Ahmed Kayssi

A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes.

Background:In 2003, the Accreditation Council for Graduate Medical Education (ACGME) mandated 80-hour resident duty limits. In 2011 the ACGME mandated 16-hour duty maximums for PGY1 (post graduate year) residents. The stated goals were to improve patient safety, resident well-being, and education. A systematic review and meta-analysis were performed to evaluate the impact of resident duty hours (RDH) on clinical and educational outcomes in surgery. Methods:A systematic review (1980–2013) was executed on CINAHL, Cochrane Database, Embase, Medline, and Scopus. Quality of articles was assessed using the GRADE guidelines. Sixteen-hour shifts and night float systems were analyzed separately. Articles that examined mortality data were combined in a random-effects meta-analysis to evaluate the impact of RDH on patient mortality. Results:A total of 135 articles met the inclusion criteria. Among these, 42% (N = 57) were considered moderate-high quality. There was no overall improvement in patient outcomes as a result of RDH; however, some studies suggest increased complication rates in high-acuity patients. There was no improvement in education related to RDH restrictions, and performance on certification examinations has declined in some specialties. Survey studies revealed a perception of worsened education and patient safety. There were improvements in resident wellness after the 80-hour workweek, but there was little improvement or negative effects on wellness after 16-hour duty maximums were implemented. Conclusions:Recent RDH changes are not consistently associated with improvements in resident well-being, and have negative impacts on patient outcomes and performance on certification examinations. Greater flexibility to accommodate resident training needs is required. Further erosion of training time should be considered with great caution.

Under-representation of Women and Ethnic Minorities in Vascular Surgery Randomized Controlled Trials

OBJECTIVES Gender and ethnicity are factors affecting the incidence and severity of vascular disease as well as subsequent treatment outcomes. Although well studied in other fields, balanced enrollment of patients with relevant demographic characteristics in vascular surgery randomized controlled trials (RCTs) is not well known. This study describes the reporting of gender and ethnicity data in vascular surgery RCTs and analyzes whether these studies adequately represent our diverse patient population. METHODS We conducted a retrospective review of United States-based RCTs from 1983 through 2007 for three broadly defined vascular procedures: aortic aneurysm repair (AAR), carotid revascularization (CR), and lower extremity revascularization (LER). Included studies were examined for gender and ethnicity data, study parameters, funding source, and geographic region. The Nationwide Inpatient Sample (NIS) database was analyzed to obtain group-specific procedure frequency as an estimate of procedure frequency in the general population. RESULTS We reviewed 77 studies, and 52 met our inclusion criteria. Only 85% reported gender, and 21% reported ethnicity. Reporting of ethnicity was strongly associated with larger (>280 participants), multicenter, government-funded trials (P < .001 for all). Women are disproportionately under-represented in RCTs for all procedure categories (AAR, 9.0% vs 21.5%; CR, 30.0% vs 42.9%; LER, 22.4% vs 41.3%). Minorities are under-represented in AAR studies (6.0% vs 10.7%) and CR studies (6.9% vs 9.5%) but are over-represented in LER studies (26.0% vs 21.8%, P < .001 for all). CONCLUSIONS Minority ethnicity and female gender are under-reported and under-represented in vascular surgery RCTs, particularly in small, non-government-funded and single-center trials. The generalizability of some trial results may not be applicable to these populations. Greater effort to enroll a balanced study population in RCTs may yield more broadly applicable results.

Health-related quality-of-life outcomes after open versus endovascular abdominal aortic aneurysm repair

OBJECTIVE Endovascular repair (EVAR) of abdominal aortic aneurysms is a safe alternative to open aneurysm repair (OAR) in selected patients. The aim of this study was to compare the health-related quality-of-life (HR-QoL) outcomes of patients following EVAR and OAR. METHODS A literature search of PubMed, EMBASE, and the Cochrane Library identified five randomized trials that reported on HR-QoL in EVAR and OAR for elective management of infrarenal abdominal aortic aneurysms. No consistent HR-QOL instrument was used among the studies. A meta-analysis was performed on the 36-Item Short Form (SF-36) and the EuroQol-5D (EQ-5D) HR-QoL results. RESULTS SF-36 general health scores were higher for EVAR at 3, 6, and 12 months postoperatively. SF-36 physical functioning scores were higher for EVAR at 6 months but this advantage was lost at 12 months. In addition, SF-36 social functioning scores were higher for EVAR at 12 months. SF-36 component summary scores were not significantly different. EVAR was associated with a better EQ-5D score at 3, 6, and 12 months, but not at 24 months of follow-up. CONCLUSIONS EVAR was associated with better HR-QoL in some domains up to 12 months postoperatively. There is insufficient data to demonstrate a HR-QoL advantage beyond 12 months. More studies are required to examine any long-term HR-QoL advantages for either intervention.

