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Background: Frailty is a recent multidimensional concept of a contemporary growing interest for understanding the complex health status of elderly population. We aimed to assess the impact of frailty scores on the outcome and complication rate of holmium laser enucleation of prostate (HoLEP). Methods: A 7-year data of HoLEP patients in a single tertiary referral center were reviewed. The preoperative, operative, early, and late postoperative outcome data were collected and compared according to the preoperative frailty scores. Frailty was assessed preoperatively using the Modified Hopkins frailty score. Results: The study included 837 patients categorized into two groups: group I included 533 nonfrail patients (frailty score = 0), whereas group II included 304 frail patients (frailty score ≥1). The median (interquartile range) age was 70 (11) and 75 (11) years for groups I and II, respectively (<0.001). The 30-day perioperative complication rate (p = 0.005), blood transfusion (p = 0.013), failed voiding trial (p = 0.0015), and 30-day postoperative readmission (p = 0.0363) rates were significantly higher in frail patients of group II. The two groups were statistically comparable regarding postoperative international prostate symptom score (p = 0.6886, 0.6308, 0.9781), incontinence rate (p = 0.475, 0.592, 0.1546), postvoid residual (p = 0.5801, 0.1819, 0.593) at 6 weeks and 3 months, and 1-year follow-up intervals, respectively. Conclusion: In elderly patients undergoing HoLEP, the preoperative frailty scores strongly correlate with the risk of perioperative complications. Frail patients should be counseled regarding their relative higher risk of early perioperative complications although they gain the same functional profit of HoLEP as nonfrail patients. [ABSTRACT FROM AUTHOR]

Introduction: One of the main adverse outcomes following Holmium laser enucleation of the prostate (HoLEP) is the development of transient de novo urinary incontinence (UI). We aimed to evaluate the correlation of multiple risk factors to UI rates post‐HoLEP. Methods: A review of prospectively maintained 7 year database for HoLEP patients in a single center was performed. UI data at 6 week, 3 month, and 1 year follow‐up intervals were assessed with bivariate and multivariate analysis of multiple potential risk factors. Results: The study included 666 patients with median (IQR) age of 72 (66–78) years old and median (IQR) preoperative prostate volume of 89 (68–126) gm. UI was seen in 287 (43%), 100 (15%) and 26 (5.8%) at 6 week, 3 month, and 1 year follow up occasions respectively. At 6 weeks follow up, UI type was stress, urge and mixed in 121 (18.16%), 118 (17.72) and 48 (7.21%) patients respectively. Using a multivariate regression analysis, obesity and pre‐operative UI were associated with postoperative UI rate at both 6 week (p =.0065,.031) and 3 month (p =.0261,.044) follow up encounters respectively. Also, larger specimen weight was another predictor for 6 week UI (p =.0399) while higher frailty score was a predictor for UI at 3 month occasion (p =.041). Conclusion: Patients with preoperative UI, obesity, frailty, and large prostate volume are at higher risk of short‐term UI post‐HoLEP up to 3 months. Patients with one or more of these risk factors should be counseled regarding the higher risk of UI. [ABSTRACT FROM AUTHOR]

Psychological safety enables the interpersonal risk-taking necessary for providing safer patient care in the operating room (OR). Limited studies look at psychological safety in the OR from the perspectives of each highly specialized team member. Therefore, we investigated each member's perspective on the factors that influence psychological safety in the OR. Interviews were conducted with operative team members of a level 1 trauma center in central Texas. The interviews were transcribed, de-identified, and coded by two investigators independently, and thematic analysis was performed. Responses were collected from 21 participants representing all surgical team roles (attending surgeons, attending anesthesiologists, circulating nurses, nurse anesthetists, scrub techs, and residents). Circulating nurse responses were redacted for confidentiality (n = 1). Six major themes influencing psychological safety in the OR were identified. Psychological safety is essential to better, safer patient care. Establishing a climate of mutual respect and suspended judgment in an OR safe for learning will lay the foundation for achieving psychological safety in the OR. Team exercises in building rapport and mutual understanding are important starting points. [ABSTRACT FROM AUTHOR]

