查看更多>>摘要：? 2021Background: New tumor biomarkers are needed to improve the management of Colon cancer (CC), the second leading cause of cancer-related deaths in the United States. Carcinoembryonic Antigen (CEA), the translated protein of carcinoembryonic antigen-related cell adhesion molecule 5 (CEACAM5) gene, is used as a biomarker for CC. Cartilage Oligomeric Matrix Protein (COMP) is overexpressed in CC compared to normal colon tissues. This study aims to evaluate the expression of COMP by disease stage, consensus molecular subtype (CMS), its impact on disease outcomes, and comparison to CEACAM5. Materials and methods: RNA-seq data from 456 CC The Cancer Genome Atlas samples and 41 matching control samples were analyzed for COMP expression and CEACAM5 expression. We stratified tumor samples by stage (I-IV), subtype (CMS1-CMS4), tumor location, and Kirsten RAt Sarcoma (KRAS) mutant status and three quartiles were established based on COMP expression. Kaplan Meier survival outcomes were evaluated. Results: COMP expression was significantly higher in tumor samples, with elevation of expression occurring in stage I and significantly increasing in stage IV. Increased COMP expression occurs in CMS4 with relatively low expression in CMS3. No significant expression difference was attributed to tumor location and KRAS mutant status. Compared to CEACAM5, COMP was a stronger molecular marker across stages and subtypes. CMS4 was associated with the high COMP expression, and higher levels of COMP were associated with poorer overall survival, disease-specific survival, and tumor progression-free intervals. CMS2 and 3 were associated with low expression and better survival. Conclusion: COMP is a potential molecular biomarker for CC and may be superior to CEA as an indicator of CC.
查看更多>>摘要：? 2021 Elsevier Inc.Background: Patients with limited English proficiency have barriers to accessing care. Rather than a binary use or no use, this study uses granular data on frequency of interpreting services to determine if this frequency is associated with differences in peri-operative length of stay for patients with limited English proficiency. Materials and Methods: This is a cross sectional study on length of stay for peri-operative admissions of at least one night during 2018, for patients who used medical interpreting services in an academic medical center in Boston, Massachusetts. The participants are split into quartiles of ascending number of interpreting events per day. The exposure for the primary outcome is the frequency of interpreting events per day during peri-operative admission. The primary study outcome measurement is peri-operative length of stay in days. Results: There was a statistically significant decrease in length of stay for patients in the highest two quartiles of interpreting service frequency, compared to the lowest quartile: quartile 2 trended shorter by 1.4 d (95% CI -4.5 to 1.7, P = 0.37), quartile 3 was 4.2 d shorter (95% CI -7.6 to -0.7, P = 0.02), and quartile 4 was 4.6 d shorter (95% CI -8.1 to -1.1, P = 0.01). Conclusions: More frequent interpreting services per day during peri-operative admission are associated with shorter length of stay in adjusted analysis. The findings merit further study in an intervention to increase use of interpreting services for surgical patients with limited English proficiency to study the impact of increased frequency of culturally competent care.
查看更多>>摘要：? 2021Background: A core tenet of medical education is the expectation that senior residents will teach junior residents and medical students. However, many general surgery residency programs lack a formalized curriculum to equip trainees with necessary teaching skills. We evaluated the impact of resident-led residents-as-teachers (RAT) workshops (RATW) and assessed adaptability from in-person to virtual delivery. We hypothesized these courses would improve trainees’ confidence in their roles as resident-teachers. Methods: Pre-COVID-19, an in-person workshop for residents (PGY1-5) was conducted over two days. During the COVID-19 pandemic, a virtual RATW for incoming interns (PGY1) was conducted during intern boot camp. Topic fidelity was preserved between the two RATWs. Resident-educators were responsible for content and delivery; the program director and associate program directors served as facilitators only. Surveys were used to evaluate residents’ confidence in four core topics. A Wilcoxon test was used to compare quantitative data. Results: There was significant improvement in confidence in all areas following RATW attendance, except for "Teaching in the OR". In sub-analysis, there was a significant improvement in this category among incoming interns post-RATW (P < 0.001). The majority of interns agreed that the RATW helped them transition into their new teaching role and agreed that the resident-led RATW was effective. Conclusions: A resident-designed and resident-led RAT curriculum in general surgery effectively improves residents’ confidence in teaching and is well received by residents. We recommend the implementation of a RAT curriculum in general surgery residency and intern boot camp. The RATW was well adapted to distance-learning format.
