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Background and Objectives: Beyond qualitative evidence legitimizing endoscopic corridors through contralateral transmaxillary (CTM) and endonasal ipsilateral transpterygoid (ITP) corridors to the petrous apex and petroclival region, surgical feasibility by direct quantitative comparative anatomy is sparse. Our cadaveric study addresses this by performing the CTM approach followed by ITP extension to quantify the extent of petrous apex resection, instrument maneuverability, and working distance to petrous apex., Methods: Anatomic dissections were performed bilaterally on 5 latex-injected human cadaveric heads (10 petrous bones). After CTM dissections were quantified, the ITP approach was added enlarging initial exposure. Differences were measured with statistical significance when P values are < .05., Results: The mean petrosectomy volume was 0.958 cm3 with CTM and 1.987 cm3 with CTM + ITP, corresponding to 14.53% and 30.52% petrous apex resection, respectively. Craniocaudal instrument mobility was more limited in the lateral extent of dissection compared with the midline for both CTM (8.062° vs 14.416°) and CTM + ITP (5.4° vs 14.4°). The CTM approach achieved the lateral-most dissection at the body of the petrous apex (15.936 mm), with lateralization more limited in the superior petroclival region (9.628 mm) and the inferior petroclival region (8.508 mm). Angle of surgical maneuverability increased superiorly vs inferiorly in the CTM approach (mean 12.596° vs 8.336°, respectively). The CTM approach offered the shortest mean working distance (88.624 mm) to the petroclival region compared with the bi-nares approach (100.5 mm). CTM + ITP achieved greater lateralization in the superior (21.237 mm) and inferior (22.087 mm) aspects of the petroclival region compared with the CTM approach., Conclusion: Operative considerations are discussed in accessing target neurovascular structures through the uniquely shaped corridors formed by the CTM or combined CTM + ITP. Allowing mobilization of the internal carotid artery laterally and eustachian tube inferiorly, addition of the ITP allowed for larger petrosectomy than CTM alone, especially in the inferior and lateral aspects of the petrous bone., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Purpose: Proximity to critical neurovascular structures can create significant obstacles during surgical resection of foramen magnum meningiomas (FMMs) to the detriment of treatment outcomes. We propose a new classification that defines the tumor's relationship to neurovascular structures and assess correlation with postoperative outcomes., Methods: In this retrospective review, 41 consecutive patients underwent primary resection of FMMs through a far lateral approach. Groups defined based on tumor-neurovascular bundle configuration included Type 1, bundle ventral to tumor; Type 2a-c, bundle superior, inferior, or splayed, respectively; Type 3, bundle dorsal; and Type 4, nerves and/or vertebral artery encased by tumor., Results: The 41 patients (range 29-81 years old) had maximal tumor diameter averaging 30.1 mm (range 12.7-56 mm). Preoperatively, 17 (41%) patients had cranial nerve (CN) dysfunction, 12 (29%) had motor weakness and/or myelopathy, and 9 (22%) had sensory deficits. Tumor type was relevant to surgical outcomes: specifically, Type 4 demonstrated lower rates of gross total resection (65%) and worse immediate postoperative CN outcomes. Long-term findings showed Types 2, 3, and 4 demonstrated higher rates of permanent cranial neuropathy. Although patients with Type 4 tumors had overall higher ICU and hospital length of stay, there was no difference in tumor configuration and rates of postoperative complications or 30-day readmission., Conclusion: The four main types of FMMs in this proposed classification reflected a gradual increase in surgical difficulty and worse outcomes. Further studies are warranted in larger cohorts to confirm its reliability in predicting postoperative outcomes and possibly directing management decisions., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Introduction: The role of resuscitative thoracotomy in the emergency department (ED) for patients that have suffered severe thoracoabdominal trauma has been the subject of much debate. Most studies that characterize emergency thoracotomy are from urban, academic, and trauma centers. We sought to describe patient and hospital characteristics of a nationally representative sample of ED thoracotomy (EDT)., Methods: The health-care cost and utilization project 2013 National ED Sample (NEDS) and the 2013 National Inpatient Sample (NIS) maintained by the agency for health-care research and quality were used to generate a nationally representative estimate of resuscitative thoracotomies performed in the ED. We obtained patient demographics and clinical characteristics and compared the descriptive statistics of the two datasets., Results: The NEDS dataset identified 124 unsuccessful EDTs, whereas the NIS dataset identified 77 admissions for thoracotomy. When weighted to create a national estimate, these represent 952 emergency thoracotomies performed in the US in 2013. Most were male (82.5% and 88.2% in NEDS and NIS, respectively). In addition, 32.9% and 36.4% in NEDS and NIS, respectively, were between the ages of 20 and 29. The majority of thoracotomies were performed at metropolitan teaching hospitals (64.2% and 75.3%, NEDS and NIS, respectively). The mean total ED charges for patients who had an unsuccessful thoracotomy were $32,664 and the mean total inpatient charges were $141,215., Conclusion: Nearly 1000 thoracotomies are performed annually on the day of presentation to U. S. hospitals. Although emergency thoracotomy for trauma is an infrequently performed procedure, it almost always occurs at an urban, high volume, and level I or level II trauma centers., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Emergencies, Trauma, and Shock.)