Transforming growth factor (TGF)-[beta]-dependent apoptosis is important in the elimination of damaged or abnormal cells from normal tissues in vivo. Previously, we have shown that TGF-[beta] inhibits the growth of rat intestinal epithelial (RIE)-1 cells. However, RIE-1 cells are relatively resistant to TGF[beta]-induced apoptosis due to a low endogenous Smad3-to-Akt ratio. Overexpression of Smad3 sensitizes RIE-1 cells (RIE-1/Smad3) to TGF-[beta]-induced apoptosis by altering the Smad3-to-Akt ratio in favor of apoptosis. In this study, we utilized a genomic approach to identify potential downstream target genes that are regulated by TGF-[beta]/Smad3. Total RNA samples were analyzed using Affymetrix oligonucleotide microarrays. We found that TGF-[beta] regulated 518 probe sets corresponding to its target genes. Interestingly, among the known apoptotic genes included in the microarray analyses, only caspase-3 was induced, which was confirmed by real-time RT-PCR. Furthermore, TGF-[beta] activated caspase-3 through protein cleavage. Upstream of caspase-3, TGF-[beta] induced mitochondrial depolarization, cytochrome c release, and cleavage of caspase-9, which suggests that the intrinsic apoptotic pathway mediates TGF-[beta]-induced apoptosis in RIE-1/Smad3 cells. apoptosis; Affymetrix oligonucleotide microarrays; caspases; transforming growth factor-[beta]

Whereas the advancement of minimally invasive surgical techniques and enhanced recovery after surgery (ERAS) pathways for partial colectomies has shortened postoperative length of stay, the ideal length of stay after partial colectomy with or without diverting loop ileostomy is still up for debate. This article examines the safety and efficacy of discharging select patients home from day surgery following partial colectomy. We performed a retrospective review of 7 patients who underwent partial colectomy at one tertiary care center from December 2020 to August 2021. None of our cases suffered complications such as anastomotic leak, surgical site infection, or bowel obstruction or required admission to the hospital. One patient was seen in the emergency department on postoperative day 1 for nausea and vomiting and was managed as an outpatient. A second patient required a fluid bolus in the clinic for high ileostomy output. In conclusion, our study suggests that appropriately selected patients can be successfully managed in the outpatient setting without increased complications following partial colectomy when preoperative preparation and education are put in place alongside our colon ERAS pathway and minimally invasive surgical techniques. [ABSTRACT FROM AUTHOR]

Background: Surgical site infection (SSI) remains a persistent and morbid problem in colorectal surgery. A novel surgical device that combines barrier surgical wound protection and continuous surgical wound irrigation was evaluated in a cohort of elective colorectal surgery patients. A retrospective analysis was performed comparing rates of SSI observed in a prospective cohort study with the predicted rate of SSI using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Risk Calculator.Patients and Methods: A prospective multi-center study of colectomy patients was conducted using a study device for surgical site retraction and protection, as well as irrigation of the incision. Patients were followed for 30 days after the surgical procedure to assess for SSI. After completion of the study, patients' characteristics were inserted into the ACS-NSQIP Risk Calculator to determine the predicted rate of SSI for the given patient population and compared with the observed rate in the study.Results: A total of 108 subjects were enrolled in the study. The observed rate of SSI in the prospective study using the novel device was 3.7% (4/108). The predicted rate of SSI in the same patient population utilizing the ACS-NSQIP Risk Calculator was estimated to be 9.5%. This demonstrated a 61% difference (3.7% vs. 9.5%, p = 0.04) in SSI from the NSQIP predicted rate with the use of the irrigating surgical wound protection and retraction device.Conclusions: These data suggest the use of a novel surgical wound protection device seems to reduce the rate of SSIs in colorectal surgery. [ABSTRACT FROM AUTHOR]

