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Surgical debriefs help reduce preventable errors in the operating room (OR) leading to patient injury. However, compliance with debriefs remains poor. The objective of this study was to evaluate the role of structured feedback to surgeons in improving compliance with and quality of surgical debriefs.Surgical cases at an 875-bed urban teaching hospital from January-June 2019 were audited via audio/video recording to evaluate debrief performance. Debriefs were evaluated for clinical completeness and teamwork quality via two structured forms. Surgeons received an evaluation of their debrief performance at two time points during the study period (February and April). Univariate and mixed-effects regression analyses were used to assess changes in debrief compliance and quality over time.A total of 878 surgical cases performed by 61 surgeons were reviewed: 198 (22.6%) cases during Period 1 (P1), 371 (42.3%) P2, and 309 (35.1%) P3. The rate at which a debrief occurred was 62.1% in P1, 73.0% in P2, and 82.2% in P3 (P 0.001). Debriefs were 1.96 (95% CI 1.31-2.95, P = 0.001) times more likely to be completed during P2 and 3.21 (95% CI 2.07-5.04, P 0.001) times more likely during P3 compared to P1. The percent of debriefs initiated by the lead surgeon increased from 59.8% in P1, to 80.0% in P2, to 81.5% in P3 (P 0.001).Providing structured feedback to surgeons on their debrief performance was associated with improvements in compliance and completeness with debriefing protocols, OR teamwork and communication, and leadership and accountability from the lead surgeons.

Background The prevalence of burnout and depression are high among surgical trainees. This study examined the impact of program-driven initiatives to improve surgical trainee wellness. Methods A survey was administered to residents and fellows at all surgical training programs across an urban academic health system. The survey measured burnout, depressive symptoms, and perceptions of program-driven wellness initiatives. Results The response rate was 44% among 369 residents. Of these, 63.2% screened positively for burnout, and 36.7% for depression. Residents who were burned out were more likely to work >80 h per week, have greater clerical duties, and miss educational activities more frequently. Conversely, having opportunities for wellness activities, dedicated faculty and housestaff wellness champions, and assistance with clerical burden were all associated with lower rates of burnout and depression. Conclusion The presence of wellness support was associated with better outcomes, suggesting the value of initiatives to manage workload and support the well-being of surgical resident physicians.

Background Locally advanced pancreatic tumors may require vascular reconstruction for complete resection. However, pancreatoduodenectomy with vascular resection (PDVR) remains a subject of debate due to increased complications. Methods Patients were identified using the ACS NSQIP Participant User Data Files from 2014 to 2019. Results The 30-day mortality rate was 2.7%; major complications occurred in 32.2%. There is an increasing trend of PDVR in patients requiring pancreatectomy. There were no significant differences in mortality between PDVR with vein, artery, or venous and arterial resections. High BMI and postoperative biliary stent were risk factors for early complications. High BMI and COPD increased risk of early mortality. Chemotherapy and chemoradiotherapy were negative predictors for early morbidities and mortality, respectively. Conclusion This study identifies the predictors of early morbidity and mortality in PDVR. The results of this study may assist decision making in perioperative management to optimize overall survival and guide additional research., Highlights • Pancreaticoduodenectomy with concomitant vascular reconstruction (PDVR) for carcinoma is increasing in frequency for locally advanced pancreatic neoplasms. • Early morbidity and mortality rates are acceptable. • Patients with elevated body mass index (BMI) and underlying COPD have a higher mortality. • Elevated BMI and preoperative biliary stenting are associated with a higher incidence of early complications. • Neoadjuvant chemotherapy and chemoradiation may also improve resectability and post-operative outcomes.

BACKGROUND The association between psychiatric illness and outcomes in trauma patients in general has only recently been investigated. The aim of this study was to describe the unique characteristics, risk factors, and outcomes of patients with comorbid psychiatric illness and penetrating abdominal and pelvic injuries. MATERIALS AND METHODS This was a retrospective review of trauma patients with open injuries to the abdomen and pelvis identified in the 2010-2015 the American College of Surgeons Trauma Quality Improvement Program database. Baseline variables extracted included demographics, comorbidities, including a discrete "psychiatric illness" variable that preexisted in the database, and injury information. Outcome variables collected included in-hospital mortality, length of stay and intensive care unit stay, and complications. Categorical variables were analyzed using chi-square and Fisher's exact test. Logistic regression was used to assess independent predictors for mortality with odds ratios (ORs) and 95% confidence intervals (CIs) constructed about group differences. RESULTS There were 22,053 patients identified, 6.1% of whom were diagnosed with a psychiatric comorbidity. Patients with psychiatric illnesses were more likely to be aged ≥65 y (5.4% versus 3.2%, P

Introduction Mitral valve repair has been established as the preferred treatment option in the management of degenerative mitral valve disease. Compared with other surgical treatment options, mitral valve repair is associated with increased survival and decreased rates of both complications and reoperations. However, among patients undergoing mitral valve repair, little is known about the predictors of postoperative outcomes. The purpose of this study is to identify preoperative patient risk factors associated with postoperative morbidity and mortality within 30 days of mitral valve repair. Methods Data was derived from the American College of Surgeons National Surgical Quality Improvement Program database to assess patients who underwent mitral valve repair from 2011 through 2017. Preoperative risk factors were analyzed to determine their association with a variety of postoperative 30-day outcome measures. Results One thousand three hundred and sixty-six patients underwent mitral valve repair; 849 (62.2%) males and 517 (37.8%) females. Ages ranged from 18 to 90 years, with a mean age of 64 years. The overall 30-day mortality was 3.1% (43 patients). Among the 12 identified risk factors associated with increased mortality on univariate analysis, pre-operative hematocrit level was the only variable significantly correlated with mortality after undergoing multivariate analysis. 259 patients (19.1%) were discharged to a location other than home, an outcome associated with 22 identified risk factors. Among these risk factors, female gender, age, dialysis, pre-operative serum sodium, pre-operative serum albumin, and partial or full living dependency remained statistically significant following multivariate analysis. 126 patients (9.2%) experienced unplanned readmission. This outcome was associated with five risk factors, of which only dyspnea upon mild exertion was significant on multivariate analysis. Reoperation occurred in 105 patients (7.7%). Of the seven identified variables associated with reoperation, patient age, pre-operative platelet count, dyspnea upon mild exertion were independent predictors on multivariate analysis. 53 patients (3.9%) underwent reintubation, which was associated with 11 identified risk factors. Among them, patient age and pre-operative INR value were predictive of reintubation on multivariate analysis. 26 patients (1.9%) experienced stroke, of whom age was the only associated risk factor on both univariate and multivariate analysis. 31 patients (2.3%) experienced acute renal failure, which correlated with 11 risk factors on univariate analysis. Of these, only patient age and pre-operative hematocrit were identified as independent predictors on multivariate analysis. Conclusions Outcomes are good following mitral valve repair. Although a substantial number of risk factors were found to be associated with adverse outcomes, only a small subset remained statistically significant following multivariate analysis. Identification of these risk factors may help guide clinical decision making with respect to which patients are the best candidates to undergo mitral valve repair., Highlights • There is minimal literature on adverse 30-day outcomes following mitral valve repair. • This study identified independent predictors of mortality, discharge location, readmission, reoperation, and reintubation. • Management of these risk factors may help guide clinical decision making., Article SummaryThe literature is limited regarding predictors of adverse 30-day outcomes following mitral valve repair. Through the use of the ACS NSQIP database, this study identified independent predictors of mortality, discharge location, readmission, reoperation, and reintubation. Management of the identified patient risk factors may help guide clinical decision making prior to undergoing surgery.