Research Productivity of Residents and Surgeons With Formal Research Training

OBJECTIVE The spectrum of the surgeon-scientist ranges from a clinician who participates in the occasional research collaboration to the predominantly academic scientist with no involvement in clinical work. Training surgeon-scientists can involve resource-intense and lengthy training programs, including Masters and PhD degrees. Despite high enrollment rates in such programs, limited data exist regarding their outcome. The aim of the study was to investigate the scientific productivity of general surgeons who completed Masters or PhD graduate training compared with those who completed clinical residency training only. DESIGN A retrospective cohort study of graduates of general surgery residency was conducted over 2 decades. Data regarding graduation year, dedicated research training type, as well as publication volume, authorship role, and publication impact of surgeons during and after training, were analyzed. SETTING The study was conducted in 2 general surgery residency training programs in Canada (University of Alberta and University of Toronto). PARTICIPANTS A cohort of 323 surgeons who completed general surgery residency between 1998 and 2012. RESULTS Overall, 25% of surgeons obtained graduate-level research degrees. Surgeons with graduate degrees were proportionately more likely to participate in research publications both during training (100% of PhD, 82% of Masters, and 38% of clinical-only graduates, p < 0.05) and after training (91% of PhD, 81% of Masters, and 44% of clinical-only graduates, p < 0.05). Among surgeons involved in publication, the individual publication volume and impact of publication were highest among those with PhD degrees, as compared with clinical-only or Masters training. CONCLUSIONS The volume and impact of research publication of PhD-trained surgeon-scientists are significantly higher than those having clinical-only and Masters training. The additional 1 or 2 years of training to obtain a PhD over a Masters degree significantly nurtures trainees to hone research skills within a supervised environment and should be encouraged for research-inclined residents.

Smartphones and Patient Care: Exploring the Use of Text-Based Messaging for Patient-Related Communication

Background. Text messaging (texting) has become a routine medium of communication in society. However, its use among clinicians has not been fully characterized. We explored general surgery residents’ practices and views on texting for patient-related communication. Methods. An email survey was distributed to all general surgery residents at a large Canadian medical school. Results. Overall, 46 (57%) of those surveyed responded. All used texting for patient-related communication. Eleven percent of residents did not have a password on their cell phone and 89% did not have encrypted phones. Texting was the most common way (41%) by which residents communicated routine patient-related information with staff physicians. Most (85%) residents agreed that texting enhances patient care. The majority (66%) did not know if their hospital had a policy on texting and were unaware of legislation surrounding texting in patient care (89%). Conclusions. Most general surgery residents use texting for communication of routine patient-related care issues. However, they acknowledge concerns regarding the security of this medium.

Do Emergency Physicians and Medical Students Find It Unethical to 'Look up' Their Patients on Facebook or Google?

Introduction The use of search engines and online social media (OSM) websites by healthcare providers is increasing and may even be used to search for patient information. This raises several ethical issues. The objective of this study is to evaluate the prevalence of OSM and web-searching for patient information and to explore attitudes towards the ethical appropriateness of these practices by physicians and trainees in the emergency department (ED). Methods We conducted an online survey study of Canadian emergency physicians and trainees listed under then Canadian Association of Emergency Physicians (CAEP) and senior medical students at the University of Toronto. Results We received 530 responses (response rate 49.1%): 34.9% medical students, 15.5% residents, 49.6% staff physicians. Most had an active Facebook account (74%). Sixty-four participants (13.5%) had used Google to research a patient and 10 (2.1%) had searched for patients on Facebook. There were no differences in these results based on level of training, and 25% of physicians considered using Facebook to learn about a patient “very unethical.” The most frequent ethical concerns were with violation of patient confidentiality, dignity, and consent. The practice was usually not disclosed to patients (14%), but often disclosed to senior colleagues (83%). Conclusion This is the first study examining the prevalence of and attitudes towards online searching for obtaining patient information in the ED. This practice occurs among staff physicians and trainees despite ethical concerns. Future work should explore the utility and desirability of searching for patient information online.