查看更多>>摘要：? 2021Background: Enhanced Recovery After Surgery (ERAS) protocols have been successfully instituted for pancreaticoduodenectomy (PD). This study evaluates reasons patients fail to meet length of stay (LOS) and areas for pathway improvement. Materials and Methods: A multidisciplinary team developed and implemented an ERAS protocol for open PD in 2017. The study includes a medical record review of all patients who were perioperatively managed with the ERAS protocol and failed to meet LOS after PD procedures. Target LOS was defined as 7 d. Results: From 2017 to 2020, 44% (93 of 213) of patients using ERAS protocol after PD procedures failed to meet target LOS. The most common reason to fail target LOS was ileus or delayed gastric emptying (47 of 93, LOS 11). Additional reasons included work-up of leukocytosis or pancreatic leak (17 of 93, LOS 14), additional “night” of observation (14 of 93, LOS 8), and orthostatic hypotension (3 of 93, LOS 10). Of these additional 46 patients, 19 patients underwent computed tomography (on or after POD 7) and only four patients received additional inpatient intervention. Conclusions: The most common reason for PD pathway failure included slow return of gastrointestinal function, a known complication after PD. The remaining patients were often kept for observation without additional intervention. This group represents an actionable cohort to target for improving LOS through surgeon awareness rather than protocol modification.
查看更多>>摘要：? 2021 Elsevier Inc.Background: With the easily available option for surgeons to soak their suture in antibiotic irrigation solution intraoperatively in mind, this study was designed to evaluate the ability of suture soaked in bacitracin irrigation solution to inhibit the growth of Staphylococcus aureus and Methicillin-resistant Staphylococcus aureus. Materials and Methods: Using standard experimental procedure, sterile suture was soaked in Bacitracin, and dried for 10 min or 6 h, incubated for 24 h on inoculated plates, and examined for zone of inhibition around the suture. This was compared to control unsoaked suture and antimicrobial suture (AMS) currently on the market to determine if the minor intraoperative procedural change of placing suture in antibiotic irrigation solution instead of on the sterile table could confer comparable antimicrobial activity. Results: The study found the Bacitracin-soaked suture (BSS) consistently inhibited the growth of the test organisms. For both organisms, the BSS exhibited a significantly larger zone of inhibition compared to the unsoaked control suture (P < 0.0001). However, both the AMS currently on the market, and a bacitracin aliquot, exhibited significantly larger zones of inhibition compared to both drying times of the BSS (P < 0.0001). Conclusions: Placing sutures in a bacitracin irrigation solution intraoperatively instead of directly on the sterile table can achieve some of the in vitro antimicrobial effect seen from AMS currently on the market. This may result in reduced rates of surgical site infections and associated costs without major procedural change and at reduced overhead.
查看更多>>摘要：? 2021 Elsevier Inc.Background: MATCH 2021 was short of the classic “in-person” component. Herein, we assess the impact of virtual interviews (VIs) on resident selection, from the perspectives of program directors (PDs) across all surgical specialties. Materials and Methods: We conducted a cross-sectional survey-based study of ACGME-accredited US residency program directors (PDs) of all surgical specialties. The survey was designed based on a review of relevant literature and inquired about the strengths, limitations, and overall utility of VIs. Results: A total of 365 PDs responded to our survey. Almost all respondents (90%) found VIs to be less expensive than in-person interviews, while only 34% agree that VIs were less time-consuming. Only a median of 5% of interviews was complicated by technical difficulties. Most PDs found it more challenging to assess applicants' fit (75%), personality and communication skills (71%), and commitment to specialty (60%). Only 14% found VIs to be overall better for assessing residency applicants. In future cycles, most PDs are planning to host both virtual and in-person interviews (57%), while 35% and 8% will host exclusive in-person and virtual interviews, respectively. Conclusions: VIs are a novel way of dealing with the restrictions imposed by COVID-19. Despite their cost and time benefit, they present particular challenges in evaluating residency applicants. A combination of both virtual and in-person interviews will likely be implemented in the coming cycles.
查看更多>>摘要：? 2021 Elsevier Inc.Background: Up to 30% of thyroid nodules are classified as indeterminate after fine needle aspiration biopsy. These indeterminate thyroid nodules (ITNs) require surgical pathology for definitive diagnosis. Molecular testing provides additional pre-operative cancer risk stratification but adds expense and invasive testing. The purpose of this study is to utilize a machine learning (ML) algorithm to predict malignancy of ITNs using data available from less invasive tests. Materials and methods: We conducted a retrospective study using medical records from one academic and one community center. Thyroid nodules with an indeterminate diagnosis on fine needle aspiration biopsy and completed diagnostic pathology were included. Linear, non–linear, and non–linear-ensemble ML methods were tested for accuracy when predicting malignancy using 10-fold cross-validation. Classifiers were evaluated using area under the receiver operating characteristics curve (AUROC). Results: A total of 355 nodules met inclusion criteria. Of these, 171 (48.2%) were diagnosed with cancer. A Random Forest classifier performed the best, producing an accuracy of 79.1%, a sensitivity of 75.5%, specificity of 82.4%, positive predicative value of 80.3%, negative predictive value of 79.0%, and an AUROC of 0.859. Conclusions: ML methods accurately risk stratify ITNs using data gathered from existing, non–invasive, and inexpensive diagnostic tests. Applying an ML model with existing data can become a cost-effective alternative to molecular testing. Future studies will prospectively evaluate the performance of this ML approach when combined with expert judgment.