Background Loss of independence (LOI) assesses patient quality of life after surgery and is associated with increased readmission and death. This paper compares LOI among the elderly who received elective versus emergent inguinal hernia repair. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant User Files from 2015 to 2017 were reviewed for inguinal hernia repairs in patients 70-years-old or older. Chi-square analysis, Student t-test, and backwards multivariate logistic analysis were performed appropriately. Results Patients undergoing elective open or laparoscopic repair were less likely to experience LOI (OR 0.061, CI 0.035–0.106) and (OR 0.052 CI 0.024–0.113), respectively, and they were less likely to experience mortality (OR 0.07, CI 0.026–0.185) and (OR 0.059, CI 0.015–0.229), respectively. Conclusions Significant debility occurs following emergency inguinal hernia repair in elderly patients. Elective surgery may be indicated more often in order to reduce emergencies and LOI in elderly patients.

Background and Objectives: With obesity rates rising in the United States, bariatric surgery has become a well-established and effective treatment for morbid obesity and its comorbid conditions. Laparoscopic Roux-en-Y gastric bypass and laparoscopic Sleeve Gastrectomy are two of the more common bariatric procedures. This study analyzes whether gender differences play a role in procedure selection and outcomes following either procedure. Methods: Using the American College of Surgeons National Surgical Quality Improvement Program database for years 2015 to 2017, we assessed demographics, postoperative complications, and readmission rates. Chi-square analysis, student t-test, and propensity analyses were performed appropriately. Results: Data review found that men presenting for bariatric surgery had a higher incidence of comorbidities and higher body mass index than women. More men than women underwent Sleeve Gastrectomy (68.5% vs 63.0%, P

It is presently considered the standard of care to perform many routine intra-abdominal operations using a minimally invasive approach. The authors recently identified a racial disparity in access to a laparoscopic approach to inguinal hernia repair, cholecystectomy, appendectomy, and colectomy. The present study further evaluates this patient cohort to assess the relationship between the race and postoperative complications and test the mediating effect of the selected surgical approach.After institutional review board approval, patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent inguinal hernia repair, cholecystectomy, appendectomy, or colectomy in 2016 were identified. Patient demographics, including the self-reported race and ethnicity, as well as clinical, operative, and postoperative variables were recorded. After the exclusion of cases associated with diagnoses of cancer, a 4:1 propensity score matching algorithm generated a clinically balanced cohort of patients of white and black self-reported race. The mediating effect of an open approach to surgery on the relationship between black self-reported race and postoperative complications was evaluated via a series of regressions.There were 41,340 unilateral inguinal hernia repairs, 3182 bilateral inguinal hernia repairs, 60,444 cholecystectomies, 50,523 appendectomies, and 58,012 colectomies included in the database in 2017. Exclusion of cases associated with cancer and subsequent propensity score matching returned 17,540 unilateral hernia repairs, 890 bilateral hernia repairs, 23,865 cholecystectomies, 11,660 appendectomies, and 12,320 colectomies. On mediation analysis, any complication, severe complication, and death were significant when regressed on black self-reported race (any: odds ratio [OR] = 1.210, 95% confidence interval [CI] = 1.132-1.291, P 0.001; severe: OR = 1.352, 95% CI = 1.245-1.466, P 0.001; death: OR = 1.358, 95% CI = 1.000-1.818, P = 0.044), and open surgery was a significant mediator in the incidence of any complication and severe complication (any: OR = 1.180, 95% CI = 1.105-1.260, P 0.001 and severe: OR = 1.307, 95% CI = 1.203-1.418, P 0.001).These findings underscore the importance of access to a minimally invasive approach to surgery. However, other factors may contribute to racial disparities in postoperative complications after common abdominal operations.

Background Cardiac events (CE) following surgery have been associated with morbidity and mortality. Defining risk factors that contribute to CE is essential to improve surgical outcomes. Study design This was a retrospective study at a large urban teaching hospital for surgery performed from 2013 to 2015. Adult patients (≥18 years) that underwent general and vascular surgery were analyzed. Patients were grouped into those who experienced postoperative CE and those who did not. Univariate and multivariate regression analyses were used to identify predictors of postoperative CE, and association of CE with adverse postoperative outcomes. Separate subgroup analyses were also conducted for general and vascular surgery patients to assess predictors of CE. Results Out of 8441 patients, 157 (1.9%) experienced CE after major general and vascular surgery. Underlying predictors for CE included age >65 years(OR 4.9, 95%CI 3.4–6.9,p 3(OR 12.0, 95%CI 8.5–16.9,p 1.2 mg/dL(OR 5.1, 95%CI 3.7–7.1,p = 0.01), hematocrit 240 min(OR 2.0, 95%CI 1.3–3.3,p = 0.02). Following surgery, CE was associated with increased mortality(OR 3.5, 95%CI 1.2–6.5,p, Highlights • Cardiac events following general and vascular surgery were associated with a mortality rate of 55%. • Underlying risk factors for cardiac events following general and vascular surgery include COPD, hypertension on medication, and renal failure. • Return to the OR, deep wound infection, unplanned intubation and ventilator dependence are also associated with a post-op cardiac event.