Avulsion injury to the profunda femoris artery after total hip arthroplasty

Vascular injuries are a rare complication of total hip arthroplasty (THA). We describe the case of 71-year-old man who underwent an elective left THA and developed a pseudoaneurysm from an avulsion injury to the first branch of the profunda femoris artery. The patient underwent urgent open primary repair of the pseudoaneurysm and recovered without any complications. This case demonstrates the importance of assessing for vascular injuries after THA and of educating patients about the associated signs and symptoms.

Using Texting for Clinical Communication in Surgery: A Survey of Academic Staff Surgeons:

Background. Text messaging has become ubiquitous and is being increasingly used within the health care system. The purpose of this study was to understand texting practices for clinical communication among staff surgeons at a large academic institution. Methods. Staff surgeons in 4 subspecialties (vascular, plastics, urology, and general surgery) were surveyed electronically. Results. A total of 62 surgeons from general surgery (n = 33), vascular surgery (n = 6), plastic surgery (n = 13), and urology (n = 10) completed the study (response rate 30%). When conveying urgent patient-related information, staff surgeons preferred directly calling other staff surgeons (61.5%) and trainees (58.8%). When discussing routine patient information, staff surgeons used email to reach other staff surgeons (54.9%) but preferred texting (62.7%) for trainees. The majority of participants used texting because it is fast (65.4%), convenient (69.2%) and allows transmitting information to multiple recipients simultaneously (63.5%). Most felt that texting enhances patient care (71.5%); however, only half believed that it enhanced trainees’ educational experiences. The majority believed that texting identifiable patient information breaches patient confidentiality. Conclusions. Our data showed high adoption of text messaging for clinical communication among surgeons, particularly with trainees. The majority of surgeons acknowledge security concerns inherent in texting for patient care. Existing mobile communication platforms fail to meet the needs of academic surgeons. Further research should include guidelines related to texting in clinical practice, educational implications of texting, and technologies to better meet the needs of clinicians working in an academic surgical settings.

Fibromuscular Dysplasia, Carotid Kinks, and Other Rare Lesions

While most extracranial cerebrovascular pathologies are secondary to atherosclerosis, several hereditary and acquired conditions may also lead to devastating complications and should be familiar to the vascular specialist. Such conditions include fibromuscular dysplasia, carotid kinks and coils, and other rarer lesions such as Takayasu’s arteritis, giant-cell arteritis, Marfan’s syndrome, and vascular-type Ehlers-Danlos syndrome. Fibromuscular dysplasia is a non-atherosclerotic, noninflammatory arteriopathy that affects middle-sized vessels such as the renal and carotid arteries. It is a chronic, non-curable condition that should be managed medically, unless patients present with complications or are refractory to medical management. Elongated carotid artery abnormalities, including carotid tortuosity, coiling, or kinking, may lead to dissections, aneurysmal degenerations, and stroke and complicate attempts at endovascular repair of the carotid artery. Finally, the management of inflammatory arteriopathies such as Takayasu’s and giant-cell arteritis is primarily medical, but there are no consensus guidelines for these lesions because of their rarity. In this chapter, we will review the medical and operative management of these conditions and provide the reader with an approach to these conditions.

Lower Limb Amputations in Patients With Diabetes and Peripheral Artery Disease: A Time-Series Analysis of Trends (2005-2016)

have a relatively higher degree of stent recoil than metal does. Hence, we hereby intended to develop novel composite bioresorbable stents (cBRSs) made of poly(pdioxanone) (PPDO) and polycaprolactone with mechanically reinforced compression performance for pediatric patients. Methods: The cBRSs with PPDO monofilaments and PPDO-polycaprolactone composite braiding yarns were fabricated on a 32-bobbin braiding machine using different ratios (7:1 for cBRS type A and 3:1 for cBRS type B) and thermally treated in air thereafter. The properties of different prototypes compressed were evaluated by a parallel compression tester. Stent stress distribution and deformation mechanisms were also analyzed by the finite element method. Results: Partial interlacing yarns were bonded, and the peeling force was as high as 2126.67 6 133.14 mN to restrict their movement greatly compared with the friction resistance (<100 mN) in the control group. The compression force was promoted dramatically in the novel composite prototype stents by 124.06% in cBRS type A and 169.58% in cBRS type B. Besides, the recovery abilities were also improved significantly. Moreover, deformation mechanisms revealed by computational simulations showed that bonded interlacing points among yarn played an important role. Conclusions: This study demonstrated a novel technique for designing bioresorbable polymeric prototype stents with reinforced compression performance using a braiding and annealing procedure. The advantage of this design lies in the bonded strand interlacing points that restricted stent elongation and yarn gliding, which was revealed by computational simulations. In addition, the degradation behavior of novel composite braided stents will be evaluated in the future.