Objectives: Since neuropathologic diagnosis in the developing world is hampered by limitations in technical infrastructure, trained laboratory personnel, and subspecialty-trained pathologists, the use of telepathology for diagnostic support, second-opinion consultations, and ongoing training holds promise as a means of addressing these challenges. This study aims to assess the utility of static teleneuropathology in improving neuropathologic diagnoses in low- and middle-income countries., Methods: Consecutive neurosurgical biopsy and resection specimens obtained at Muhimbili National Hospital in Tanzania between July 1, 2018, and June 30, 2019, were selected for retrospective, blinded static-image neuropathologic review followed by on-site review by an expert neuropathologist., Results: A total of 75 neuropathologic cases were reviewed. The agreement of static images and on-site glass diagnosis was 71% with strict criteria and 88% with less stringent criteria. This represents an overall improvement in diagnostic accuracy from 36% by general pathologists to 71% by a neuropathologist using static telepathology (or from 76% to 88% with less stringent criteria)., Conclusions: Telepathology offers a promising means of providing diagnostic support, second-opinion consultations, and ongoing training to pathologists practicing in resource-limited countries. Moreover, static digital teleneuropathology is an uncomplicated, cost-effective, and reliable way to achieve these goals., (© American Society for Clinical Pathology, 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Data for the use of embedded performance validity tests (ePVTs) with multiple sclerosis (MS) patients are limited. The purpose of the current study was to determine whether ePVTs previously validated in other neurological samples perform similarly in an MS sample., Methods: In this retrospective study, the prevalence of below-criterion responding at different cut-off scores was calculated for each ePVT of interest among patients with MS who passed a stand-alone PVT., Results: Previously established PVT cut-offs generally demonstrated acceptable specificity when applied to our sample. However, the overall cognitive burden of the sample was limited relative to that observed in prior large-scale MS studies., Conclusion: The current study provides initial data regarding the performance of select ePVTs among an MS sample. Results indicate most previously validated cut-offs avoid excessive false positive errors in a predominantly relapsing remitting MS sample. Further validation among MS patients with more advanced disease is warranted., (© The Author(s) 2020. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Preoperative risk assessment is important, but inexact because physiologic reserves are difficult to measure. When assessing quality of life for patients with brain tumors, having a better predictor of postsurgical outcome would be beneficial in counseling these patients. Frailty is thought to estimate physiologic reserves, and it has been found to predict postoperative complications, length of stay, and discharge to a skilled nursing facility or assisted living facility in patients undergoing various types of surgery. Frailty as an adjunct to preoperative assessment of neurosurgical patients has never been evaluated. This study aimed to determine whether frailty predicts neurosurgical complications in patients with brain tumors and enhances current perioperative risk models., Methods: Frailty was preoperatively assessed in 260 patients undergoing surgery for brain tumor resection using a validated scale that assessed weakness, weight loss, exhaustion, low physical activity, and slowed walking speed. Patients were classified as nonfrail (score of 0-1), moderately frail (score of 2-3), or frail (score of 4-5). Moderately frail and frail patients were combined for analysis., Results: Preoperative frailty was associated with an increased risk for discharge to a location other than home (10.36; 95% confidence interval, 3.6-30.1), postoperative complications (2.09; 95% confidence interval, 1.09-3.98), and a longer length of stay (1.66; 95% confidence interval, 1.24-2.21)., Conclusions: Frailty independently predicts discharge disposition, postoperative complications, and length of stay in patients undergoing surgery for brain tumor resection. Preoperative assessment of frailty can help neurosurgeons and patients make more informed decisions about pursing surgical treatment., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The use of venous duplex ultrasonography (VDU) for confirmation of deep venous thrombosis in neurosurgical patients is costly and requires experienced personnel. We evaluated a protocol using D-dimer levels to screen for venous thromboembolism (VTE), defined as deep venous thrombosis and asymptomatic pulmonary embolism., Methods: We used a retrospective bioinformatics analysis to identify neurosurgical inpatients who had undergone a protocol assessing the serum D-dimer levels and had undergone a VDU study to evaluate for the presence of VTE from March 2008 through July 2017. The clinical risk factors and D-dimer levels were evaluated for the prediction of VTE., Results: In the 1918 patient encounters identified, the overall VTE detection rate was 28.7%. Using a receiver operating characteristic curve, an area under the curve of 0.58 was identified for all D-dimer values (P = 0.0001). A D-dimer level of ≥2.5 μg/mL on admission conferred a 30% greater relative risk of VTE (sensitivity, 0.43; specificity, 0.67; positive predictive value, 0.27; negative predictive value, 0.8). A D-dimer value of ≥3.5 μg/mL during hospitalization yielded a 28% greater relative risk of VTE (sensitivity, 0.73; specificity, 0.32; positive predictive value, 0.24; negative predictive value, 0.81). Multivariable logistic regression showed that age, male sex, length of stay, tumor or other neurological disease diagnosis, and D-dimer level ≥3.5 μg/mL during hospitalization were independent predictors of VTE., Conclusions: The D-dimer protocol was beneficial in identifying VTE in a heterogeneous group of neurosurgical patients by prompting VDU evaluation for patients with a D-dimer values of ≥3.5 μg/mL during hospitalization. Refinement of this screening model is necessary to improve the identification of VTE in a practical and cost-effective manner., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Esophageal squamous cell carcinoma (ESCC) has been poorly studied, approached with therapeutic nihilism, and likely undertreated. We studied the impact of clinical and patient factors on the survival of ESCC in the United States., Methods: We selected patients with stage I to III ESCC from 2004 to 2013, using the National Cancer Database. Patients were categorized into the following treatment modalities: (1) definitive chemoradiation therapy (CR), (2) neoadjuvant therapy followed by esophageal resection (ER), (3) ER alone, and (4) ER followed by adjuvant therapy. Our main outcome measure was overall survival., Results: We identified 11,229 patients with ESCC undergoing definitive CR (78.6%); neoadjuvant therapy followed by ER (8.5%), ER alone (10.1%), and ER followed by adjuvant therapy (2.6%). Compared with neoadjuvant therapy, both ER alone and definitive CR were associated with substantially increased mortality. Patients treated at high-volume centers (>20), regardless of whether they underwent ER, had improved survival compared with facilities that performed 10 to 19, 5 to 9, and less than 5 ERs per year., Conclusions: Patients treated at high-volume facilities were more likely to receive neoadjuvant therapy, and there was a marked inverse relationship between annual surgical volume and long-term survival for both surgically and non-surgically treated patients with stage I to III ESCC., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: This study evaluated a videoconference-based psychiatric emergency consultation program (telepsychiatry) at geographically dispersed emergency department (ED) sites that are part of the network of care of an academic children's hospital system. The study compared program outcomes with those of usual care involving ambulance transport to the hospital for in-person psychiatric emergency consultation prior to disposition to inpatient care or discharge home., Methods: This study compared process outcomes in a cross-sectional, pre-post design at five network-of-care sites before and after systemwide implementation of telepsychiatry consultation in 2015. Clinical records on 494 pediatric psychiatric emergencies included ED length of stay, disposition/discharge, and hospital system charges. Satisfaction surveys regarding telepsychiatry consultations were completed by providers and parents or guardians., Results: Compared with children who received usual care, children who received telepsychiatry consultations had significantly shorter median ED lengths of stay (5.5 hours and 8.3 hours, respectively, p<.001) and lower total patient charges ($3,493 and $8,611, p<.001). Providers and patient caregivers reported high satisfaction with overall acceptability, effectiveness, and efficiency of telepsychiatry. No safety concerns were indicated based on readmissions within 72 hours in either treatment condition., Conclusions: Measured by charges and time, telepsychiatry consultations for pediatric psychiatric emergencies were cost-efficient from a hospital system perspective compared with usual care consisting of ambulance transport for in-person consultation at a children's hospital main campus. Telepsychiatry also improved clinical and operational efficiency and patient and family experience, and it showed promise for increasing access to other specialized health care needs.