Background: Surgical site infection (SSI) remains a persistent and morbid problem in colorectal surgery. Key to its pathogenesis is the degree of intraoperative bacterial contamination at the surgical site. The purpose of this study was to evaluate a novel wound retractor at reducing bacterial contamination.Methods: A prospective multicenter pilot study utilizing a novel wound retractor combining continuous irrigation and barrier protection was conducted in patients undergoing elective colorectal resections. Culture swabs were collected from the incision edge prior to device placement and from the exposed and protected incision edge prior to device removal. The primary and secondary endpoints were the rate of enteric and overall bacterial contamination on the exposed incision edge as compared to the protected incision edge, respectively. The safety endpoint was the absence of serious device-related adverse events.Results: A total of 86 patients were eligible for analysis. The novel wound retractor was associated with a 66% reduction in overall bacterial contamination at the protected incision edge compared to the exposed incision edge (11.9 vs. 34.5%, P < 0.001), and 71% reduction in enteric bacterial contamination (9.5% vs. 33.3%, P < 0.001). The incisional SSI rate was 2.3% in the primary analysis and 1.2% in those that completed the protocol. There were no adverse events attributed to device use.Conclusions: A novel wound retractor combining continuous irrigation and barrier protection was associated with a significant reduction in bacterial contamination. Improved methods to counteract wound contamination represent a promising strategy for SSI prevention (NCT 02413879). [ABSTRACT FROM AUTHOR]

Lower limb ischemia in diabetic patients is a result of macro- and microcirculation dysfunction. Diabetic patients undergoing limb amputation carry high mortality and morbidity rates, and decision making concerning the level of amputation is critical. Aim of this study is to evaluate a novel microdialysis technique to monitor tissue microcirculation preoperatively and predict the success of limb amputation in such patients. Overall, 165 patients with type 2 diabetes mellitus undergoing lower limb amputation were enrolled. A microdialysis catheter was placed preoperatively at the level of the intended flap for the stump reconstruction, and the levels of glucose, glycerol, lactate and pyruvate were measured for 24 consecutive hours. Patients were then amputated and monitored for 30 days regarding the outcome of amputation. Failure of amputation was defined as delayed healing or stump ischemia. Patients were divided into two groups based on the success of amputation. There was no difference between the two groups regarding gender, ASA score, body mass index, comorbidities, diagnostic modality used, level of amputation, as well as glucose, glycerol, and pyruvate levels. However, local concentrations of lactate were significantly different between the two groups and lactate/pyruvate (L/P) ratio was independently associated with failed amputation (threshold defined at 25.35). Elevated preoperative tissue L/P ratio is independently associated with worse outcomes in diabetic patients undergoing limb amputation. Therefore, preoperative tissue L/P ratio could be used as a predicting tool for limb amputation's outcome, although more clinical data are needed to provide safer conclusions. [ABSTRACT FROM AUTHOR]

The article presents abstracts on medical topics which include the ocular injuries in secluded orbital fractures, the association of congestive heart failure with increased risk of pneumonia and reintubation and the measurement of intraoperative portal vein flows.

Background: The relation between MRSA colonization and empyema culture results is unknown. We hypothesized that MRSA-colonized patients would be more likely to develop MRSA empyema, and sought to determine if MRSA culture positive empyema had an effect on clinical management or patient outcomes.Methods: The medical records of patients with a diagnosis of empyema from 2007-2010 were retrospectively reviewed for demographics, MRSA colonization status, comorbidities, culture results, clinical management, and discharge disposition. The relationship between MRSA colonization status and culture results was analyzed by bivariate testing. Logistic regression was utilized to determine relations between empyema culture results, comorbidities, and clinical course.Results: Of 147 patients identified with empyema, 16 (10.8%) were MRSA colonized. Colonized patients had substantially higher rates of MRSA-positive empyema cultures (75% vs. 4.6%; p<0.001). A greater percentage of the MRSA-positive empyema patients 66.7% were managed with tube thoracostomy alone, compared with culture positive patients with an organism other than MRSA and those with negative cultures (39% and 34% respectively; p=0.043). Neither empyema culture results nor colonization status were substantial risk factors for poor discharge (skilled nursing facility, long-term care hospital, or death).Conclusions: MRSA-colonized patients hospitalized with empyema are highly likely to have cultures positive for MRSA. [ABSTRACT FROM AUTHOR]

