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Over time, each school builds its own culture and approach to education. Students, faculty, and alumni become accustomed to the style and pace of their university setting and expect it to continue. Thus, deliberate changes to this culture are not undertaken lightly and the effects of such changes are watched closely. This paper discusses the process and results of a change initiated by the School of Business Administration (SBA) at Loyola University Chicago. The change involved the increase of the maximum class size on the undergraduate level. In the fall of 2006, it was increased by 50 percent. The effect of this change was tracked in two ways: both student results, as measured by the grade point average, and faculty results, as measured by instructor evaluations, were collected and are reported here for a period of three years. This study uses data collected over the three years and includes results from 833 sections representing 23,247 student evaluations. For all terms in this period, data from the traditional and larger sized classes were compared and no significant difference was found either in instructor or student performance.

Background: The impact of socioeconomic status on outcomes after sepsis has been challenging to define, and no polysocial metric has been shown to predict mortality in sepsis. The primary objective of this study was to evaluate the association between the Area Deprivation Index (ADI) and mortality in patients admitted to the surgical intensive care unit (SICU) with sepsis. Patients and Methods: All patients admitted to the SICU with sepsis (Sequential Organ Failure Assessment [SOFA] score ≥2) were retrospectively reviewed. The ADI scores were obtained and classified as "high ADI" (≥85th percentile, n = 400, representative of high socioeconomic deprivation) and "control ADI" (ADI <85th percentile, n = 976). Baseline demographic and clinical characteristics were compared between groups. The primary outcome was 90-day mortality. Results: High ADI patients were younger (mean age 58.5 vs. 60.8; p = 0.01) and more likely to be non-white (23.7% vs. 10.0%; p < 0.0005) and to present with chronic obstructive pulmonary disease (26.5% vs. 19.0%; p = 0.002). High ADI patients had increased in-hospital (27.3% vs. 21.6%; p = 0.025) and 90-day mortality (35.0% vs. 28.9%; p = 0.03). High ADI patients also had increased rates of renal failure (20.3% vs. 15.3%; p = 0.02). Both cohorts had similar intensive care unit (ICU) lengths of stay and median hospital stay, Charlson comorbidity index, and rate of discharge to home. High ADI is an independent risk factor for 90-day mortality after admission for surgical sepsis (odds ratio [OR], 1.39 ± 0.24; p = 0.014). Conclusions: High ADI is an independent predictor of 90-day mortality in patients with surgical sepsis. Targeted community interventions are needed to reduce sepsis mortality for these at-risk patients. [ABSTRACT FROM AUTHOR]

