Amber W. Trickey

Website Usage and Weight Loss in a Free Commercial Online Weight Loss Program: Retrospective Cohort Study

Background Online weight loss programs are increasingly popular. However, little is known about outcomes and associations with website usage among members of free online weight loss programs. Objective This retrospective cohort study examined the association between website usage and weight loss among members of a free commercial online weight loss program (SparkPeople). Methods We conducted a retrospective analysis of a systematic random sample of members who joined the program during February 1 to April 30, 2008, and included follow-up data through May 10, 2010. The main outcome was net weight change based on self-reported weight. Measures of website usage included log-ins, self-monitoring entries (weight, food, exercise), and use of social support tools (discussion forums, friendships). Results The main sample included 1258 members with at least 2 weight entries. They were 90.7% female, with mean (SD) age 33.6 (11.0) and mean (SD) BMI 31.6 (7.7). Members with at least one forum post lost an additional 1.55 kg (95% CI 0.55 kg to 2.55 kg) relative to those with no forum posts. Having at least 4 log-in days, weight entry days, or food entry days per 30 days was significantly associated with weight loss. In the multiple regression analysis, members with at least 4 weight entry days per 30 days reported 5.09 kg (95% CI 3.29 kg to 6.88 kg) more weight loss per 30 days than those with fewer weight entry days. After controlling for weight entry days, the other website usage variables were not associated with weight change. Conclusions Weekly or more frequent self-monitoring of weight is associated with greater weight loss among members of this free online weight loss program.

Carotid endarterectomy under local and/or regional anesthesia has less risk of myocardial infarction compared to general anesthesia: An analysis of national surgical quality improvement program database.

Multiple studies have evaluated the effect of anesthesia type on carotid endarterectomy with inconsistent results. Our study compared 30-day postoperative myocardial infarction, stroke, and mortality between carotid endarterectomy under local or regional anesthesia and carotid endarterectomy under general anesthesia utilizing National Surgical Quality Improvement Program database. All patients listed in National Surgical Quality Improvement Program database that underwent carotid endarterectomy under general anesthesia and local or regional anesthesia from 2005 to 2011 were included with the exception of patients undergoing simultaneous carotid endarterectomy and coronary artery bypass grafting. The data revealed substantial differences between the two groups compared, and these were adjusted using multiple logistic regression. Postoperative myocardial infarction, stroke, and death at 30 days were compared between the two groups. A total of 42,265 carotid endarterectomy cases were included. A total of 37,502 (88.7%) were performed under general anesthesia and 4763 (11.3%) under local or regional anesthesia. Carotid endarterectomy under local or regional anesthesia had a significantly decreased risk of 30-day postoperative myocardial infarction when compared to carotid endarterectomy under general anesthesia (0.4% vs 0.86%, p = 0.012). No statistically significant differences were found in postoperative stroke or mortality. Carotid endarterectomy under local or regional anesthesia carries a decreased risk of postoperative myocardial infarction when compared to carotid endarterectomy under general anesthesia. Therefore, patients at risk of postoperative myocardial infarction undergoing carotid endarterectomy, consideration of local or regional anesthesia may reduce that risk.

Applicant Characteristics Associated With Selection for Ranking at Independent Surgery Residency Programs

OBJECTIVES This study evaluated characteristics of applicants selected for interview and ranked by independent general surgery residency programs and assessed independent program application volumes, interview selection, rank list formation, and match success. DESIGN Demographic and academic information was analyzed for 2014-2015 applicants. Applicant characteristics were compared by ranking status using univariate and multivariable statistical techniques. Characteristics independently associated with whether or not an applicant was ranked were identified using multivariable logistic regression modeling with backward stepwise variable selection and cluster-correlated robust variance estimates to account for correlations among individuals who applied to multiple programs. SETTING The Electronic Residency Application Service was used to obtain applicant data and program match outcomes at 33 independent surgery programs. PARTICIPANTS All applicants selected to interview at 33 participating independent general surgery residency programs were included in the study. RESULTS Applicants were 60% male with median age of 26 years. Birthplace was well distributed. Most applicants (73%) had ≥1 academic publication. Median United States Medical Licensing Exams (USMLE) Step 1 score was 228 (interquartile range: 218-240), and median USMLE Step 2 clinical knowledge score was 241 (interquartile range: 231-250). Residency programs in some regions more often ranked applicants who attended medical school within the same region. On multivariable analysis, significant predictors of ranking by an independent residency program were: USMLE scores, medical school region, and birth region. Independent programs received an average of 764 applications (range: 307-1704). On average, 12% interviews, and 81% of interviewed applicants were ranked. Most programs (84%) matched at least 1 applicant ranked in their top 10. CONCLUSIONS Participating independent programs attract a large volume of applicants and have high standards in the selection process. This information can be used by surgery residency applicants to gauge their candidacy at independent programs. Independent programs offer a select number of interviews, rank most applicants that they interview, and successfully match competitive applicants.