Background: Recent American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP)-based evidence indicates that laparoscopic (LAP) colectomy results in improved outcomes compared to hand-assisted laparoscopic (HAL) colectomy in the general population. Previous comparative studies demonstrated that the HAL technique offers distinct advantages for obese patients. The aim of this study was to perform comparative analyses of HAL and LAP colectomy and low anterior resection (LAR) in obese patients., Methods: The ACS-NSQIP public use file and targeted colectomy dataset, 2012-2014, were utilized for patients undergoing colectomy and LAR. Only obese patients (BMI > 30) and laparoscopic or hand-assisted operations were included. Patient, operation, and outcome variables were compared in two separate cohorts: colectomy and LAR. Bivariate analysis compared the approaches, followed by multivariable regression., Results: Of 9610 obese patients included, HAL and LAP colectomy were performed in 3126 and 3793 patients and LAR in 1431 and 1260 patients, respectively. In comparison to LAP colectomy, HAL colectomy patients had increased comorbidities including class 2 and 3 obesity. HAL colectomy was associated with higher overall morbidity (20 vs. 16%, p < 0.001), infectious complications (10.2 vs. 7.7%, p < 0.001), anastomotic leaks (3.0 vs. 2.2%, p = 0.03), and ileus (11 vs. 8%, p < 0.001). Multivariate analysis indicated that overall morbidity (OR 1.27, 95% CI 1.11-1.44), infectious complications (OR 1.35, 95% CI 1.14-1.59), and ileus (OR 1.33, 95% CI 1.12-1.57) were each increased in the HAL colectomy cohort but not different for HAL and LAP LAR., Conclusions: In comparison to LAP colectomy, the HAL technique is used more often in obese patients with an increased operative risk profile. While inherent bias and unmeasured variables limit the analysis, the available data indicate that the HAL technique is associated with increased perioperative morbidity. Alternatively, HAL and LAP LAR are performed in obese patients with a similar risk profile and result in similar postoperative outcomes.