Background: Necrotizing soft tissue infections (NSTIs) are life-threatening infections requiring prompt intervention. The Distressed Communities Index (DCI) is a comprehensive ranking of socioeconomic well-being based on zip code. We sought to identify the role of DCI in predicting mortality in NSTI, because it remains unknown. Patients and Methods: A retrospective, single-institution analysis of patients diagnosed with NSTI (2011-2020) requiring surgical intervention. The DCI is a composite score based on community-level factors: unemployment, education level, poverty rate, median income, business growth, and housing vacancies. The DCI scores were matched to the patient's zip code and stratification was performed using quintiles. Parametric and non-parametric analyses were performed to evaluate both the demographic and clinical characteristics. Multivariable regression analyses were performed to identify independent variables associated with outcomes. Results: Six hundred twenty patients met inclusion criteria. Ninety-day mortality was 12.4% (n = 77). Patients who died were more likely to be female (58.4%), older (median age 60.5 ± 11.3 years), have a body mass index (BMI) ≥30 (61.5%), have a higher Charlson Comorbidity Index (3; interquartile range [IQR], 2-7). After regression analysis, neither the composite DCI by quintile, nor the individual component scores, were found to correlate with mortality. Interestingly, underlying heart disease, hepatic dysfunction, and renal disease at baseline were found to significantly correlate with mortality from NSTI with p values <0.05. Conclusions: Socioeconomic status and insurance payer are championed for inclusion when constructing risk models, evaluating resource utilization, comparing hospitals, and determining patient management. The severity of community distress measured by DCI did not correlate with mortality for NSTI, despite contrasting evidence in other diseases. This finding is likely caused by a combination of both individual and community-level resources. This is highlighted by the recognition that comorbidities did correlate with mortality. The absence of DCI-related associations observed in this study warrants further investigation, as do mechanisms for the prevention of further organ dysfunction. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic magnetic sphincter augmentation (MSA) has emerged as an alternative to laparoscopic Nissen fundoplication (LNF) for the management of symptomatic gastroesophageal reflux disease (GERD). While short-term outcomes of MSA compare favorably to those of LNF, direct comparisons of long-term outcomes are lacking. We hypothesized that the long-term patient-reported outcomes of MSA would be similar to those achieved with LNF. Methods: We tested this hypothesis in a retrospective cohort undergoing primary LNF or MSA between March 2013 and July 2015. The primary outcome was GERD-Health Related Quality of Life (GERD-HRQL) score at long-term follow-up relative to baseline. Secondary outcomes included dysphagia and bloating scores, proton-pump inhibitor (PPI) cessation, reoperations, and overall satisfaction with surgery. Results: 70 patients (25 MSA, 45 LNF) met criteria for study inclusion. MSA patients had lower baseline BMI (median: 27.1 [IQR: 22.7–29.9] versus 30.4 [26.4–32.8], p = 0.02), lower total GERD-HRQL (26 [19–32] versus 34 [25–40], p = 0.02), and dysphagia (2 [0–3] versus 3 [1–4], p = 0.02) scores. Median follow-up interval exceeded 5 years (MSA: 68 [65–74]; LNF: 65 months [62–69]). Total GERD-HRQL improved from 26 to 9 after MSA (p < 0.001) and from 34 to 7.5 after LNF (p < 0.01); these scores did not differ between groups (p = 0.68). Dysphagia (MSA: 1 [0–2]; LNF: 0 [0–2], p = 0.96) and bloating (MSA: 1.5 [0.5–3.0]; LNF: 3.0 [1.0–4.0], p = 0.08) scores did not show any statistically significant differences. Device removal was performed in 4 (16%) MSA patients and reoperation in 3 (7%) LNF patients. Eighty-nine percent of LNF patients reported satisfaction with the procedure, compared to 70% of MSA patients (p = 0.09). Conclusions: MSA appears to offer similar long-term improvement in disease-specific quality of life as LNF. For MSA, there was a trend toward reduced long-term bloating compared to LNF, but need for reoperation and device removal may be associated with patient dissatisfaction. [ABSTRACT FROM AUTHOR]

Background: The impact of obesity on the pathogenesis and prognosis of necrotizing soft tissue infections (NSTIs) is unclear. The goal of this study was to characterize differences in NSTI presentation and outcomes by obesity status. Patients and Methods: A retrospective analysis of institutional data for patients diagnosed with NSTIs were identified (n = 619; 2011-2020). Patients were divided based on obesity (body mass index [BMI] ≥ 30 kg/m2) and non-obese (BMI <30 kg/m2). Primary outcomes included NSTI location, micro-organisms, and index hospitalization data. Multiple logistic regression was used to model predictors of in-hospital and 90-day mortality. Results: The obese cohort (n = 390; 63%) had higher rates of congestive heart failure and type 2 diabetes mellitus. There were no differences in length of stay, mortality, or discharge disposition between groups. A higher rate of respiratory failure was observed in the obese versus non-obese group (36.7% vs. 20.9%; p < 0.0005). The obese cohort was associated with perineal (40.8% vs. 27.0%) and torso NSTIs (20.9% vs. 15.8%; p < 0.005) but reduced staphylococcal (19.2% vs. 27.4%; p = 0.02) and group A streptococcal (2.6% vs. 6.5%; p = 0.03) infections, and increased polymicrobial infections. Class 2 obesity was a negative predictor for in-hospital mortality (odds ratio [OR], 0.1; 95% confidence interval [CI], 0.03-0.5) and 90-day mortality (OR, 0.3; 95% CI, 0.1-0.8), when adjusting for demographic data, type of infection, and baseline comorbidities. Conclusions: Necrotizing soft tissue infections in obesity may present with unique distributions and microbial characteristics. Class 2 obesity may exhibit a survival benefit compared with non-obese patients, suggestive of an obesity paradox. [ABSTRACT FROM AUTHOR]