Background Endovascular approaches to aortoiliac disease are becoming increasingly frequent due to decreases in recovery time, bleeding, and discomfort. Despite this trend, little is known about the predictors of complications. This study was designed to identify risk factors for major 30-day morbidity and mortality after endovascular repair. Methods Data were derived from the 2015–2016 Participant User Files and Procedure Targeted databases of the American College of Surgeons National Surgical Quality Improvement Program. Demographics and comorbidities of patients undergoing repair were assessed. Preoperative risk factors were analyzed using univariate and multivariate analysis. Results Twelve hundred and nine patients underwent endovascular aortoiliac repair, including 532 females (44.0%) and 677 males (56.0%). The 30-day mortality rate was 0.7%. Diabetes mellitus requiring medication, chronic steroid use, dialysis, pre-existing open wound, age, and low serum albumin and hematocrit increased mortality. After logistic regression, 30-day mortality was correlated with low serum albumin (survivors = 3.77, nonsurvivors = 2.60; P = .003) and chronic steroid use (P = .020). Multivariate analysis identified high preoperative white blood cell count as a risk factor for amputation. Diabetes, smoking history, and low serum sodium were risk factors for return to the operating room. Female sex and steroid use were risk factors for myocardial infarction and stroke. Open wounds and high platelets were risk factors for the need for an operative bypass after endovascular intervention. Preprocedural statin use was protective against need for a later operative bypass and reintervention. Conclusions Open wound, smoking, preprocedural steroid use, diabetes, female sex, high platelet and white blood cell count, and low serum albumin are the most strongly associated risk factors for adverse 30-day postoperative outcomes. Mortality rates remain low after endovascular aortoiliac revascularization.

Objectives To determine if there is a correlation between the numbers of evaluations submitted by faculty and the perception of the quality of feedback reported by trainees on a yearly survey. Method 147 ACGME-accredited training programs sponsored by a single medical school were included in the analysis. Eighty-seven programs (49 core residency programs and 38 advanced training programs) with 4 or more trainees received ACGME survey summary data for academic year 2013–2014. Resident ratings of satisfaction with feedback were analyzed against the number of evaluations completed per resident during the same period. R-squared correlation analysis was calculated using a Pearson correlation coefficient. Results 177,096 evaluations were distributed to the 87 programs, of which 117,452 were completed (66%). On average, faculty submitted 33.9 evaluations per resident. Core residency programs had a greater number of evaluations per resident than fellowship programs (39.2 vs. 27.1, respectively, p = 0.15). The average score for the “satisfied with feedback after assignment” survey questions was 4.2 (range 2.2–5.0). There was no overall correlation between the number of evaluations per resident and the residents' perception of feedback from faculty based on medical, surgical or hospital-based programs. Conclusions Resident perception of feedback is not correlated with number of faculty evaluations. An emphasis on faculty summative evaluation of resident performance is important but appears to miss the mark as a replacement for on-going, data-driven, structured resident feedback. Understanding the difference between evaluation and feedback is a global concept that is important for all medical educators and learners., Highlights • Residents and fellows do not perceive that regular evaluations are the same as feedback. • The quantity of faculty evaluations does not correlate the resident perception of quality feedback. • A greater emphasis is necessary to instruct faculty on providing regular, timely and data-driven feedback to residents and fellows with specific comments on performance. • Faculty summative evaluation of resident performance is important but this is not a replacement for structured feedback.

Background Morbid obesity can complicate perioperative management. Best practice guidelines have been published but are typically followed only in bariatric patients. Little is known regarding physician awareness of and compliance with these clinical recommendations for nonbariatric operations. Our study evaluated if an educational intervention could improve physician recognition of and compliance with established best practices for all morbidly obese operatively treated patients. Methods A care map outlining best practices for morbidly obese patients was distributed to all surgeons and anesthesiologists at 4 teaching hospitals in 2013. Pre- and postintervention surveys were sent to participants in 2012 and in 2015 to evaluate changes in clinical practice. A chart audit performed postintervention determined physician compliance with distributed guidelines. Results In the study, 567 physicians completed the survey in 2012 and 375 physicians completed the survey in 2015. Postintervention, statistically significant improvements were seen in the percentage of surgeons and anesthesiologists combined who reported changing their management of morbidly obese, operatively treated patients to comply with best practices preoperatively (89% vs 59%), intraoperatively (71% vs 54%), postoperatively (80% vs 57%), and overall (88% vs 72%). Results were similar when surgeons and anesthesiologists were analyzed separately. A chart audit of 170 cases from the 4 hospitals found that 167 (98%) cases were compliant with best practices. Conclusion After care map distribution, the percentage of physicians who reported changing their management to match best practices significantly improved. These findings highlight the beneficial impact this educational intervention can have on physician behavior. Continued investigation is needed to evaluate the influence of this intervention on clinical outcomes.

Background: Sepsis is an uncommon occurrence after appendectomy, but the morbidity and mortality of patients who develop sepsis after appendectomy remains exceedingly high. The purpose of ...

The objective of this study was to determine whether a correlation exists between patient age and hospital expenditures for common complex elective surgical procedures. Hospital charges at an urban academic medical center were categorized by diagnosis related group (DRG) and separated into two cohorts based on patient age (≥65 years old and

This study analyzed trends in laparoscopic inguinal hernia repair over time, rates of laparoscopic repair in women, and subsequent postoperative outcomes.Data for 237,503 patients undergoing repair of an initial, reducible inguinal hernia were analyzed using the National Surgical Quality Improvement Program (NSQIP) database for years 2006-2017. Data were analyzed by univariate and multivariate analysis.Since 2006, there was an increased proportion of laparoscopic inguinal hernia surgeries, from 20.49% in 2006 to 36.36% in 2017 (p .001). The percentage of women with bilateral inguinal hernias that underwent laparoscopic repair was less than the percentage of men (31.58% vs. 41.43%, p .001). Based on multivariate analysis, women were less likely to have laparoscopic hernia repair (OR 0.74, CI 0.71-0.76). Postoperative complications were overall low.A greater proportion of inguinal hernia repairs are performed laparoscopically. Women with bilateral inguinal hernias are more likely than men to undergo open rather than laparoscopic inguinal hernia repair.

Background: Diaphragmatic hernia is a complication of trauma that may lead to significant morbidity and mortality if unrecognized. The clinical sequelae following missed traumatic diaphragmatic hernia (TDH) diagnoses have not been well-defined. Methods: The 2005–2015 ACS-NSQIP databases were accessed to identify patients ≥18 years old who underwent operative repair of acute and chronic TDH. Patient demographics, health characteristics, pertinent complications, and 30-day outcomes were collected. Categorical variables were analyzed using chi-square and Fisher’s Exact Test. Logistic regression was used to perform multivariate analyses with odds ratios (OR) and 95% confidence intervals (CI) constructed about group differences. Results: From 2005–2015, 1000 patients underwent operative repair for TDH, of which 285 (28.5%) were acute and 715 (71.5%) were chronic. Patients undergoing acute repairs had a greater percentage of emergency procedures (29.8% vs. 10.2%, p 2 (51.2% vs 43.2%, p = 0.02). Acute TDH patients were more likely to develop postoperative wound infection (1.40% vs 0.28%, p = 0.05), infectious process (11.2% versus 7.0%, p = 0.03), failure to wean from mechanical ventilation (8.1% vs 3.4%, p = 0.0015), and remain hospitalized at 30 days (4.3% vs 0.9%, p = 0.0058). Conclusions: Patients with acute TDH repair are more likely to develop postoperative complications. Further study is necessary to determine the optimal timing of surgery for TDH discovered following initial resuscitation and evaluation.