Objective: Previous randomized controlled trials have defined specific size thresholds to guide surgical decision-making in patients presenting with an abdominal aortic aneurysm (AAA). With recent advances in endovascular techniques, the anatomic considerations of AAA repair are rapidly changing. Our specific aims were to evaluate the most recent national population data to compare anatomic differences and perioperative outcomes in patients with AAA., Methods: The American College of Surgeons National Surgical Quality Improvement Program was queried from 2011 to 2015 using the targeted vascular public use file. Patients with AAA undergoing elective open or endovascular repair were included. Risk factors and outcomes were stratified by size and divided into quartiles for categorical comparison. A logistic regression model was used to compare the impact of size on morbidity and mortality with each technique. A risk adjustment model used all preoperative criteria to generate observed and expected values for open and endovascular repair., Results: There were 10,026 patients who underwent elective AAA repair, 8182 (81.6%) endovascular and 1844 (18.4%) open. Repairs were divided into density quartiles for a logistic analysis: smallest quartile, 3.5 to 5 cm; second quartile, 5.01 to 5.5 cm; third quartile, 5.51 to 6.2 cm; and largest quartile, >6.2 cm. Patients with larger aneurysms (>6.2 cm) were more likely to be male, to have a dependent functional status, and to have increased blood urea nitrogen concentration and American Society of Anesthesiologists score (P < .05). Larger aneurysms had longer operative time (162 vs 135 minutes) and greater extension toward the renal and iliac vessels (all P < .05). Risk adjustment revealed an observed/expected morbidity plot that favored endovascular repair throughout the size range but confirmed lack of size effect within the open repair category. The adjusted increase in morbidity with endovascular repair is 9.7% per centimeter increase in size of AAA. These trends remained true with an infrarenal subgroup analysis., Conclusions: Patients with a larger AAA have comorbidities and anatomic factors associated with a more difficult repair. The higher morbidity seen with larger aneurysms represents both anatomic and patient factors but seems to have a greater impact on endovascular repairs. However, endovascular repair still results in fewer near-term complications than open repair across all size strata., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Unplanned return to the operating room (uROR) has been suggested as a hospital quality indicator. The purpose of this study was to determine reasons for uROR to identify opportunities for patient care improvement., Methods: uROR reported by our institution's American College of Surgeons National Surgical Quality Improvement Program underwent secondary review., Results: The uROR rate reported by clinical reviewers was 4.3%. Secondary review re-categorized 64.7% as "true uROR" with the most common reasons for uROR being infection (30.9%) and bleeding (23.6%). Remaining cases were categorized as "false uROR" with the most common reasons being inadequate documentation (60.0%) and not directly related to index procedure (16.7%)., Conclusions: Strict adherence to NSQIP definitions results in misidentification of true uROR. This raises concerns for using NSQIP-identified uROR as a hospital quality metric. Improved processes of care to prevent infection and hemorrhage at our institution could reduce the rate of true uROR., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Previous studies have demonstrated improved in-hospital mortality after hepatic resection for hepatocellular carcinoma (HCC) at teaching hospitals. The objective of this study was to evaluate if resection of HCC at academic cancer programs (ACP) is associated with improved 10-year survival., Study Design: Using the National Cancer Data Base (NCDB) (1998 to 2011), we evaluated patients undergoing hepatic resection for HCC at ACPs, comprehensive community cancer programs (CCCPs), and community cancer programs (CCPs). High volume cancer programs (HVCPs) were defined as performing 10 or more hepatectomies per year. Multivariate Cox proportional hazard models by stepwise selection were applied to estimate hazard ratios (HR) of predictors of survival. The Kaplan-Meier method was used to generate survival curves at each facility type, and survival rates were compared using the log-rank test., Results: We identified 12,757 patients undergoing hepatic resection for HCC at ACPs (n = 8,404), CCPs (n = 483), and CCCPs (n = 3,870). Sixty-two percent (n = 5,191) of patients treated at ACPs were at high volume institutions compared with 11.6% (n = 446) and 0% of CCCPs and CCPs, respectively (p < 0.0001). On multivariable analysis, patients undergoing hepatic resection at transplant centers (p < 0.0001) and HVCPs had significantly improved survival (p < 0.0001). Adjusted 10-year survival rates were 28.7% at high volume ACPs, 28.2% at high volume CCCPs, 24.9% at low volume CCCPs, 25.1% at low volume ACPs, and 21.3% at CCPs (p ≤ 0.0001)., Conclusions: Patients undergoing hepatic resection for HCC at HVCPs had a significantly improved 10-year survival. Regionalization of HCC treatment to HVCPs may improve long-term survival., (Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: Since 2004, the Clinical Faculty Scholars Program (CFSP) at the University of Colorado Anschutz Medical Campus has provided intensive interdisciplinary mentoring and structured training for early-career clinical faculty from multiple disciplines conducting patient-oriented clinical and outcomes research. This study evaluated the two-year program's effects by comparing grant outcomes for CFSP participants and a matched comparison cohort of other junior faculty., Method: Using 2000-2011 institutional grant and employment data, a cohort of 25 scholars was matched to a cohort of 125 comparison faculty (using time in rank and pre-period grant dollars awarded). A quasi-experimental difference-in-differences design was used to identify the CFSP effect on grant outcomes. Grant outcomes were measured by counts and dollars of grant proposals and awards as principal investigator. Outcomes were compared within cohorts over time (pre- vs. post-period) and across cohorts., Results: From pre- to post-period, mean annual counts and dollars of grant awards increased significantly for both cohorts, but mean annual dollars increased significantly more for the CFSP than for the comparison cohort (delta $83,427 vs. $27,343, P < .01). Mean annual counts of grant proposals also increased significantly more for the CFSP than for the comparison cohort: 0.42 to 2.34 (delta 1.91) versus 0.77 to 1.07 (delta 0.30), P < .01., Conclusions: Institutional investment in mentored research training for junior faculty provided significant grant award gains that began after one year of CFSP participation and persisted over time. The CFSP is a financially sustainable program with effects that are predictable, significant, and enduring.