Objective: Surgeon scientists bring to bear highly specialized talent and innovative and impactful solutions for complicated clinical problems. Our objective is to inform and provide framework for early stage surgeon scientist training and support. Summary of Background Data: Undergraduate, medical student, and residency experiences impact the career trajectory of surgeon scientists. To combat the attrition of the surgeon scientist pipeline, interventions are needed to engage trainees and to increase the likelihood of success of future surgeon scientists. Methods: A surgery resident writing group at an academic medical center, with guidance from faculty, prepared this guidance document for early stage surgeon scientist trainees with integration of the published literature to provide context. The publicly available National Institutes of Health RePORTER tool was queried to provide data salient to early stage surgeon scientist training. Results: The educational path of surgeons and the potential research career entry points are outlined. Challenges and critical supportive elements needed to inspire and sustain progress along the surgeon scientist training path are detailed. Funding mechanisms available to support formal scientific training of early stage surgeon scientists are identified and obstacles specific to surgical careers are discussed. Conclusions: This guidance enhances awareness of essential education, communication, infrastructure, resources, and advocacy by surgery leaders and other stakeholders to promote quality research training in residency and to re-invigorate the surgeon scientist pipeline. [ABSTRACT FROM AUTHOR]

The role of adipose tissue (AT) inflammation in obesity and its multiple related-complications is a rapidly expanding area of scientific interest. Within the last 30 years, the role of the adipocyte as an endocrine and immunologic cell has been progressively established. Like the macrophage, the adipocyte is capable of linking the innate and adaptive immune system through the secretion of adipokines and cytokines; exosome release of lipids, hormones, and microRNAs; and contact interaction with other immune cells. Key innate immune cells in AT include adipocytes, macrophages, neutrophils, and innate lymphoid cells type 2 (ILC2s). The role of the innate immune system in promoting adipose tissue inflammation in obesity will be highlighted in this review. T cells and B cells also play important roles in contributing to AT inflammation and are discussed in this series in the chapter on adaptive immunity. [ABSTRACT FROM AUTHOR]

Although the results of a laparoscopic repair of a paraesophageal hernia are convincing and accepted, controversies still persist regarding indications for elective repair, the need for a concurrent fundoplication, the use of mesh, and the need for a Collis gastroplasty. This article is a description of our surgical approach to the patient with a paraesophageal hernia in need of a repair. [ABSTRACT FROM AUTHOR]

Background: Anxiety and depression have been associated with an increased perception of gastroesophageal reflux symptoms, but there is a paucity of data regarding the outcomes of laparoscopic Nissen Fundoplication (LNF) in this patient population.Methods: We performed a retrospective cohort study including all patients undergoing LNF between 2011 and 2017. Patients were stratified by baseline usage of serotonin-modulating medication or benzodiazepines as a proxy for depression and anxiety, respectively. Outcome measures included postoperative gastroesophageal health-related quality of life (GERD-HRQL) scores and overall satisfaction rates after surgery. A p value of < 0.05 was considered statistically significant.Results: The population consisted of 271 patients of which 103 patients had depression and 44 patients had anxiety. Patients with depression reported no significant difference in pre- or postoperative GERD-HRQL scores compared to patients without depression and long-term satisfaction rates after surgery were similar in both groups at 76% vs 71%, respectively (p = 0.55). Patients with anxiety reported higher baseline HRQL scores (34 vs. 29, p = 0.05). At long-term follow-up (15 months), patients with anxiety reported slightly worse HRQL scores compared to controls (7 vs. 4, p = 0.11) despite no difference in usage of anti-acid medications or need for endoscopic dilations between the two groups. Patients with anxiety were less likely to report being "satisfied" after surgery (40% vs. 71%, p = 0.01) compared to controls.Conclusion: Patients with anxiety have higher subjective reporting of GERD symptoms and are more likely to report being "satisfied" during long-term follow-up after LNF. Patients on medication for depression appear to have similar reporting of GERD symptoms and derive as much benefit from LNF as patients that are not. While LNF does improve the symptom burden in patients with anxiety, satisfaction is rarely achieved in long-term follow-up. [ABSTRACT FROM AUTHOR]