Laparoscopy has become the standard of care for the majority of cases for inguinal hernia repair, cholecystectomy, appendectomy, and colectomy due to the shortened patient recovery time compared to open surgery. This study sought to determine if there exists racial disparity in access to a laparoscopic approach to these common surgeries. This was an IRB-approved retrospective study utilizing data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Individuals who underwent inguinal hernia repair, cholecystectomy, appendectomy, and colectomy in 2016 were identified. Information on self-reported race and ethnicity and other demographic and pre-operative clinical covariates were recorded. Propensity matching was conducted to evaluate the association between race and a laparoscopic approach to surgery. There were 44,522, 60,444, 50,523, and 58,012 cases of inguinal hernia repair, cholecystectomy, appendectomy, and colectomy identified, respectively. Of these patients, 8.38, 8.76, 6.69, and 9.02% self-identified as black, respectively. Confounding effects of variables other than race were balanced by propensity matching. After propensity matching, there were 7460, 10,574, 10,470, and 6758 cases of hernia repair, cholecystectomy, colectomy, and appendectomy, respectively. On univariate (Chi square) analysis with laparoscopic surgery as the primary outcome, black race was significantly associated with lower likelihood of undergoing a minimally-invasive surgical approach in all four surgical procedures under investigation (33.86% of white patients and 21.69% of black patients, p

Background Using finger-stick capillary blood to assess lactate from the microcirculation may have utility in treating critically ill patients. Our goals were to determine how finger-stick capillary lactate correlates with arterial lactate levels in patients from the surgical intensive care unit, and to compare how capillary and arterial lactate trend over time in patients undergoing resuscitation for shock. Methods Capillary whole blood specimens were obtained from finger-sticks using a lancet, and assessed for lactate via a handheld point-of-care device as part of an “investigational use only” study. Comparison was made to arterial blood specimens that were assessed for lactate by standard laboratory reference methods. Results 40 patients (mean age 68, mean APACHEII 18, vasopressor use 62%) were included. The correlation between capillary and arterial lactate levels was 0.94 (p, Highlights • Finger-stick capillary lactate correlates with blood gas and core lab values. • Capillary lactate trends closely over time with arterial lactate. • Rising or falling capillary lactate reflects the adequacy of global perfusion. • Capillary lactate measurements require a fraction of the time and blood to process. • Preliminary results imply capillary lactate may be used in lieu of invasive methods.

Background A chronic state of impaired glucose metabolism affects multiple components of the immune system, possibly leading to an increased incidence of post-operative infections. Such infections increase morbidity, length of stay, and overall cost. This study evaluates the correlation between elevated pre-operative glycosylated hemoglobin (HbA1c) and post-operative infections. Study design Adult patients undergoing non-emergent procedures across all surgical subspecialties from January 2010 to July 2014 had a preoperative HbA1c measured as part of their routine pre-surgical assessment. 2200 patient charts (1100, Highlights • This study reviews the impact of pre-operative HbA1c across many specialties undergoing elective surgery. • The risk factors of post-operative infection are multiple and likely synergistic. • Elevated serum HbA1c is not independently associated with an increased risk of post-operative infection.

Background Components separation technique emerged several years ago as a novel procedure to improve durability of repair for ventral abdominal hernias. Almost twenty-five years since its initial description, little comprehensive risk adjusted data exists on the morbidity of this procedure. This study is the largest analysis to date of short-term outcomes for these cases. Methods The ACS-NSQIP database identified open ventral or incisional hernia repairs with components separation from 2005 to 2012. A data set of cohorts without this technique, matched for preoperative risk factors and operative characteristics, was developed for comparison. A comprehensive risk-adjusted analysis of outcomes and morbidity was performed. Results A total of 68,439 patients underwent open ventral hernia repair during the study period (2245 with components separation performed (3.3%) and 66,194 without). In comparison with risk-adjusted controls, use of components separation increased operative duration (additional 83 min), length of stay (6.4 days vs. 3.8 days, p, Highlights • The repair of large abdominal wall hernias is more frequently performed using components separation. • While this technique appears to reduce recurrence, morbidity has not been previously studied. • When compared to a large cohort, components separation has a higher complication rate than traditional open hernia repair.

Introduction: When evaluating the cost of a lifesaving operation, one must consider the economic value, which can be defined as the relative cost per additional year of life lived. This evaluation might provide useful information for the application of costly procedures. The objective of this study was to determine the cost per year of life saved for the costliest operations performed at an urban academic medical center. Methods: Total hospital expenditures were categorized by diagnosis related group (DRG) between January 1, 2015 and December 31, 2016. Average cost and patient age for each procedure were calculated. Average lifespan following successful outcome was determined based upon published benchmarks. Cost per year of life saved was calculated for each procedure. Only those elective procedures necessary to prolong life and enhance health were analyzed. Results: 114,448 hospital admissions were reviewed. The 12 costliest procedures were identified and ranked according to cost per year of life saved: Coronary bypass ($1,345.45), portacaval shunt procedure ($2,261.70), cardiac valve/other major cardiothoracic procedure ($2,733.78), major bladder procedure ($2,733.78), cardiac defibrillator implant ($5,047.65), bone marrow transplant ($5,181.80), intracranial vascular procedures ($8,572.05), kidney transplant ($9,024.87), liver transplant ($11,112.73), endovascular cardiac valve replacement ($12,842.25), simultaneous pancreas/kidney transplant ($14,087.50), and heart transplant ($20,472.11). Conclusion: Among the costliest procedures, coronary bypass was the most economic, having the lowest cost per year of life saved ($1,345.45) and longest post-procedure life expectancy (17.6 years). These findings combined with further analysis of the identified procedures may allow us to better determine their relative value.

Background Few guidelines exist on safe prescription of postoperative analgesia to obese patients undergoing ambulatory surgery. This study examines the preferences of providers in the standard treatment of postoperative pain in the ambulatory setting. Methods Providers from five academic medical centers within a single US city were surveyed from May–September 2015. They were asked to provide their preferred postoperative analgesic routine based upon the predicted severity of pain for obese and non-obese patients. McNemar’s tests for paired observations were performed to compare prescribing preferences for obese vs. non-obese patients. Fisher’s exact tests were performed to compare preferences based on experience: > 15 years vs. ≤15 years in practice, and attending vs. resident physicians. Results A total of 452 providers responded out of a possible 695. For mild pain, 119 (26.4%) respondents prefer an opioid for obese patients vs. 140 (31.1%) for non-obese (p = 0.002); for moderate pain, 329 (72.7%) for obese patients vs. 348 (77.0%) for non-obese (p = 0.011); for severe pain, 398 (88.1%) for obese patients vs. 423 (93.6%) for non-obese (p 15 years in practice vs. 86 (74.5%) with ≤15 years (p = 0.047), and 177 (68.0%) attending physicians vs. 129 (83.0%) residents (p = 0.002). Conclusions While there is a trend to prescribe less opioid analgesics to obese patients undergoing ambulatory surgery, these medications may still be over-prescribed. Less experienced physicians reported prescribing opioids to obese patients more frequently than more experienced physicians.