Are pediatric concussion patients compliant with discharge instructions

BACKGROUND Concussions are commonly diagnosed in pediatric patients presenting to the emergency department (ED). The primary objective of this study was to evaluate compliance with ED discharge instructions for concussion management. METHODS A prospective cohort study was conducted from November 2011 to November 2012 in a pediatric ED at a regional Level 1 trauma center, serving 35,000 pediatric patients per year. Subjects were aged 8 years to 17 years and were discharged from the ED with a diagnosis of concussion. Exclusion criteria included recent (past 3 months) diagnosis of head injury, hospital admission, intracranial injury, skull fracture, suspected nonaccidental trauma, or preexisting neurologic condition. Subjects were administered a baseline survey in the ED and were given standardized discharge instructions for concussion by the treating physician. Telephone follow-up surveys were conducted at 2 weeks and 4 weeks after ED visit. RESULTS A total of 150 patients were enrolled. The majority (67%) of concussions were sports related. Among sports-related concussions, soccer (30%), football (11%), lacrosse (8%), and basketball (8%) injuries were most common. More than one third (39%) reported return to play (RTP) on the day of the injury. Physician follow-up was equivalent for sport and nonsport concussions (2 weeks, 58%; 4 weeks, 64%). Sports-related concussion patients were more likely to follow up with a trainer (2 weeks, 25% vs. 10%, p = 0.06; 4 weeks, 29% vs. 8%, p < 0.01). Of the patients who did RTP or normal activities at 2 weeks (44%), more than one third (35%) were symptomatic, and most (58%) did not receive medical clearance. Of the patients who had returned to activities at 4 weeks (64%), less than one quarter (23%) were symptomatic, and most (54%) received medical clearance. CONCLUSION Pediatric patients discharged from the ED are mostly compliant with concussion instructions. However, a significant number of patients RTP on the day of injury, while experiencing symptoms or without medical clearance. LEVEL OF EVIDENCE Care management, level IV. Epidemiologic study, level III.

The impact of missing trauma data on predicting massive transfusion

BACKGROUND Missing data are inherent in clinical research and may be especially problematic for trauma studies. This study describes a sensitivity analysis to evaluate the impact of missing data on clinical risk prediction algorithms. Three blood transfusion prediction models were evaluated using an observational trauma data set with valid missing data. METHODS The PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study included patients requiring one or more unit of red blood cells at 10 participating US Level I trauma centers from July 2009 to October 2010. Physiologic, laboratory, and treatment data were collected prospectively up to 24 hours after hospital admission. Subjects who received 10 or more units of red blood cells within 24 hours of admission were classified as massive transfusion (MT) patients. Correct classification percentages for three MT prediction models were evaluated using complete case analysis and multiple imputation. A sensitivity analysis for missing data was conducted to determine the upper and lower bounds for correct classification percentages. RESULTS PROMMTT study enrolled 1,245 subjects. MT was received by 297 patients (24%). Missing percentage ranged from 2.2% (heart rate) to 45% (respiratory rate). Proportions of complete cases used in the MT prediction models ranged from 41% to 88%. All models demonstrated similar correct classification percentages using complete case analysis and multiple imputation. In the sensitivity analysis, correct classification upper-lower bound ranges per model were 4%, 10%, and 12%. Predictive accuracy for all models using PROMMTT data was lower than reported in the original data sets. CONCLUSION Evaluating the accuracy clinical prediction models with missing data can be misleading, especially with many predictor variables and moderate levels of missingness per variable. The proposed sensitivity analysis describes the influence of missing data on risk prediction algorithms. Reporting upper-lower bounds for percent correct classification may be more informative than multiple imputation, which provided similar results to complete case analysis in this study.

Acceptability of narratives to promote colorectal cancer screening in an online community.

OBJECTIVE To assess the acceptability of narratives to promote colorectal cancer (CRC) screening among members of an online weight loss community. METHOD Members of online weight loss community completed an Internet survey in 2010. Multiple logistic regression models examined demographic and attitudinal correlates of interest in sharing and receiving CRC screening narratives. RESULTS Participants (n=2386) were 92% female with mean (SD) age 58 (6) years; 68% were up-to-date with CRC screening. Among those who were up-to-date, 39% were interested in sharing their narratives with other members. African-Americans were more likely than other racial groups to be interested in sharing narratives (adjusted OR 2.02, 95% CI 1.14-3.57). Older, married members and those with greater CRC screening worries were less likely to be interested in sharing narratives. Among those not up-to-date, 63% were interested in receiving narratives from online community members, and those with higher perceived salience of CRC screening were more likely to be interested in receiving narratives (adjusted OR 1.86, 95% CI 1.31-2.65). CONCLUSIONS Members of this online weight loss community expressed interest in sharing and receiving narratives for CRC screening promotion. Attitudes and demographic characteristics may predict successful recruitment of those who would share and receive narratives.

