affect on patient outcomes, these recommendations are important because they facilitate appropriate antibiotic use and patient risk stratification.

Contexte: Les Tokyo Guidelines, publiées en 2007, puis mises à jour en 2013 et en 2018, contiennent des recommandations sur le diagnostic et la prise en charge de la cholécystite aiguë. Nous avons évalué le respect de ces lignes directrices dans notre centre universitaire et son incidence sur les issues pour les patients. Méthodes: Ce document est une revue rétrospective de dossiers des patients atteints de cholécystite aiguë calculeuse qui ont subi une cholécystectomie dans notre établissement entre novembre 2013 et mars 2015. La gravité de la cholécystite a été établie de manière rétrospective si elle n'avait pas été documentée avant l'opération. Le respect des recommandations des Tokyo Guidelines concernant le recours à des antibiotiques et la durée de l'opération a été étudié. Nous avons comparé statistiquement les groupes de gravité de la cholécystite, et avons utilisé une régression logistique pour déterminer les prédicteurs de complications. Résultats: Au total, 150 patients ont été inclus dans l'étude. Parmi eux, 104 avaient une cholécystite légère, 45, une cholécystite modérée et 1, une cholécystite grave. La gravité de la maladie n'avait été documentée avant l'opération pour aucun patient. Le respect des recommandations sur les antibiotiques était faible (18,0 %) et ne variait pas selon la gravité de la cholécystite (p = 0,90). Le respect des recommandations sur la durée de l'opération était de 86,0 %, sans différence entre les groupes (p = 0,63); il était toutefois plus élevé lorsqu'une équipe de soins chirurgicaux aigus participait aux soins (91,0 % c. 76,0 %, p = 0,025). L'analyse multivariée a permis de déterminer que les comorbidités (rapport des cotes [RC] 1,47, intervalle de confiance [IC] de 95 % 1,19­1,85, p < 0,001) et la conversion en laparotomie (RC 13,45, IC de 95 % 2,16­125,49, p = 0,01) étaient des prédicteurs de complications postopératoires, alors que la gravité de la cholécystite et le respect des recommandations sur les antibiotiques et la durée de l'opération n'avaient pas d'effet. Conclusion: Dans cette étude, le respect des Tokyo Guidelines était acceptable seulement pour la durée de l'opération. Bien qu'un faible respect des recommandations quant à la documentation de la gravité et à l'utilisation d'antibiotiques n'ait pas eu d'effets négatifs sur les issues pour les patients, ces recommandations sont importantes parce qu'elles favorisent l'utilisation appropriée des antibiotiques et une bonne stratification du risque pour le patient.

Drivers of Inpatient Costs After Colorectal Surgery Within a Publicly Funded Healthcare System.

BACKGROUND: The morbidity and mortality associated with colorectal resections are responsible for significant healthcare use. Identification of efficiencies is vital for decreasing healthcare cost in a resource-limited system. OBJECTIVE: The purpose of this study was to characterize the short-term cost associated with all colon and rectal resections. DESIGN: This was a population-based, retrospective administrative analysis. SETTINGS: This analysis was composed of all colon and rectal resections with anastomosis in Canada (excluding Quebec) between 2008 and 2015. PATIENTS: A total of 108,304 patients ≥18 years of age who underwent colon and/or rectal resections with anastomosis were included. MAIN OUTCOME MEASURES: Total short-term inpatient cost for the index admission and the incremental cost of each comorbidity and complication (in 2014 Canadian dollars) were measured. Cost predictors were modeled using hierarchical linear regression and Monte Carlo Markov Chain estimation. RESULTS: Multivariable regression demonstrated that the adjusted average cost of a 50-year-old man undergoing open colon resection for benign disease with no comorbidities or complications was $9270 ((95% CI, $7146-$11,624; p = <0.001). With adjustment for complications, laparoscopic colon resections carried a cost savings of $1390 (95% CI, $1682-$1099; p = <0.001) compared with open resections. Surgical complications were the main driver for increased cost, because anastomotic leaks added $9129 (95% CI, $8583-$9670; p = <0.001). Medical complications such as renal failure requiring dialysis ($16,939 (95% CI, $15,548-$18,314); p = <0.001) carried significant cost. Complications requiring reoperation cost $16,313 (95% CI, $15,739-$16,886; p = <0.001). The costliest complication cumulatively was reoperation, which exceeded $95 million dollars over the course of the study. LIMITATIONS: Inherent biases associated with administrative databases limited this study. CONCLUSIONS: Medical and surgical complications (especially those requiring reoperation) are major drivers of increased resource use. Laparoscopic colorectal resection with or without adjustment for complications carries a clear cost advantage. There is opportunity for considerable cost savings by reducing specific complications or by preoperatively optimizing select patients susceptible to costly complication. See Video Abstract at http://links.lww.com/DCR/A839.

Serologic testing in celiac disease: Practical guide for clinicians.