Background Limited health literacy has been associated with poorer health outcomes and increased morbidity and mortality. Though caring for surgical patients requires communication about complex topics, there is limited literature on health literacy competency in this population. The objective of this study was to assess health literacy in an adult surgical outpatient clinic population, to explore potential determinants of adequate health literacy, and to assess patient satisfaction with physician-patient communication. Materials and methods A prospective cross-sectional study was performed and anonymous data including health literacy, demographics, and patient satisfaction with provider communication were collected. The study population included adult patients who visited an outpatient surgical practice over a one-month period. Health literacy was assessed using the Newest Vital Sign while the satisfaction questions came from the Outpatient Satisfaction Survey (Press-Ganey Associates, Chicago, IL). Results 148 patients participated in the study. The mean age was 49 years, 41% of those who gender identified were male, and 76% were White/Caucasian. 34 (27%) of those who answered the question had received a four-year undergraduate/university degree. 55 (37%) of the patients were identified as having low health literacy. More years of education was significantly associated with adequate health literacy and those patients who were more educated and had adequate health literacy were more satisfied with provider communication. Conclusion Patients on average were highly satisfied with provider communication in this outpatient surgical clinic. Higher education levels were associated with better health literacy and patients with both characteristics were more satisfied with provider communication.

Introduction: Adhesive small bowel obstruction (SBO) is a disease process that has been difficult to prevent. Mechanical barriers and chemical agents exist to disrupt the formation of adhesions following surgery but each associated with medical risk and financial burden. Identifying risk factors for developing SBO in patients post laparotomy would aid in the appropriate use of such agents. We hypothesize that there might be additional risk factors that are associated with a higher likelihood of SBO. Methods: A retrospective analysis from 2008 to 2012 was performed. Cases of SBO following previous laparotomy were compared to those without SBO. Results: 468 medical records were reviewed (57% male). Operations that caused the highest risks for SBO included gynecological, colorectal and hernia operations with prosthetic materials. 66% percent of patients underwent a prior abdominal or pelvic high-risk procedure. The average time from surgery to the development of SBO was 24 months (median 19 months). Patients who developed SBO had a median age of 58.4 years on initial surgery, average previous operative time of 4.3 hours, and an av-erage of two prior operations. For every hour of operative time, the odds of developing SBO increased by 33% (p 3 decreased the odds of SBO (p = 0.05). Conclusions: Longer operative times are associated with post-operative adhesive small bowel obstruction. Patients with an ASA score greater than or equal to 3 appear to have a reduced risk of adhesive small bowel obstruction.

Objective To evaluate the effect of resident involvement in thoracic endovascular aortic repair (TEVAR). Summary of Background Data Although the influence of resident intraoperative involvement in several types of surgical procedures has been reported, the effect of resident participation in TEVAR is unknown. We evaluated patient outcomes in resident-involved TEVAR procedures. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was analyzed for TEVAR performed from 2010 to 2012. Current procedural terminology codes were used to identify adult patients (≥18 y) who underwent TEVAR. Patients were grouped into those with and without resident involvement. Descriptive and binomial logistic statistics were used to determine the effect of resident involvement on post-TEVAR outcomes. p values Results A total of 676 patients met inclusion criteria for this study. Of these, 517 (76.5%) had residents involved. Overall mortality was 9.8%, with no significant difference between the 2 groups (p = 0.88). Resident involvement was not a significant predictor of any post-TEVAR complication. Postoperative pneumonia (3.5% vs 6.9%, p = 0.06), prolonged mechanical ventilation (11.8% vs 11.9%, p = 0.96), stroke (2.7% vs 5.7%, p = 0.07), urinary tract infection (3.3% vs 4.4%, p = 0.50), progressive renal insufficiency (1.2% vs 2.5%, p = 0.22), acute renal failure (4.1% vs 5.0%, p = 0.60), cardiac arrest (2.9% vs 5.0%, p = 0.20), myocardial infarction (1.7% vs 1.9%, p = 0.91), deep venous thrombosis (1.7% vs 1.3%, p = 0.67), red blood cells transfusions (29.2% vs 36.5%, p = 0.08), sepsis (2.9% vs 4.4%, p = 0.35), septic shock (1.9% vs 3.8%, p = 0.18), and unplanned reintubation (8.7% vs 9.4%, p = 0.78) were not significantly affected. Additionally, resident involvement did not significantly affect operative time (176.1 ± 122.8 min vs 180.3 ± 119.1 min, p = 0.71) and anesthesia time (282.1 ± 146.6 min vs 278.3 ± 140.5 min, p = 0.78). Conclusions The participation of residents in TEVAR did not significantly affect all 30-day patient outcomes. Resident involvement in TEVAR is safe and should be encouraged. Mini abstract This study evaluated the effect of resident participation on postoperative outcomes of thoracic endovascular aortic repair (TEVAR) using the American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database. Results showed that resident involvement in TEVAR does not negatively affect patient outcomes.

Background The surgical management of patients with morbid obesity (body mass index ≥ 40) is notable for a relatively high risk of complications. To address this problem, a perioperative care map was developed using precautions and best practices commonly employed in bariatric surgery. It requires additional medical assessments, sleep apnea surveillance, more stringent guidelines for anesthetic management, and readily available bariatric operating room equipment, among other items. This care map was implemented in 2013 at 4 major urban teaching hospitals for use in patients undergoing all types of nonambulatory surgery with a body mass index greater than 40 kg/m2. The impact on patient outcomes was evaluated. Methods The American College of Surgeons National Surgical Quality Improvement Program database was used to compare 30-day outcomes of morbidly obese patients before the year 2013 and after the years 2015 care-map implementation. In addition, trends in 30-day outcomes for morbidly obese patients were compared with those for non-obese patients. Results Morbidly obese patients, between 2013 and 2015, saw an adjusted decrease in the rate of unplanned return to the operating room (OR = 0.49; P = .039), unplanned readmission (OR = 0.57; P = .006), total duration of stay (−0.87 days; P = .009), and postoperative duration of stay (−0.69 days; P = .007). Of these, total duration of stay (−0.86 days; P = .015), and postoperative duration of stay (−0.69 days; P = .012) improved significantly more for morbidly obese patients than for nonmorbidly obese patients. Conclusion Outcomes in morbidly obese patients improved from 2013 to 2015. Implementation of a perioperative care map may have contributed to these improvements. The care map should be further investigated and considered for more widespread use.