Background: Increased focus on reducing patient harm has led to surgical safety initiatives, including time-out, surgical safety checklists, and debriefings. The perception of the lay public of the surgical safety process is largely unknown. Methods: A 20-question survey focused on perceptions of surgical safety practice was distributed to a random sample of patients following elective operations requiring hospitalization. Responses were measured by a 7-point Likert scale. Qualitative feedback was obtained through nonphysician-moderated sessions. Participation was voluntary and anonymous. Results: Surveys were distributed to 345 patients of whom 102 (29.5%) responded. Overall, patients felt safe as evidenced by scores for the questions ''I felt safe the day of my surgery" (6.53 ± 0.72) and "Mistakes rarely happen during surgery" (5.39 ± 1.51). Patients undergoing their first surgery and patients with higher income levels were associated with a significant decrease in specific safety perceptions. Qualitative feedback sessions identified the physician-patient relationship as the most important factor positively influencing patient safety perceptions. Conclusion: Current surgical safety practice is perceived positively by our patients; however, patients still identify physicianpatient interactions, relationships, and trust as the most positive factors influencing their perception of the safety environment. [ABSTRACT FROM AUTHOR]

Health care is evolving into a value-based reimbursement system focused on quality and outcomes. Reported outcomes from national databases are used for quality improvement projects and public reporting. This study compared reported outcomes in cardiac and thoracic surgery from two validated reporting databases—the Society of Thoracic Surgeons (STS) database and the National Surgical Quality Improvement Program (NSQIP)— from January 2011 to June 2012. Quality metrics and outcomes included mortality, wound infection, prolonged ventilation, pneumonia, renal failure, stroke, and cardiac arrest. Comparison was made by chi-square analysis. A total of 737 and 177 cardiac surgery cases and 451 and 105 thoracic surgery cases were captured by the STS database and NSQIP, respectively. Within cardiac surgery, there was a statistically significant difference in the reported rates of prolonged ventilation, renal failure, and mortality. No significant differences were found for the thoracic surgery data. In conclusion, our data indicated a significant discordance in quality reporting for cardiac surgery between the NSQIP and the STS databases. The disparity between databases and duplicate participation strongly indicates that a unified national quality reporting program is required. Consolidation of reporting databases and standardization of morbidity definitions across all databases may improve participation and reduce hospital cost. [ABSTRACT FROM AUTHOR]

Introduction: In contrast with victims of major trauma, patients who suffer minor injuries receive little specialist input. In most cases, this causes no difficulty, but there are situations where minor trauma results in persistent disability affecting the quality of life. Case Presentation: A young man sustained a perineal puncture wound resulting from a fall onto a bush. Following an initial delay, he sought medical advice for a continual pain in his right leg, and a discharging perineal wound. A computed tomography (CT) scan and flexible sigmoidoscopy failed to identify the cause, and he was subsequently discharged from hospital. One year after his initial presentation, a magnetic resonance imaging (MRI) scan identified a retained foreign body consistent with a fragment of wood. Conclusions: Penetrating trauma from wooden fragments provides a diagnostic challenge. A stubborn discharge from a wound must always raise the suspicion of retained fragment. Early and appropriate surgical exploration is imperative. [ABSTRACT FROM AUTHOR]

BACKGROUND: The Surgical Safety Checklist (SSC) improves patient safety and outcomes; however, barriers to effective use include the perceived negative impact on operating room (OR) efficiency. The purpose of this study was to determine the effect of SSC implementation on OR efficiency. METHODS: All operations at our large multispecialty tertiary care hospital were reviewed for 1-year pre- and 1-year post-SSC implementation. OR efficiency included operating room time, operation time, first starts on time, same-day cancellations, and OR disposable cost. RESULTS: A total of 35,570 operations were reviewed: 17,204 pre-SSC and 18,366 post-SSC. There was no difference between groups for operating room time (P = .93), operation time (P = .66), first starts on time (P =.15), and same-day cancellations (P =.57). The mean OR disposable cost was significantly lower ($70/operation) for the post-SSC group (P < .01). CONCLUSIONS: The implementation of an SSC does not negatively impact OR efficiency and should not be considered a barrier to effective use. Our data suggest that SSC use can reduce overall cost per surgical procedure. [ABSTRACT FROM AUTHOR]