Background: Anaplastic pancreatic carcinoma (APC) is a rare and poorly characterized disease. We sought to compare the clinical characteristics and outcomes of APC to pancreatic adenocarcinoma (PDAC)., Methods: The American National Cancer Data Base was queried for patients with resected APC and PDAC using histologic and operative codes. APC cases were matched 1:5 with PDACs based on age, sex, pathologic tumor stage, operative margin status, lymph node positivity ratio, and use of adjuvant chemotherapy., Results: After 1:5 matching, 192 APCs and 960 PDACs were analyzed. When comparing APC vs PDAC the median tumor size was 45 mm (interquartile range, 33-60) vs 30 mm (interquartile range, 23-40; P < .001), and metastatic nodal disease was present in 40.6% and 38.0% of the cases (P = .25), respectively. APC cases were distributed equally between the head and the body/tail region of the pancreas (50%), while PDAC cases were located mainly in the head of the pancreas (75%; P < .001). Although the resected APC group had a lesser survival during the first year after the diagnosis (51% vs 69%; P = .029), the overall survival was similar in the 2 groups, with 21.6% vs 17.4% alive at 5 years, respectively for APC and PDAC (P = .32). Subgroup analysis of patients with APC with (n = 18) versus those without (n = 80) osteoclastlike giant cells showed a greater 5-year survival (50% versus 15%, P < .001)., Conclusion: Patients with resected APC tend to present with large tumors equally distributed between the head and body/tail of the pancreas. While APC is thought to have a more aggressive biology, our matched analysis showed similar overall survival compared with PDAC. The presence of osteoclastlike giant cells portends a significantly better prognosis compared with other histologic features of APCs., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To determine the relative risk of invasive methicillin-resistant Staphylococcus aureus (MRSA) infection among non-colonized (NC) patients, intermittently colonized (IC) patients, and persistently colonized (PC) patients., Design: Observational cohort study of patient data collected longitudinally over a 41-month period., Setting: Department of Veterans Affairs Eastern Colorado Healthcare System, a tertiary care medical center., Patients: Any patient who received ≥5 MRSA nasal swab tests between February 20, 2010, and July 26, 2013. In total, 3,872 patients met these criteria, 0 were excluded, 95% were male, 71% were white, and the mean age was 62.9 years on the date of study entry., Methods: Patients were divided into cohorts based on MRSA colonization status. Physicians reviewed medical records to identify invasive infection and were blinded to colonization status. Cox and Kaplan-Meier analyses were used to assess the relationship between colonization status and invasive infection., Results: In total, 102 patients developed invasive MRSA infections, 16.3% of these were PC patients, 11.2% of these were IC patients, and 0.5% of these were NC patients. PC patients were at higher risk of invasive infection than NC patients (hazard ratio [HR] 36.8; 95% CI, 18.4-73.6; P<.001). IC patients were also at higher risk than NC patients (HR, 22.8; 95% CI, 13.3-39.3; P<.001). The difference in risk between PC and IC patients was not statistically significant (HR, 1.61; 95% CI, 0.94-2.78, P=.084). Alternate analysis methods confirmed these results., Conclusions: The risk of invasive MRSA infection is much higher among PC and IC patients, supporting routine clinical testing for colonization. However, this risk is similar among PC and IC patients, suggesting that distinguishing between the 2 colonization states may not be clinically important.

Objective: In-person weight loss maintenance visits have been shown to reduce weight regain after initial weight loss. This study examined, in a primary care population, whether in-person visits plus portion-controlled meals were more effective in reducing 12-month weight regain than mailed materials plus portion controlled meals., Methods: Study participants (n = 106) received 6 months of intensive behavioral treatment. Participants who completed this phase (n = 84) were then randomized to continue monthly in-person visits for weight loss maintenance as well as telephone calls between visits ("intensified maintenance") or to receive materials by mail ("standard maintenance"). All participants had access to subsidized portion-controlled foods during the 6-month run-in and the 12 months of maintenance. The primary outcome was weight change during the 12 months after randomization., Results: During months 0-12 after randomization, individuals assigned to standard maintenance regained 5.3% ± 0.8% of body weight, while those assigned to intensified maintenance regained 1.6% ± 1.2% of body weight. The difference between groups (3.7% ± 1.4%) was statistically significant (P = 0.01)., Conclusions: In a primary care population, continued in-person visits during the weight loss maintenance phase led to greater weight loss than contact by mail., (© 2015 The Obesity Society.)

Background: We examined providers' perceptions of the Decision Support for Safer Surgery (DS3) tool, which provided preoperative patient-level risk estimates of postoperative adverse events., Methods: The DS3 tool was evaluated at 2 academic medical centers. During the validation study, surgeons provided usefulness ratings of the DS3 tool for each patient before surgery. At the end of the study, providers' perceptions of the DS3 tool were assessed via questionnaire. Data were analyzed using descriptive statistics and independent samples t tests., Results: During the trial, 23 surgeons completed usefulness ratings of the DS3 tool for 1,006 patients. Surgeons rated the tool as "very useful" or "moderately useful" in 251 (25%) of the cases, "neutral" in 469 (46.6%) of the cases, and "moderately unuseful" or "not useful" in 286 (28.4%) cases. At the end of the trial, 32 providers completed the questionnaire; perceptions were relatively neutral, although several aspects were rated quite favorably., Conclusion: The DS3 tool may be most useful for achieving particular tasks (eg, training novice surgeons, increasing patient engagement) or encouraging specific processes (eg, team-based care) in surgical care settings., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: Polypharmacy and medication adherence are well known challenges facing older adults. Medication regimen complexity increases the demands of self-care in the home. Some medication regimens may be more complex than others, especially when dosage form, frequency of dosing, and additional usage directions are included in complexity along with the number of medications In older adults with depression, it is unknown what features of their medications most influence their medication regimen complexity., Methods: A sample cohort of 100 adults ≥65 years old with a diagnosis of depression was randomly selected from electronic medical records (EMR) in ambulatory clinics at the University of Colorado (CU) and University of San Diego (SD). Demographic, medical history, and medication-related information was extracted from the EMR. Complexity was determined using the Medication Regimen Complexity Index (MRCI). IRB approval was obtained., Findings: The cohort mean age was 74.3 years (SD) and 79.7 years (CU). The mean unweighted Charlson comorbidity index for 1.0 (SD) and 1.8 (CU). The mean number of medications was 7.1 and 8.0, with 1.1 and 1.2 depression meds, 5.4 and 4.3 non-depression prescription meds, and 0.6 and 2.4 OTC meds for the SD and CU cohorts, respectively. 66% of SD adults and 70% of CU adults took six or more meds. Individual MRCI scores were on average 17.62 (SD) and 19.36 (CU). Dosing frequency contributed to 57-58% of the MRCI score, with patients facing an average of 7-8 unique dosing frequencies in their regimen. In both cohorts, there was an average of 3 additional directions added to the regimens to clarify dosing., Implications: As expected, in our older adult cohorts with depression the majority of patients took multiple medications. Using a standardized instrument, we characterized the regimen complexity and found that it was increasingly complex due to numerous dosing forms, frequencies and additional directions for use. Patient-level medication regimen complexity should go beyond depression medication to encompass the patient's entire regimen for opportunities to reduce complexity and improve ease of self-care., (Copyright © 2014 Elsevier HS Journals, Inc. All rights reserved.)