Teamwork in the operating room decreases the risk of preventable patient harm. Observation in the operating room allows for evaluation of compliance with best-practice surgical guidelines. This study examines the relative ability of video and live observation to promote operating room teamwork.Video and audio cameras were installed in 2014 into all operating rooms at an 875-bed, urban teaching hospital. Recordings were chosen at random for review by an internal quality improvement team. Concurrently, live observers were deployed into a random selection of operations. A customized tool was used to evaluate compliance to TeamSTEPPS skills during surgical briefs and debriefs.A total of 1,410 briefs were evaluated: 325 (23%) through live observation and 1,085 (77%) through video; 1,398 debriefs were evaluated: 166 (12%) live and 1,232 (88%) video. For briefs, greater compliance was observed under live observation compared to video for recognition of team membership (87% vs 44%, P.001), anticipation of complex procedural events (61% vs 45%, P.001), and monitoring of resources (58% vs 42%, P.001). For debriefs, greater compliance was observed under live observation for determination of team structure (90% vs 60%, P.001), establishment of a leader (70% vs 51%, P.001), postoperative planning (77% vs 48%, P.001), case review and feedback (49% vs 33%, P.001), team engagement (64% vs 41%, P.001), and check back (61% vs 46%, P.001) compared to video.Video observations may not be as effective as evaluating live performance in promoting teamwork in the OR. Live observation enables immediate feedback, which may improve behavior and decrease barriers to compliance with surgical safety practices.

In recent years, medical educators have been making meaningful attempts to rethink how premedical students are prepared for medical school, and how medical students are prepared for residency. Among the many challenges to redesigning premedical and medical school curricula, one that stands out is the constraint imposed by our current methods of assessing aptitude, particularly our use of the Medical College Admissions Test (MCAT) and the United States Medical Licensing Examination (USMLE). For much of the past century, medical school and residency admissions committees have relied heavily on MCAT and USMLE scores to evaluate and rank candidates to their programs. These high-stakes exams determine to a large extent what is taught, and what is stressed, in preparation for and during medical school-despite the fact that scores have limited ability to predict future success in clinical medicine or biomedical research. Additionally, evidence indicates that students from disadvantaged and minority backgrounds do not fare as well on these exams and, as a result, may be disproportionately excluded from the medical profession. While medical school admissions committees have made limited incremental gains in holistic review, residency programs appear to be increasingly focused on USMLE Step scores and veering away from the spirit of holistic review. The authors propose that substantive change will remain slow in coming unless members of the medical education community radically rethink how we report scores from these exams, and how we use them in our selection of future medical students and residents.

Breast conservation therapy (BCT) has a reported incidence of positive margins ranging widely in the literature from 20% to 70%. Efforts have been made to refine standards for partial mastectomy and to predict which patients are at highest risk for incomplete excision. Most have focused on histology and demographics. We sought to further define modifiable risk factors for positive margins and residual disease. A retrospective study was conducted of 567 consecutive partial mastectomies by 21 breast and general surgeons from 2009 to 2012. Four hundred fourteen cases of neoplasm were reviewed for localization, intraoperative assessment, excision technique, rates, and results of re-excision/mastectomy. Histologic margins were positive in 23% of patients, 25% had margins 0.1-0.9 mm, and 7% had tumor within 1-1.9 mm. Residual tumor was identified at-in 61 cases: 38% (disease at margin), 21% (0.1-0.9 mm), and 14% (1-1.9 mm). Ductal carcinoma in situ (DCIS) was present in 85% of residual disease on re-excision and correlated to higher rates of re-excision (p =

Colon capsule endoscopy (CCE) was first put into clinical practice for the evaluation of the small bowel in patients presenting with a gastrointestinal bleed unsuccessfully diagnosed by upper GI endoscopy and colonoscopy. With the recent advent of new technology, there is improved visualization of the intestinal mucosa and subsequently a higher sensitivity for identification of mural pathology, as seen in many recent prospective studies. CCE has now been studied both in the US and in Europe as a modality for colon cancer screening as well as for the diagnosis of inflammatory bowel disease. When compared to conventional colonoscopy, CCE has been shown to have a sensitivity of greater than 88% for identifying 6 mm colonic polyps and over 90% for 1 cm polyps. Therefore its use as a screening tool for colon cancer must be evaluated. In patients suspected to have colitis secondary to inflammatory bowel disease (IBD), it has been shown to have 89% sensitivity for identifying active colonic inflammation. For higher risk patients that requiring urgent colonoscopy, CCE offers an attractive alternative with the potential for a reduced risk on iatrogenic injury. Colon capsule endoscopy may also play an important role in the diagnosis and surveillance of IBD with colonic manifestations. Colonoscopy during active severe disease is associated with an increased risk of perforation due to mucosal inflammation and friability, allowing us to consider CCE as a potentially safer alternative. CCE appears to be most useful for patients with acute lower GI bleeding, inflammatory bowel disease, colonic ischemia or other mucosal-based lesions.

Background: Historically, the incidence of C. difficile-associated colitis has increased significantly over the last decade. Of these patients, approximately 10% - 20% will ultimately require colectomy due to fulminant disease and progression to toxic colitis. Despite operative intervention, the mortality for this population remains high (35% - 80%). This study evaluates for preoperative risk factors for mortality. Methods: Retrospective medical record review of 47 patients who underwent emergent colectomy for fulminant C. ddifficile colitis over a five-year period at three teaching hospitals in New York City. Results: Forty-seven patients with Clostridium difficile colitis underwent colectomy from January 2003 to December 2008. The mean age was 66 years with 31 (67%) male and 16 (34%) female. The 30-day mortality was 34% (16/47 patients). Thirty-eight (81%) underwent subtotal colectomy, six (13%) Hartmann resection, two (4%) right hemicolectomy, and one (2%) underwent left colectomy. Univariate analysis showed that age (71.6 vs. 67.5 years; p = 0.402), white blood cell count (35,500 vs. 27,700/mm3; p = 0.271), and use of vaso-pressors in the pre-operative period *p = 0.440) were not statistically predictive of postoperative mortality. Conversely, preoperative serum lactate level (4.3 vs. 2.1 mmol/L p + 0.009) was statistically greater in the postoperative mortality group. Conclusion: In the setting of fulminant C. difficile colitis, serum lactate levels can help predict postoperative outcome following emergent colectomy and should be closely followed to facilitate the decision to proceed with surgery.