Introduction: Vitamin A deficiency (VAD) is an underreported micronutrient deficiency after bariatric surgery (BS). Objectives: The goal of this study was to characterize VAD prevalence in patients undergoing malabsorptive and restrictive procedures up to 2 years postoperatively. Methods: Primary sleeve gastrectomy (SG; n = 322) and gastric bypass (GB; n = 249) patients were reviewed. Levels for overall VAD (oVAD; retinol <39 mcg/dL) and moderate VAD (mVAD; retinol <30 mcg/dL) were reported preoperatively and 6, 12, and 24 months postoperatively. Differences in demographic, surgical, and postoperative data were tested between these groups. Settings: Single-center academic institution. Results: Serum retinol levels were documented for 56%, 74%, 61%, and 37% of patients for listed time points. Baseline retinol inversely correlated to preop body mass index (BMI) (R = -0.15, P = .007). Both oVAD and mVAD peaked 6 months postoperatively (33% vs. 15%, P < .005; 12% vs. 4%, P = .0004, respectively). oVAD remained elevated at 24 months (22% vs. 15%, P = .03). Compared to SG, oVAD was higher following GB at 6 months (39% vs. 28%, P = .001) and 12 months (26% vs. 17%, P = .04), and mVAD was greater with GB at 6 months (18% vs. 6%, P < .0005). African American patients had higher oVAD/mVAD preoperatively (26% vs. 13%, P = .02; 13% vs. 3%, P = .001, respectively) and at 6 months (19% vs. 10%, P = .04). Prior mild VAD (retinol 1.05-1.35 μM) was significantly associated with mVAD up to 12 months postoperatively. Conclusions: Although higher following LRYGB, VAD is prevalent following both malabsorptive and restrictive procedures. Preoperative serum retinol is inversely correlated to increasing BMI, and African American race and mild VAD are associated with moderate VAD. [ABSTRACT FROM AUTHOR]

Obesity is associated with a state of chronic low-grade inflammation both systemically and within specific tissues, including adipose tissue (AT). In murine models of obesity, there is a shift in the inflammatory profile of the AT immune cells, with an accumulation of proinflammatory M1 macrophages that surround the expanding adipocyte. However, much less is known about the immune cell composition and how to best define AT macrophages in humans. Objective. The goals of the current study were to determine the contribution of macrophages to the stromal vascular fraction (SVF) in lean versus obese human visceral AT (VAT); examine the expression of common M1, M2, and pan macrophage markers; and determine the association of specific macrophage types with known biomarkers of obesity-related cardiometabolic disease. Research Design and Methods. VAT biopsies were obtained from obese (n=50) and lean (n=8) patients during elective surgery. Adipocytes and SVF were isolated, and the SVF was subjected to flow cytometry analyses. Results. Our results indicate that VAT macrophages are increased in obesity and associate with biomarkers of CVD but that many macrophages do not fall into currently defined M1/M2 classification system based on CD206 receptor expression levels. Conclusions. VAT macrophages are increased in obese subjects, but the current markers used to define macrophage populations are inadequate to distinguish differences in human obesity. Further studies are needed to delineate the function of AT macrophages in the maintenance and progression of human AT inflammation in obesity. [ABSTRACT FROM AUTHOR]