Factors and Influences That Determine the Choices of Surgery Residency Applicants

OBJECTIVE We sought to evaluate characteristics of residency applicants selected to interview at independent general surgery programs, identify residency information resources, assess if there is perceived bias toward university or independent programs, and determine what types of programs applicants prefer. STUDY DESIGN An electronic survey was sent to applicants who were selected to interview at a participating independent program. Open-ended responses regarding reasons for program-type bias were submitted. Multivariable logistic regression models were estimated to identify applicant characteristics associated with program-type preference. SETTING Independent general surgery residency programs. PARTICIPANTS A total, of 1220 applicants were selected to interview at one of 33 independent programs. RESULTS In total, 670 surveys were completed (55% response rate). Demographics of respondents were similar to the full invited population. Median United States Medical Licensing Examination Step 1 and Step 2 scores were between 230 to 239 and 240 to 249, respectively. Most applicants reported receiving general information about surgery residency programs and specific information about independent programs from residency program websites. 34% of respondents perceived an imbalanced representation of program types, with 96% of those reporting bias toward university programs. CONCLUSIONS Applicants selected to interview at independent programs are competitive for general surgery training and primarily use residency program websites for information gathering. Bias is common toward university programs for a variety of perceived reasons. This information will be useful in applicant evaluation and selection, serve as a stimulus to update program websites, and challenge independent program directors to work to alleviate bias against their programs.

A Novel Decision Tree Approach Based on Transcranial Doppler Sonography to Screen for Blunt Cervical Vascular Injuries

Early detection and treatment of blunt cervical vascular injuries prevent adverse neurologic sequelae. Current screening criteria can miss up to 22% of these injuries. The study objective was to investigate bedside transcranial Doppler sonography for detecting blunt cervical vascular injuries in trauma patients using a novel decision tree approach.

Speaking Up and Sharing Information Improves Trainee Neonatal Resuscitations

Objectives To identify teamwork behaviors associated with improving efficiency and quality of simulated resuscitation training. Methods Secondary analysis of a randomized controlled trial of trainees undergoing neonatal resuscitation training was performed. Trainees at a large academic center (n = 100) were randomized to receive standard curriculum (n = 36) versus supplemental team training curriculum (n = 62). A 2-hour team training session focused on communication skills, and team behaviors served as the intervention. Outcomes of interest included resuscitation duration, time required to complete a simulated newborn resuscitation, and performance score, determined by evaluation of each of the team’s steps during simulated resuscitation scenarios. Results The teamwork behaviors assertion and sharing information were associated with shorter resuscitation duration and higher performance scores. Each additional use of assertion (per minute) was associated with a duration reduction of 41 s (95% confidence interval [CI], −71.5 to −10.2) and an increase in performance score of 1.6% (95% CI, 0.4–2.7). Each additional use of sharing information (per minute) was associated with a 14-second reduction in duration (95% CI, −30.4 to 2.9) and a 0.8% increase in performance score (95% CI, 0.05–1.5). Conclusions Teamwork behaviors of assertion and sharing information are 2 important mediators of efficiency and quality of resuscitations.

Deep vein thrombosis screening and risk factors in a high-risk trauma population

BACKGROUND Trauma patients requiring acute inpatient rehabilitation are significantly injured, with increased risk for deep vein thrombosis (DVT). We evaluated routine screening for occult DVT in such patients, and analyzed DVT risk factors. MATERIALS AND METHODS Data from level I trauma center patients discharged to a single acute rehabilitation center (ARC) from 2007-2011 were retrospectively reviewed. Routine lower extremity duplex was performed on ARC admission. Follow-up data were collected for patients with occult DVT (ARC DVT). DVT predictors were evaluated using logistic regression. RESULTS Of 622 patients, 534 (86%) had screening duplex; 26 (4.8%) had an ARC DVT. A majority of 442 patients (71%) received enoxaparin prophylaxis in hospital, for a median 64% of hospital days. Of ARC DVT patients, 17 received full anticoagulation and 16 received vena cava filters. Thirty-seven patients had DVT diagnosed in the hospital (hospital DVT) before discharge to ARC. Hospital DVT and ARC DVT groups were comparable except shorter median hospital length of stay and lower head abbreviated injury scale in ARC DVT patients. On multivariate analysis, increased intensive care unit length of stay, age >65 y, a lower percentage of hospital days receiving chemoprophylaxis, and delayed initiation of chemoprophylaxis were significantly predictive of DVT after adjustment for sex, mechanism, injury severity score, and admission systolic blood pressure. Presence of pelvic fractures and ages 50-65 y also posed an increased risk. CONCLUSIONS The incidence of occult DVT on ARC admission is low in trauma patients. Several risk factors for DVT in the trauma ARC population were identified. Nonselective screening of all trauma patients on admission to ARC is not supported by this analysis.