Background: Patients with HIV often have multiple medications besides antiretrovirals (ARV). Medication regimen complexity-formulations, dosing frequencies, and additional directions-expands pill burden by considering self-care demands. Studies show an inverse association between ARV adherence and medication complexity for ARVs only. Patient-level medication regimen complexity beyond ARV complexity is unknown., Objective: To measure and characterize Patient-level Medication Regimen Complexity Index (pMRCI) and Antiretroviral Medication Regimen Complexity Index (ARCI) for patients in 2 HIV clinics. We hypothesized that an all-medication complexity metric will exceed disease-state-defined complexity metrics; for ARVs only, the pMRCI score will be smaller than the ARCI score by capturing fewer features of regimens. Associations between complexity and adherence were not assessed., Method: Electronic records supplied a retrospective, random sample of adult patients with HIV; medication lists were used to code the pMRCI (n=200). A random subsample (n=66) was coded using ARCI for ARV regimens only., Result: Medication counts ranged from 1 to 27; pMRCI scores ranged from 2 to 67.5. ARVs contributed roughly 25% to the pMRCI; other prescriptions contributed about 66%. Dosing frequency made the largest contribution of all components (62%) to the pMRCI. For ARVs, pMRCI and ARCI scores did not differ statistically., Conclusion: Unique dosing frequencies raised complexity and may provide opportunities for intervention. Other prescriptions drove pMRCI scores, suggesting that HIV management programs should review all medications. A patient-level approach added value to understanding the role of medications in patient complexity; future work can assess association of pMRCI with adherence and patient outcomes., (© The Author(s) 2014.)

Background: The Medication Regimen Complexity Index (MRCI) is a 65-item instrument that can be used to quantify medication regimen complexity at the patient level, capturing all prescribed and over-the-counter medications. Although the MRCI has been used in several studies, the narrow scope of the initial validation limits application at a population or clinical practice level., Purpose: To conduct a MRCI validation pertinent to the desired clinical use to identify patients for medication therapy management interventions., Methods: An expert panel of clinical pharmacists ranked medication regimen complexity for two samples of cases: a single-disease cohort (diabetes mellitus) and a multiple-disease cohort (diabetes mellitus, hypertension, human immunodeficiency virus infection, geriatric depression). Cases for expert panel review were selected from 400 ambulatory clinic patients, and each case description included data that were available via claims or electronic medical records (EMRs). Construct validity was assessed using patient-level MRCI scores, medication count, and additional patient data. Concordance was evaluated using weighted κ agreement statistic, and correlations were determined using Spearman rank-order correlation coefficient (ρ) or Kendall τ., Results: Moderate to good concordance between patient-level MRCI scores and expert medication regimen complexity ranking was observed (claims data, consensus ranking: single-disease cohort 0.55, multiple disease cohort 0.63). In contrast, only fair to moderate concordance was observed for medication count (single-disease cohort 0.33, multiple-disease cohort 0.48). Adding more-detailed administration directions from EMR data did not improve concordance. MRCI convergent validity was supported by strong correlations with medication count (all cohorts 0.90) and moderate correlations with morbidity measures (e.g., all cohorts; number of comorbidities 0.46, Chronic Disease Score 0.46). Nonsignificant correlation of MRCI scores with age and gender (all cohorts 0.08 and 0.06, respectively) supported MRCI divergent validity., Limitations: This study used cross-sectional, retrospective patient data for a small number of patients and clinical pharmacists from only two universities; therefore, results may have limited generalizability., Conclusions: The patient-level MRCI is a valid tool for assessing medication regimen complexity that can be applied by using data commonly found in claims and EMR databases and could be useful to identify patients who may benefit from medication therapy management., (© 2014 The Authors Pharmacotherapy published by Wiley Periodicals, Inc. on behalf of Pharmacotherapy Publications, Inc.)

Background: Surgical quality improvement tools such as NSQIP are limited in their ability to prospectively affect individual patient care by the retrospective audit and feedback nature of their design. We hypothesized that statistical models using patient preoperative characteristics could prospectively provide risk estimates of postoperative adverse events comparable to risk estimates provided by experienced surgeons, and could be useful for stratifying preoperative assessment of patient risk., Study Design: This was a prospective observational cohort. Using previously developed models for 30-day postoperative mortality, overall morbidity, cardiac, thromboembolic, pulmonary, renal, and surgical site infection (SSI) complications, model and surgeon estimates of risk were compared with each other and with actual 30-day outcomes., Results: The study cohort included 1,791 general surgery patients operated on between June 2010 and January 2012. Observed outcomes were mortality (0.2%), overall morbidity (8.2%), and pulmonary (1.3%), cardiac (0.3%), thromboembolism (0.2%), renal (0.4%), and SSI (3.8%) complications. Model and surgeon risk estimates showed significant correlation (p < 0.0001) for each outcome category. When surgeons perceived patient risk for overall morbidity to be low, the model-predicted risk and observed morbidity rates were 2.8% and 4.1%, respectively, compared with 10% and 18% in perceived high risk patients. Patients in the highest quartile of model-predicted risk accounted for 75% of observed mortality and 52% of morbidity., Conclusions: Across a broad range of general surgical operations, we confirmed that the model risk estimates are in fairly good agreement with risk estimates of experienced surgeons. Using these models prospectively can identify patients at high risk for morbidity and mortality, who could then be targeted for intervention to reduce postoperative complications., (Published by Elsevier Inc.)