查看更多>>摘要：? 2021 Elsevier Inc.Background: Traditionally, reversal of neuromuscular blocking agents following the completion of surgery was achieved with cholinesterase inhibitors. Recently, sugammadex has been increasingly relied upon. Sugammadex is a γ-cyclodextrin molecule that rapidly reverses steroidal neuromuscular blocking drugs. Its use following colorectal surgery has become more common, and while the rapidity of reversal is undoubtedly improved, whether sugammadex impacts clinical postoperative outcomes is unknown. This systematic review and meta-analysis aims to compare postoperative outcomes in patients receiving sugammadex to those receiving a control during colorectal surgery. Methods: Medline, Embase, and CENTRAL were systematically searched. Articles were included if they compared sugammadex with a control (e.g., neostigmine, pyridostigmine, placebo) in patients undergoing colorectal surgery in terms of total hospital length of stay and frequency of postoperative adverse respiratory events. Pairwise meta-analyses using inverse variance random effects was performed. Results: From 269 citations, five studies with 535 patients receiving sugammadex (45.8% female; mean age: 64.4) and 569 patients receiving a control (45.0% female; mean age: 64.3) were included. There was no significant difference in length of stay between the two groups (MD -0.01, 95% CI -0.27 to 0.25, P = 0.95). The risk of adverse respiratory events postoperatively was similar between the two groups (RR 1.33, 95% CI 0.81-2.19, P = 0.25). Conclusion: There are no current data to suggest an improvement in postoperative outcomes with the use of sugammadex in patients undergoing colorectal surgery. This study is limited by the number of included studies. Further prospective studies comparing sugammadex and a control in colorectal surgery is required.
查看更多>>摘要：? 2021Background: Serum thyroglobulin (Tg) levels are used to monitor for differentiated thyroid cancer (DTC) recurrence and have been correlated with posttreatment disease burden. The clinical significance of Tg in the preoperative setting to predict the risk of DTC is unclear. Our aim is to examine the clinical utility of preoperative Tg levels in those undergoing thyroidectomies for DTC or benign disease. Materials and methods: From a prospectively collected database, we identified 385 patients who underwent thyroidectomy from 01/14 to 12/19 and had preoperative Tg levels available. Preoperative Tg levels were compared by preoperative indication for surgery, Bethesda category of biopsied nodules, presence of DTC on surgical pathology, and number of metastatic lymph nodes. Results: There was no difference in mean preoperative Tg level when comparing indication for surgery (P = 0.2) or Bethesda classification (P = 0.4). Mean preoperative Tg levels were lower in patients with DTC (238 ± 77) compared to without DTC (532 ± 97) on final pathology (P = 0.02). Among 188 DTC patients who had lymph nodes removed, there was no significant correlation between the preoperative Tg level and number of positive lymph nodes on final pathology (P = 0.4). Conclusions: Preoperative serum Tg levels were lower in patients with DTC compared to those with benign disease on final pathology and did not correlate with extent of lymph node metastasis in patients with DTC. We found that serum Tg levels obtained in the preoperative setting do not predict DTC or lymph node metastasis and, therefore, do not inform the extent of surgery for differentiated thyroid cancer.
查看更多>>摘要：? 2021Background: Routine frailty assessment has emerged recently in the surgical literature and is an important prognostication and risk stratification tool. The aim of our study was to review our 7-y experience with two frailty assessment tools and changing trends in their use. Methods: We performed a 7-y (2011-2017) analysis of our prospectively maintained frailty database. Frail patients were identified using the emergency general surgery and trauma specific frailty indices. Outcome measures were rates of compliance with frailty assessment, overall complications, discharge to skilled nursing facility (SNF)/rehab, and mortality over the study period. Multivariate logistic regression and Cochran-Armitage trend analyses were performed. Results: We evaluated a total of 1045 geriatric patients (Trauma: 587, EGS: 458). Mean age was 74.5 ± 7.9 y, 74% were males, and 81% were white. Overall, 34% of the patients were frail. Compared to non-frail patients, frail patients had higher adjusted rates of complications (OR 2.4 [1.9-2.9]), mortality (OR 1.8 [1.4-2.3]), and rehab/SNF disposition (OR 3.7 [3.1-4.3]). The compliance rate of measuring frailty increased from 12% in 2011 to 78% in 2017, P < 0.001 (Figure). The complication rate decreased (33% versus 21%, P < 0.001), while the rate of discharge disposition to SNF/Rehab increased (41% versus 58%, P < 0.001). There was no difference in mortality (11% versus 9.8%, P = 0.48) over the study period. Conclusions: Adherence to frailty measurement increased over the study period. This was accompanied by a significant decline in overall in-hospital complications. Frailty indices can be utilized to identify high-risk patients and develop post-operative strategies to improve outcomes in acute care surgery.
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