OBJECTIVE: To address the questions and challenges commonly faced by primary care physicians when ordering serologic tests for celiac disease (CD) and provide practical clinical tips to help in the interpretation of test results. SOURCES OF INFORMATION: MEDLINE was searched from 2000 to 2015 for English-language guidelines on the diagnosis and management of CD published by professional gastroenterological organizations. MAIN MESSAGE: To screen patients for CD, measurement of the immunoglobulin A (IgA) tissue transglutaminase antibody is the preferred test. Total serum IgA level should be measured to exclude selective IgA deficiency and to avoid false-negative test results. Patients with positive serologic test results should be referred to a gastroenterologist for endoscopic small intestinal biopsies to confirm the diagnosis. Testing for human leukocyte antigens DQ2 and DQ8 can help exclude the diagnosis. A gluten-free diet should not be started before confirming the diagnosis of CD. CONCLUSION: Serologic testing is very useful for screening patients with suspected CD. Early diagnosis is essential to prevent complications of CD.

Diagnosis and management of bile leaks after severe liver injury: A Trauma Association of Canada multicenter study.

BACKGROUND: Optimal management of bile leaks (BLs) after severe liver injury is unknown. Study objectives were to define current practices in diagnosis and management of BL to determine which patients may benefit from endoscopic retrograde cholangiopancreatography (ERCP). METHODS: American Association for the Surgery of Trauma grade ≥III liver injuries from 10 North American trauma centers were included in this retrospective study (February 2011 to January 2021). Groups were defined as patients who developed BL versus those who did not. Subgroup analysis of BL patients was performed by management strategy. Bivariate analysis compared demographics, clinical/injury data, and outcomes. Receiver operating characteristic curves were performed to investigate the relationship between bilious drain output and ERCP. RESULTS: A total of 2,225 patients with severe liver injury met the study criteria, with 108 BLs (5%). Bile leak patients had higher American Association for the Surgery of Trauma grade of liver injury ( p < 0.001) and were more likely to have been managed operatively from the outset (69% vs. 25%, p < 0.001). Bile leak was typically diagnosed on hospital day 6 [4-10] via surgical drain output (n = 37 [39%]) and computed tomography scan (n = 34 [36%]). On the BL diagnosis day, drain output was 270 [125-555] mL. Endoscopic retrograde cholangiopancreatography was the most frequent management strategy (n = 59 [55%]), although 32 patients (30%) were managed with external drains alone. Bile leak patients who underwent ERCP, surgery, or percutaneous transhepatic biliary drain had higher drain output than BL patients who were managed with external drains alone (320 [180-720] vs. 138 [85-330] mL, p = 0.010). Receiver operating characteristic curve analysis of BL demonstrated moderate accuracy (area under the receiver operating characteristic curve, 0.636) for ERCP at a cutoff point of 390 mL of bilious output on the day of diagnosis. CONCLUSION: Patients with BL >300 to 400 mL were most likely to undergo ERCP, percutaneous transhepatic biliary drain, or surgical management. Once external drainage of BL has been established, we recommend ERCP be reserved for patients with BL >300 mL of daily output. Prospective multicenter examination will be required to validate these retrospective data. LEVEL OF EVIDENCE: Therapeutic and Care Management; Level IV.

The Delaware Pain Database: a set of painful expressions and corresponding norming data.

INTRODUCTION: Facial expressions of pain serve an essential social function by communicating suffering and soliciting aid. Accurate visual perception of painful expressions is critical because the misperception of pain signals can have serious clinical and social consequences. Therefore, it is essential that researchers have access to high-quality, diverse databases of painful expressions to better understand accuracy and bias in pain perception. OBJECTIVES: This article describes the development of a large-scale face stimulus database focusing on expressions of pain. METHODS: We collected and normed a database of images of models posing painful facial expressions. We also characterized these stimuli in terms of the presence of a series of pain-relevant facial action units. In addition to our primary database of posed expressions, we provide a separate database of computer-rendered expressions of pain that may be applied to any neutral face photograph. RESULTS: The resulting database comprises 229 unique (and now publicly available) painful expressions. To the best of our knowledge, there are no existing databases of this size, quality, or diversity in terms of race, gender, and expression intensity. We provide evidence for the reliability of expressions and evaluations of pain within these stimuli, as well as a full characterization of this set along dimensions relevant to pain such as perceived status, strength, and dominance. Moreover, our second database complements the primary set in terms of experimental control and precision. CONCLUSION: These stimuli will facilitate reproducible research in both experimental and clinical domains into the mechanisms supporting accuracy and bias in pain perception and care.

Perceptual contributions to racial bias in pain recognition.