Introduction: Distributed Data Networks (DDNs) offer infrastructure solutions for sharing electronic health data from across disparate data sources to support comparative effectiveness research. Data sharing mechanisms must address technical and governance concerns stemming from network security and data disclosure laws and best practices, such as HIPAA., Methods: The Scalable Architecture for Federated Translational Inquiries Network (SAFTINet) deploys TRIAD grid technology, a common data model, detailed technical documentation, and custom software for data harmonization to facilitate data sharing in collaboration with stakeholders in the care of safety net populations. Data sharing partners host TRIAD grid nodes containing harmonized clinical data within their internal or hosted network environments. Authorized users can use a central web-based query system to request analytic data sets., Discussion: SAFTINet DDN infrastructure achieved a number of data sharing objectives, including scalable and sustainable systems for ensuring harmonized data structures and terminologies and secure distributed queries. Initial implementation challenges were resolved through iterative discussions, development and implementation of technical documentation, governance, and technology solutions.

Objectives: To determine the rate of, and potential risk factors for, unscheduled PICU readmission and assess for variability among PICUs within the United States., Design and Data Source: This retrospective cohort study used 2005-2008 data from 73 PICUs in the Virtual PICU Systems database., Methods and Measurements: Early (within 48 hr of PICU discharge) and late (later than 48 hr) unscheduled readmission rates were calculated. Hierarchical logistic regression, with a random intercept for site, was used to identify factors independently associated with early readmission. Significant random effects identified sites with an outlying risk of readmission, adjusting for patient and admission characteristics., Main Results: For 117,923 children meeting inclusion criteria, the unscheduled readmission rate was 3.7% with 38% (1.4%) occurring early. Half of early readmissions had the same primary diagnosis as the first admission. Patients with late readmissions had a higher mortality (6.6% vs 3.3%, p < 0.001) and longer median total PICU length of stay (11 d vs 6 d, p < 0.0001) than those with early readmission. Patient characteristics strongly associated with increased risk of early readmission included the following: age < 6 months, acute respiratory and renal disease, and several underlying chronic conditions such as liver disease, bone marrow transplant, airway stenosis, and abnormal antidiuretic hormone balances. An initial PICU admission that was unscheduled, originated from the general floor, or with a discharge time between 4 PM and 8 AM was associated with higher risk of readmission. A quarter of sites were identified as potential high (16%) or low (8%) outliers., Conclusions: The rate of unscheduled PICU readmission was low but associated with worse outcomes. Patient and admission/discharge characteristics associated with increased risk of readmissions could be used to target high-risk populations or modifiable factors to improve outcome. Variation of risk among centers suggests room for improvement.

Background: Expected treatment effectiveness from medications can be diminished due to suboptimal adherence. Medication nonadherence has been linked to pill burden from the quantity of medications; however, medication regimens with similar quantities of medications vary in complexity due to multiple dosage forms, frequency of dosing, and additional usage directions. Thus, a simple medication count ignores medication regimen complexity, especially as it pertains to a patient-level perspective that includes prescription and over-the-counter medications. A gap exists in the study of a patient-level medication regimen complexity metric across disease-specific populations., Objective: The goal of this study was to implement the quantitative Medication Regimen Complexity Index (MRCI) at the patient level in defined populations with chronic disease (geriatric depression, HIV, diabetes mellitus, and hypertension). Patient-level medication regimen complexity included all prescribed medications and over-the-counter medications documented in the electronic medication list., Methods: Using electronic medical records at the University of Colorado Hospital ambulatory clinics, we sampled 4 retrospective cohorts of adult patients in active care in 2011 with a qualifying medical diagnosis and prescribed disease-specific medication. Samples were randomly selected from all qualifying patients; de-identified information was coded using the MRCI., Results: Cohort-defining disease-specific prescription medications (eg, antidepressants for the depression-defined cohort) contributed <20% to the total patient-level complexity MRCI score; the MRCI score was dominated by complexity associated with all other prescription medications. Within disease-specific cohorts, MRCI scores differentiated patients with the highest and lowest medication counts, comorbidity counts, and the Charlson comorbidity index scores. For example, geriatric depression patients had a highest quartile mean MRCI score of 41 and a lowest quartile mean MRCI score of 13. Between disease-specific cohorts, high and low MRCI scores differed because each cohort had its own MRCI ranges. For example, highest quartile MRCI scores varied from a mean MRCI score of 41 (geriatric depression) to 30 (hypertension); lowest quartile scores ranged from a mean MRCI score of 7 (hypertension and HIV) to 13 (geriatric depression)., Conclusions: MRCI components of dosing frequency and prescribed medications outside of the cohort-defining disease medications contributed the most to the patient-level scores. Thus, chronic disease management programs may want to consider all medications that patients are taking and examine ways to reduce complexity, such as reducing multiple dosing frequencies when possible. MRCI scores differentiated high and low patient-level complexity measures, representing possible utility as a prospective tool to identify target patients for intervention. Future work includes simplifying the MRCI and enhancing the scores with medication risk factors, as well as explicitly linking to adherence and health services., (Copyright © 2013 Elsevier HS Journals, Inc. All rights reserved.)