Background Temporal artery biopsy is performed in patients suspected of having giant cell arteritis. This study was conducted to evaluate clinical and laboratory criteria correlating with positive biopsy results in an effort to limit the number of negative biopsies performed. Methods A retrospective review was performed of patients who underwent temporal artery biopsy at two urban medical centers from 2002 to 2009. A multivariate analysis of patient demographics, clinically relevant signs and symptoms, laboratory data, and pathologic outcomes was performed. Results Temporal artery biopsy histologically confirmed giant cell arteritis in 24% of cases. The mean age of those with disease was 77.8 y and those without were 73.1 y; age was found to be statically significant (P = 0.0227); 76% were female and 24% were male; gender was not significant (P = 0.9594); 42% were Caucasian (39% had a positive temporal artery biopsy), 27% were Hispanic (17% positive), and 31% of the patients were African-American (3% positive); ethnicity was significant (P = 0.0005). The PPV of elevated ESR was 27%; sensitivity was 100%; specificity was 16%. A history of headache or visual disturbance was not predictive of a positive biopsy Conclusion Fewer negative biopsy results may be achieved by screening patients with normal ESR or lower risk patients with other modalities.

Background. Gainsharing is a pay-for-performance (P4P) program that provides incentives to attending physicians to reduce hospital costs while maintaining quality care. Hypothesis. Overall hospital costs decreased because of the gainsharing program during the past 4 years, while ICU costs increased over the same period because the incentives were given only to the discharging physician of record. Methods. Retrospective analysis was performed on the most frequent hospital and ICU admissions by All Patient Refined–Diagnosis Related Group (APR-DRG). A best practice norm was calculated by taking the mean hospital cost of the top 25 percentile. Savings opportunity (SO) was defined by subtracting the BPN from the actual cost. Gainsharing payments to the discharging physicians required meeting specific quality standards. Results. A total of 9034 patients were admitted to the ICU during the study period under this program. Among all APR-DRGs, total hospital costs decreased by $2.7 million (10%) for these specific admissions, mostly related to a shorter overall hospital stay. However, average ICU costs actually rose during the same period by $0.9 million (32%). The DRG with the greatest ICU SO was “tracheostomy with long-term mechanical ventilation” ($1.7 million). This group averaged $67 000 in ICU costs per patient but accounted for only 0.8% of the total number of admissions. There was also a savings opportunity for “septicemia” ($0.4 million, 2% of patients) and “small- and large-bowel surgery” ($0.4million, 1.5% of patients). Conclusions. The incentive to reduce costs was absent to physicians in the ICU, unlike the overall hospital, which experienced cost savings.

BACKGROUND: Gainsharing is a way to provide incentives to physicians to decrease hospital costs without compromising quality. METHODS: A pay-for-performance program was instituted over a three-year period from July 2006 to June 2009. Baseline length of stay (LOS) and case costs were developed during the year prior to the inception of the program. Best practice norms (BPNs) were established at the top 25th percentile of physicians for each all patient refined (APR)-diagnosis related group (DRG). Hospital costs were analyzed in several areas, including operating room charge (OR), supplies and implants, nursing and per-diem room costs. Payments were based upon case level performance compared to BPN's and the physician's historic performance. Eligible cases included commercial insurance only for the first 2 years but Medicare cases were included after October 2008 resulting from a Centers for Medicare and Medicaid Services (CMS)-approved demonstration project. Payments to physicians required meeting quality thresholds, including chart completion, and compliance with core measures. RESULTS: A total of 184 (54%) physicians enrolled into the program. There was a $25.1 million reduction in hospital costs during the 3 years ($16 million from participating and $9.1 million from non-participating physicians, P < 0.01). Most cost reductions were attributed to reduced LOS and reductions in medical supply costs. Total physician payouts were over $2 million (average $1,866 per quarter). Delinquent medical records decreased from an average of 43% in the second quarter 2006 to 30% (P < 0.0001) in the second quarter 2009. Quality measures improved during the study period but not by a statistical significance. CONCLUSIONS: Gainsharing provided an incentive for physicians to reduce hospital costs while maintaining hospital quality. Journal of Hospital Medicine 2010. © 2010 Society of Hospital Medicine.

Background: Acute appendicitis has historically been considered a clinical diagnosis, necessitating a CT scan only in the face of equivocal signs and symptoms. The purpose of this study is to determine whether or not the liberal use of CT in the work up of acute appendicitis results in a decreased negative appendectomy rate (NAR). Methods: The medical records of 940 consecutive patients who underwent emergency appendectomy between January 2002 and December 2006 were reviewed. Data collected included patient demographics, length of stay (LOS), results of contrast enhanced CT scans, emergency department (ED) work up time, and final pathology. Results: During the study period 940 patients (mean age 34.5±16.7 years, 53% males) underwent emergency appendec- tomy (64% laparoscopic). Eight hundred thirteen (86% patients, 50% males) underwent pre-operative CT scans. Final pathology was 76.1% acute appendicitis, 10% acute appendicitis with perforation, 7.7% gangrenous appendicitis, 1.2% acute appendicitis with abscess, 0.7% chronic appendicitis, and 4.3% negative for appendicitis. No difference was noted in the overall appendicitis rate by gender in the CT (Fishers exact test, p=0.96) or non-CT group (Fishers exact test, p=0.75). Similarly, no difference was noted by age (CT p=0.14, non-CT p=0.26). The NAR was lower for the CT group (3.4%) compared to the non-CT group (9.4%) (p=0.002). The NAR did not differ significantly by gender (Fishers exact test, p=0.491). Despite prolonging the ED work up time by 4.3 hours, the perforation rate did not differ between the CT (9.5%) and non-CT (12.6%) groups (p=0.30), nor did the LOS (3.67 vs. 3.63 days, p= 0.92). The sensitivity, specificity, negative predictive value, and positive predictive value of CT scans was 99%, 61%, 68%, and 99%, with an overall accu- racy of 98%. The positive and negative likelihood ratios were 2.52 and 0.02 respectively. The ROC for CT scans in pre- dicting appendicitis was 79.8% (95% CI: 76.9%, 82.5%). Conclusions: The use of CT in the work up of acute appendicitis is associated with a lower negative appendectomy rate independent of gender and age. The additional time spent obtaining a CT does not appear to increase the risk of perfora- tion nor increase the LOS.