The pain of Black Americans is systematically underdiagnosed and undertreated, compared to the pain of their White counterparts. Extensive research has examined the psychological factors that might account for such biases, including status judgments, racial prejudice, and stereotypes about biological differences between Blacks and Whites. Across seven experiments, we accumulated evidence that lower-level perceptual processes also uniquely contribute to downstream racial biases in pain recognition. We repeatedly observed that White participants showed more stringent thresholds for perceiving pain on Black faces, compared to White faces. A tendency to see painful expressions on Black faces less readily arose, in part, from a disruption in configural processing associated with other-race faces. Subsequent analyses revealed that this racial bias in pain perception could not be easily attributed to stimulus features (e.g., color, luminance, or contrast), subjective evaluations related to pain tolerance and experience (e.g., masculinity, dominance, etc.), or objective differences in face structure and expression intensity between Black and White faces. Finally, we observed that racial biases in perception facilitated biases in pain treatment decisions, and that this relationship existed over and above biased judgments of status and strength, explicit racial bias, and endorsement of false beliefs regarding biological differences. A meta-analysis across 9 total experiments (N = 1,289) confirmed the robustness and size of these effects. This research establishes a subtle, albeit influential, perceptual pathway to intergroup bias in pain care and treatment. Implications for racial bias, face perception, and medical treatment are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Comparing knowledge and attitudes towards genetic testing in Parkinson's disease in an American and Asian population.

INTRODUCTION: Recent discoveries of disease-causing genes in Parkinson's disease (PD) have generated considerable interest regarding genetic testing in PD. The attitudes toward genetic testing are largely influenced by knowledge and preconceived notions. OBJECTIVE: We investigated the relationship between knowledge of and attitude towards predictive genetic testing of PD in two independent centers in America and Asia involving PD patients and caregivers. METHODS: In a prospective study involving 515 subjects comprising of PD patients and their caregivers in two independent centers in America and Asia, the level of knowledge about genetic testing and patients' attitudes towards such testing were evaluated using a standardized questionnaire. RESULTS: American PD patients had a higher level of knowledge of PD genetics than Asian PD (31.1% vs. 12.3%, p=0.0002). A greater number of American PD patients and caregivers reported a positive attitude towards the potential medical benefits of genetic testing compared to their Asian counterparts (85.4% vs. 42.2%, 92.2% vs. 32.1%, p<0.00005), but a more negative attitude towards potential compromise in getting health and life insurance (43.7% vs. 25.8%, p=0.0002). However, in the Asian cohort, multivariate analysis revealed that a high level of genetics knowledge was associated with a positive attitude response regarding the potential medical benefits of testing (p<0.0005), but a negative attitude towards compromises in healthcare and life insurance, getting a job and starting a family (p<0.0005). These associations were not observed amongst American subjects. CONCLUSIONS: The relationship between level of genetic knowledge and attitude towards potential risks and benefits of predictive genetic testing in PD was distinctly different in two independent, racially and culturally different PD populations and caregivers. These observations have clinical implications in the development of PD genetic counseling programs.

Comparison of immunization rates of adults ages 65 years and older managed within two nurse practitioner-owned clinics with national immunization rates.

BACKGROUND AND PURPOSE: Adults ages ≥65 years are at increased risk for infectious diseases. Ensuring these individuals are fully vaccinated is imperative. The purpose of this study was to assess the immunization rates of adults ages ≥65 years managed by nurse practitioners (NPs) and compare the results with national immunization rates and Healthy People 2020 goals. METHODS: A convenience sample of adults ages ≥65 years was obtained from two NP-managed clinics. The vaccine records of each subject were reviewed for documentation of having received five vaccines (tetanus, diphtheria, and pertussis; influenza; pneumococcal polysaccharide vaccine 23; pneumococcal conjugate vaccine 13; and herpes zoster vaccine). CONCLUSIONS: One hundred and fifty females (70.8%) and 62 males (29.2%) met inclusion criteria. NP-managed patients had higher immunization rates than the national averages across all five major vaccines. The herpes zoster vaccination rates exceeded the recommendations from Healthy People 2020 whereas pneumococcal and influenza rates were below. IMPLICATIONS FOR PRACTICE: The stocking of vaccines within the NP-managed clinics, direct billing to Medicare for Part D vaccines, and previsit care planning likely contributed to the high vaccination rates. These high immunization rates in patients managed by NPs provide support for the important role that NPs play in the care of older adults.

Unilateral storage of fear memories by the amygdala.

Pavlovian fear conditioning is an associative learning task in which subjects are trained to respond defensively to a neutral conditioned stimulus (CS) by pairing it with an aversive unconditioned stimulus (US). This type of learning depends critically on the amygdala, and evidence suggests that synaptic plasticity within the lateral nucleus of the amygdala (LA) may be responsible for storing memories of the CS-US association. In the present study, we trained rats to fear an auditory CS by pairing it with a shock US delivered to one eyelid. Conditioning was assessed by measuring freezing responses evoked by the CS during a subsequent test session. The amygdala was unilaterally inactivated during either the training or the testing session by intracranial infusions of muscimol into the LA. We found that both acquisition and expression of conditioned freezing to the CS depended on the amygdala contralateral but not ipsilateral from the eyelid where the shock US was delivered. To explain this surprising result, we propose that the shock US is relayed from the eyelid to the amygdala via lateralized nociceptive sensory pathways, which causes memories of the CS-US association to be stored by the amygdala contralateral but not ipsilateral from the shocked eyelid. Our results demonstrate that the fear-learning circuitry of the amygdala is functionally lateralized according to the anatomical source of predicted threats. In future studies, the cellular mechanisms of emotional memory storage might be pinpointed by identifying cellular processes that occur only in the amygdala contralateral but not ipsilateral from the US during lateralized fear conditioning.