The purpose of this study was to explore the feasibility of prospectively identifying patients at high risk for surgical complications using automatable methods focused on patient characteristics. We used data from the Michigan Surgical Quality Collaborative (60,411 elective surgeries) performed between 2003 and 2008. Regression models for postoperative mortality, overall morbidity, cardiac, thromboembolic, pulmonary, renal, and surgical site infection complications were developed using preoperative patient and planned procedure data. Risk was categorized by quartiles of predicted probability: "low" risk corresponding to the bottom quartile, "average" to the middle two quartiles, and "high" to the top quartile. C-indices were calculated to measure discrimination; model validity was assessed by cross-validation. Models were repeated using only patient characteristics. Risk category was closely related to event rates; 80 to 90 per cent of mortality and cardiac, renal, and pulmonary complications occurred among the 25 per cent of "high-risk" patients. Although thromboembolisms and surgical site infections were less predictable, 60 to 70 per cent of events occurred among high-risk patients. Cross-validation results were consistent and only slightly attenuated when predictors were restricted to patient characteristics alone. Adverse postoperative events are concentrated among patients identifiable preoperatively as high risk. Preoperative risk assessment could allow for efficient interventions targeted to high-risk patients.

Background: Studies using Medicare data have suggested that African American race is an independent predictor of death after major surgery. We hypothesized that the apparent adverse effect of race on surgical outcomes is due to confounding by comorbidity, not race itself., Methods: We identified all non-Hispanic white and African American general surgery, private sector patients included in the National Surgery Quality Improvement Program (NSQIP) Patient Safety in Surgery Study (2001-2004). Patient characteristics, comorbidities, and postoperative outcomes were collected/analyzed using NSQIP methodology. Characteristics between races were compared using Student t and chi(2) tests. Odds ratios (OR) for 30-day morbidity and mortality were calculated using multivariable logistic regression., Results: We identified 34,141 white and 5068 African American patients. African Americans were younger but more likely to undergo emergency surgery and present with hypertension, dyspnea, diabetes, renal failure, open wounds/infection, or advanced American Society of Anesthesiology class (all P < 0.001). African Americans underwent less complex procedures but had higher unadjusted 30-day morbidity (14.33% vs. 12.35%; P < 0.001) and mortality (2.09% vs. 1.65%; P = 0.02). After controlling for comorbidity, African American race had no independent effect on mortality (OR 0.95, (0.74-1.23)) but was associated with a higher risk of postoperative cardiac arrest (OR 2.49, (1.80-3.45)) and renal insufficiency/failure (OR 1.70 (1.32-2.18))., Conclusion: African American race is associated with greater comorbidity and cardiac/renal complications but is not an independent predictor of perioperative mortality after general surgery. Efforts to improve postoperative outcomes in African Americans should focus on reducing the need for emergency surgery and improving perioperative management of comorbid conditions.

Background: Obesity is an increasingly common serious chronic health condition. We sought to determine the impact of body mass index (BMI) on perioperative outcomes in patients undergoing major intra-abdominal cancer surgery., Methods: A prospective, multi-institutional, risk-adjusted cohort study of patients undergoing major intra-abdominal cancer surgery was performed from the 14 university hospitals participating in the Patient Safety in Surgery Study of the National Surgical Quality Improvement Program (NSQIP). Demographic, clinical, and intraoperative variables and 30-day morbidity and mortality were prospectively collected in standardized fashion. Analysis of variance, Bonferroni multiple comparisons of means tests, and multivariable logistic regression analysis were performed., Results: We identified 2258 patients who underwent esophagectomy (n = 29), gastrectomy (n = 223), hepatectomy (n = 554), pancreatectomy (n = 699), or low anterior resection/proctectomy (n = 753). Patients were stratified by National Institutes of Health (NIH)-defined BMI obesity class, with 573 (25.4%) patients classified as obese (BMI > 30 kg/m(2)). There were no differences in mean work relative value units, total time of operation, or length of stay amongst the BMI classes. After adjusting for other risk factors, obesity was not a risk factor for death or major complications but was a risk factor for wound complications. The risk of postoperative death was greatest in underweight patients (odds ratio [OR] 5.24; 95% confidence interval [CI] 1.7-16.2)., Conclusion: In patients undergoing major intra-abdominal cancer surgery, obesity is not a risk factor for postoperative mortality or major complications. Importantly, underweight patients have a fivefold increased risk of postoperative mortality, perhaps a consequence of their underlying nutritional status.

Objective: To examine the association between surgical start time and morbidity and mortality for nonemergent procedures., Summary Background Data: Patients require medical services 24 hours a day. Several studies have demonstrated a difference in outcomes over the course of the day for anesthetic adverse events, death in the ICU, and dialysis care. The relationship between operation start time and patient outcomes is yet undefined., Methods: We performed a retrospective cohort study of 144,740 nonemergent general and vascular surgical procedures performed within the VA Medical System 2000-2004 and entered into the National Surgical Quality Improvement Program Database. Operation start time was the independent variable of interest. Logistic regression was used to adjust for patient and procedural characteristics and to determine the association between start time and, in 2 independent models, mortality and morbidity., Results: Unadjusted later start time was significantly associated with higher surgical morbidity and mortality. After adjustment for patient and procedure characteristics, mortality was not significantly associated with start time. However, after appropriate adjustment, operations starting between 4 pm and 6 pm were associated with an elevated risk of morbidity (OR = 1.25, P < or = 0.005) over those starting between 7 am and 4 pm as were operations starting between 6 pm and 11 pm (OR = 1.60, P < or = 0.005)., Conclusions: When considering a nonemergent procedure, surgeons must bear in mind that cases that start after routine "business" hours within the VA System may face an elevated risk of complications that warrants further evaluation.