Background In 2005, the American College of Surgeons Consensus Conference issued a statement about the diagnostic workup of image-detected breast abnormalities. Guidelines include use of image-guided percutaneous needle biopsy as the gold standard for diagnosing image-detected breast abnormalities. In this study, we evaluate a method to audit use of excisional biopsy among different breast surgeons at our institution. Study Design From March to September 2007, 465 patients undergoing breast operation for benign or malignant lesions at our institution were interviewed by a surgical resident or physician's assistant. If an excisional biopsy was scheduled for initial diagnosis, the patient and surgeon were asked whose preference it was to perform the operation. Three attending groups were designated: academic breast surgeons, private practice breast surgeons on clinical faculty, and general surgeons who perform breast operations in addition to other procedures. Use of excisional biopsy was compared between these groups. Results Compliance for preoperative interview completion was 79%, differing substantially between surgeon groups with rates of 91%, 74%, and 58% for the academic breast, private practice, and general surgeons, respectively. Excisional biopsy for diagnosis made up 10%, 35%, and 37% of the case load for academic breast, private practice, and general surgeons, respectively. Patient and surgeon agreed 85% of the time for preference of performing diagnostic excisional biopsies. Conclusions Excisional biopsies continue to be performed as the initial diagnostic procedure for 40% of patients. Tracking biopsy practices by surgeon can improve adherence with current recommendations.

Background Gastric bypass operation has become a very common procedure for treatment of obesity. Changes in calcium absorption can result in changes in total body calcium, parathyroid hormone (PTH), and vitamin D levels. There is little known about the longterm effects of Roux-en-Y gastric bypass on calcium metabolism and bone homeostasis. Study Design Between January 2000 and January 2006, 535 morbidly obese patients underwent standard Roux-en-Y gastric bypass. All patients were given a standard multivitamin, vitamin D, and calcium supplement starting on day 12 after the operation. Metabolic parameters, such as serum calcium levels, vitamin D, and PTH, both pre- and postoperatively, were measured and compared at several intervals. Results Four-hundred and forty-four patients were followed for a minimum of 2 years. No statistical significance was found between the pre- and postoperative serum levels of calcium and vitamin D, although vitamin D levels generally increased during the first year after operation. Serum levels of PTH were substantially higher at 18 and 44 weeks after the operation. Conclusions Hypocalcemia did not develop in any patients during the postoperative period. Increased PTH levels were observed after gastric bypass operation. This can result in calcium mobilization of calcium from the skeleton and increased renal calcium reabsorption. Total body calcium depletion could occur from bone mobilization, if longterm calcium supplementation is not maintained. Vitamin D supplementation can assist in prevention of bone calcium depletion.

Modified Early Warning Scores (MEWS) provide real-time vital sign (VS) trending and reduce ICU admissions in post-operative patients. These early warning calculations classically incorporate oxygen saturation, heart rate, respiratory rate, systolic blood pressure, and temperature but have not previously included end-tidal CO2 (EtCO2), more recently identified as an independent predictor of critical illness. These systems may be subject to failure when physiologic data is incorrectly measured, leading to false alarms and increased workload. This study investigates whether the implementation of automated devices that utilize ongoing vital signs monitoring and MEWS calculations, inclusive of a score for end-tidal CO2 (EtCO2), can be feasibly implemented on the general care hospital floor and effectively identify derangements in a post-operative patient's condition while limiting the amount of false alarms that would serve to increase provider workload. From July to November 2014, post-operative patients meeting the inclusion criteria (BMI > 30 kg/m2, history of obstructive sleep apnea, or the use of patient-controlled analgesia (PCA) or epidural narcotics) were monitored using automated devices that record minute-by-minute VS included in classic MEWS calculations as well as EtCO2. Automated messages via pagers were sent to providers for instances when the device measured elevated MEWS, abnormal EtCO2, and oxygen desaturations below 85 %. Data, including alarm and message details from the first 133 patients, were recorded and analyzed. Overall, 3.3 alarms and pages sounded per hour of monitoring. Device-only alarms sounded 2.7 times per hour-21 % were technical alarms. The remaining device-only alarms for concerning VS sounded 2.0/h, 70 % for falsely recorded VS. Pages for abnormal EtCO2 sounded 0.4/h (82 % false recordings) while pages for low blood oxygen saturation sounded 0.1/h (55 % false alarms). 143 times (0.1 pages/h) the devices calculated a MEWS warranting a page (rise in MEWS by 2 or 5 or greater)-62 % were false scores inclusive of falsely recorded VS. An abnormal EtCO2 value resulted in or added to an elevated MEWS score in 29 % of notifications, but 50 % of these included a falsely abnormal EtCO2 value. To date, no adverse events have occurred. There were no statistically significant demographic, post-operative condition, or pre-existing comorbidity differences between patients who had a majority of true alarms from those who had mostly false-positive alarms. Although not statistically significant, the group of patients in whom automated MEWS suggested greater utility included those with a history of hypertension (p = 0.072) and renal disease (p = 0.084). EtCO2 monitoring was more likely to be useful in patients with a history of type 2 diabetes, coronary artery disease, and obstructive sleep apnea (p

Diagnostic colonoscopy has evolved to become the gold standard for the screening for carcinoma and other diseases of the colon. Injuries to the colon are rare and may be managed in a variety of ways. This includes observation and bowel rest or operative intervention and repair. Other organs are at risk during colonoscopy. The present report describes a patient who underwent colonoscopy for the work-up of anaemia. Following colonoscopy she developed signs of haemorrhagic shock and was found to have haemoperitoneum. She underwent surgery, and adenocarcinoma of the cecum was identified and managed during exploration. The clinical management is described.

DOI of original article: 10.1016/j.jss.2012.1 * Corresponding author. Department of Surg Suite 2M, New York, NY 10003. Tel.: þ1 212 E-mail address: mleitman725@me.com (I 0022-4804/$ e see front matter a 2013 Elsev http://dx.doi.org/10.1016/j.jss.2013.01.010 Surgeons have been extracting metallic foreign bodies (MFB) for centuries. Perhaps the earliest literary account comes from Homer’s epic poem The Iliad (ca BC 800), based on events of the Trojan War from Greek mythology. Makaon operated on an arrow wound to the abdomen of King Menelaus by extracting the arrow, sucking blood from the wound to remove poison, and applying a salve [1]

DOI of original article: 10.1016/j.jss.2012.0 * Corresponding author. Department of Surge 2M, New York, NY 10003. Tel.: 212 844 8570; E-mail address: mleitman@chpnet.org (I. 0022-4804/$ e see front matter a 2013 Elsev doi:10.1016/j.jss.2012.02.031 From the discovery of circulation by Dr. William Harvey in 1628, to the first successful human-to-human blood transfusion by Dr. James Blundell in 1818, to the creation of the American Red Cross in 1941, our understanding of blood transfusion has evolved. The so-called hazards of transfusions have been documented since World War II and include infectious complications, hemolytic-related reactions, and, in more recent times, transfusion-related lung injuries and transfusion-induced immunomodulation [1,2]. This immunologic consequence of blood transfusions is not a novel concept. During the 1970s, the immunosuppressive effects of blood transfusion were first recognized when Opelz and Teraski [3] reported improvement in kidney transplant graft survival with an increased number of blood transfusions. This landmark study was the first to highlight the pro-inflammatory and immunosuppressive effects of transfused blood. Despite these