Villous adenoma of the genitourinary system is rarely encountered by the general urologist. Although commonly seen in a colorectal practice, this tumor has been infrequently described in the urethra or bladder. In the genitourinary tract, this tumor appears to have excellent survival when isolated; however, it does have an association with adenocarcinoma of the genitourinary or gastrointestinal tract. Here we present a case of villous adenoma of the urethra managed with a multidisciplinary approach, which led to discovery of invasive adenocarcinoma of the rectum. [ABSTRACT FROM AUTHOR]

Background: Residents and fellows perform a large portion of the hands-on patient care in tertiary referral centers. As frontline providers, they are well suited to identify quality and patient safety issues. As payment reform shifts hospitals to a fee-for-value-type system with reimbursement contingent on quality outcomes, preventive health, and patient satisfaction, house staff must be intimately involved in identifying and solving care delivery problems related to quality, outcomes, and patient safety. Many challenges exist in integrating house staff into the quality improvement infrastructure; these challenges may ideally be managed by the development of a house staff quality council (HSQC). Methods: Residents and fellows at Scott & White Memorial Hospital interested in participating in a quality council submitted an application, curriculum vitae, and letter of support from their program director. Twelve residents and fellows were selected based on their prior quality improvement experience and/or their interest in quality and safety initiatives. Results: In only 1 year, our HSQC, an Alliance of Independent Academic Medical Centers National Initiative III project, initiated 3 quality projects and began development of a fourth project. Conclusion: Academic medical centers should consider establishing HSQCs to align institutional quality goals with residency training and medical education. [ABSTRACT FROM AUTHOR]

Background: The World Health Organization (WHO) surgical safety checklist has been shown to decrease mortality and complications and has been adopted worldwide. However, system flaws and human errors persist. Identifying provider perspectives of patient safety initiatives may identify strategies for improvement. The purpose of this study was to determine provider perspectives of surgical safety checklist implementation in an effort to improve initiatives that enhance surgical patients' safety. Methods: In September 2010, a WHO-adapted surgical safety checklist was implemented at our institution. Surgical teams were invited to complete a checklist-focused questionnaire 1 month before and 1 year after implementation. Baseline and follow-up results were compared. Results: A total of 437 surgical care providers responded to the survey: 45% of providers responded at baseline and 64% of providers responded at follow-up. Of the total respondents, 153 (35%) were nurses, 104 (24%) were anesthesia providers, and 180 (41%) were surgeons. Overall, we found an improvement in the awareness of patient safety and quality of care, with significant improvements in the perception of the value of and participation in the time-out process, in surgical team communication, and in the establishment and clarity of patient care needs. Some discordance was noted between surgeons and other surgical team members, indicating that barriers in communication still exist. Overall, approximately 65% of respondents perceived that the checklist improved patient safety and patient care; however, we found a strong negative perception of operating room efficiency. Conclusion: Implementation of a surgical safety checklist improves perceptions of surgical safety. Barriers to implementation exist, but staff feedback may be used to enhance the sustainability and success of patient safety initiatives. [ABSTRACT FROM AUTHOR]

Background: It has been shown in many solid tumors that the overexpression of the pro-survival Bcl-2 family members Bcl-2/Bcl-xL and Mcl-1 confers resistance to a variety of chemotherapeutic agents. We designed the BH3 α-helix mimetic JY-1-106 to engage the hydrophobic BH3-binding grooves on the surfaces of both Bcl-xL and Mcl-1. Methods: JY-1-106-protein complexes were studied using molecular dynamics (MD) simulations and the SILCS methodology. We have evaluated the in vitro effects of JY-1-106 by using a fluorescence polarization (FP) assay, an XTT assay, apoptosis assays, and immunoprecipitation and western-blot assays. A preclinical human cancer xenograft model was used to test the efficacy of JY-1-106 in vivo. Results: MD and SILCS simulations of the JY-1-106-protein complexes indicated the importance of the aliphatic side chains of JY-1-106 to binding and successfully predicted the improved affinity of the ligand for Bcl-xL over Mcl-1. Ligand binding affinities were measured via an FP assay using a fluorescently labeled Bak-BH3 peptide in vitro. Apoptosis induction via JY-1-106 was evidenced by TUNEL assay and PARP cleavage as well as by Bax-Bax dimerization. Release of multi-domain Bak from its inhibitory binding to Bcl-2/Bcl-xL and Mcl-1 using JY-1-106 was detected via immunoprecipitation (IP) western blotting. At the cellular level, we compared the growth proliferation IC50s of JY-1-106 and ABT-737 in multiple cancer cell lines with various Bcl-xL and Mcl-1 expression levels. JY-1-106 effectively induced cell death regardless of the Mcl-1 expression level in ABT-737 resistant solid tumor cells, whilst toxicity toward normal human endothelial cells was limited. Furthermore, synergistic effects were observed in A549 cells using a combination of JY-1-106 and multiple chemotherapeutic agents. We also observed that JY-1-106 was a very effective agent in inducing apoptosis in metabolically stressed tumors. Finally, JY-1-106 was evaluated in a tumor-bearing nude mouse model, and was found to effectively repress tumor growth. Strong TUNEL signals in the tumor cells demonstrated the effectiveness of JY-1-106 in this animal model. No significant side effects were observed in mouse organs after multiple injections. Conclusions: Taken together, these observations demonstrate that JY-1-106 is an effective pan-Bcl-2 inhibitor with very promising clinical potential. [ABSTRACT FROM AUTHOR]

AbstractBackground and Purpose:Minimally invasive adrenalectomy is the preferred surgical approach for small, benign adrenal neoplasms. Posterior retroperitoneoscopic adrenalectomy is associated with potential surgical advantages. We sought to investigate the feasibility and early outcomes for robot-assisted posterior adrenalectomy, which has not been previously reported.Patients and Methods:Patients were selected for adrenalectomy based on standard clinical indications. The study was conducted under a protocol approved by the Institutional Review Board. Patients with adrenal masses larger than 7.0 cm, or with a body mass index (BMI) greater than 40, were excluded. Patient demographics, clinical and pathologic data, operative times, and patient outcomes were collected prospectively.Results:Six consecutive patients underwent robot-assisted posterior retroperitoneoscopic adrenalectomy (RAPRA) between June 23, 2009 and January 21, 2010. Five women and one man, ages 45 to 75 years (mean 55.5 years), with a mean BMI of 30, were included. There were three right adrenal tumors and three left adrenal tumors. Mean operative time was 121 minutes with a mean robot time of 57 minutes for the five patients in whom the entire adrenal dissection was performed robotically. There was essentially no morbidity and no mortality.Conclusion:This study represents the first report of RAPRA, and demonstrates the feasibility of performing this procedure with good patient outcomes. [ABSTRACT FROM AUTHOR]

The American Recovery and Reinvestment Act mandates "meaningful use" of an electronic health record (EHR) to receive current financial incentives and to avoid future financial penalties. Surgeons' ongoing adoption of an EHR nationally will be influenced by the early experiences of institutions that have made the transition from paper to electronic records. We conducted a survey to query surgeons at our institution regarding their perception of the EHR 3 months after institutional implementation. A total of 59 surveys were obtained from 24 senior staff and 35 residents. Results showed that surgeons believed the EHR was more effective as a billing tool than as a form of clinical documentation and believed the billing was more complete and accurate with the EHR. Surgeons also expressed concern that the EHR would negatively impact patient satisfaction, but in spite of this, they indicated that their personal quality of life was not negatively impacted. [ABSTRACT FROM AUTHOR]