Christian de Virgilio

Objective criteria may assist in distinguishing necrotizing fasciitis from nonnecrotizing soft tissue infection.

BACKGROUNDnOptimal treatment of necrotizing fasciitis (NF) requires rapid diagnosis. The purpose of the study was to identify objective admission measurements that help differentiate NF from nonnecrotizing (non-NF) infection and, among NF patients, to identify admission factors that predict mortality.nnnMETHODSnTwenty-one NF cases were paired with matched non-NF controls. Statistical comparison of admission vital signs, laboratory values, and radiographic studies was performed.nnnRESULTSnOn multivariate analysis, admission white blood cell count (WBC) >14 x 10(9)/L, serum sodium <135 mmol/L, and blood urea nitrogen (BUN) >15 mg/dL separated NF from non-NF patients. Mortality for NF patients was predicted by admission WBC >30 x 10(9)/L. Mortality was also significantly increased for patients transferred from an outside institution prior to definitive therapy.nnnCONCLUSIONSnObjective admission criteria (elevated WBC and BUN and decreased serum sodium) can assist in distinguishing NF from non-NF infections. The best objective predictor of mortality in NF patients is marked elevation of admission WBC.

Predicting Performance on the American Board of Surgery Qualifying and Certifying Examinations: A Multi-institutional Study

BACKGROUNDnWe sought to determine whether US Medical Licensing Examination (USMLE) Step 1 score, American Board of Surgery (ABS) In-Training Examination (ABSITE) score, and other variables are associated with failing the ABS qualifying and certifying examinations. Identifying such factors may assist in the early implementation of an academic intervention for at-risk residents.nnnDESIGNnRetrospective review.nnnSETTINGnSeventeen general surgery training programs in the western United States.nnnPARTICIPANTSnSix hundred seven residents who graduated in 2000-2007.nnnMAIN OUTCOME MEASURESnFirst-time pass rates on the qualifying and certifying examinations, US vs non-US medical school graduation, USMLE Steps 1 and 2 scores, ABSITE scores, operative case volume, fellowship training, residency program type, and mandatory research.nnnRESULTSnThe first-time qualifying and certifying examination pass rates for the 607 graduating residents were 78% and 74%, respectively. On multivariable analysis, scoring below the 35th percentile on the ABSITE at any time during residency was associated with an increased risk of failing both examinations (odds ratio, 0.23 [95% confidence interval, 0.08-0.68] for the qualifying examination and 0.35 [0.20-0.61] for the certifying examination), as was scoring less than 200 on the USMLE Step 1 (0.36 [0.21-0.62] for the qualifying examination and 0.62 [0.42-0.93] for the certifying examination). A mandatory research year was associated with an increased likelihood of passing the certifying examination (odds ratio, 3.3 [95% confidence interval, 1.6-6.8]).nnnCONCLUSIONSnResidents who are more likely to fail the ABS qualifying and certifying examinations can be identified by a low USMLE Step 1 score and by poor performance on the ABSITE at any time during residency. These findings support the use of the USMLE Step 1 score in the surgical residency selection process and a formal academic intervention for residents who perform poorly on the ABSITE.

Risk of surgery following recent myocardial infarction.

Objective: We aimed to assess the impact of recent myocardial infarction (MI) on outcomes after subsequent surgery in the contemporary clinical setting. Background: Prior work shows that a history of a recent MI is a risk factor for complications following noncardiac surgery. However, this data does not reflect current advances in clinical management. Methods: Using the California Patient Discharge Database, we retrospectively analyzed patients undergoing hip surgery, cholecystectomy, colectomy, elective abdominal aortic aneurysm repair, and lower extremity amputation from 1999 to 2004 (n = 563,842). Postoperative 30-day MI rate, 30-day mortality, and 1-year mortality were compared for patients with and without a recent MI using univariate analyses and multivariate logistic regression. Relative risks (RR) with 95% confidence intervals were estimated using bootstrapping with 1000 repetitions. Results: Postoperative MI rate for the recent MI cohort decreased substantially as the length of time from MI to operation increased (0–30 days = 32.8%, 31–60 days = 18.7%, 61–90 days = 8.4%, and 91–180 days = 5.9%), as did 30-day mortality (0–30 days = 14.2%, 31–60 days = 11.5%, 61–90 days = 10.5%, and 91–180 days = 9.9%). MI within 30 days of an operation was associated with a higher risk of postoperative MI (RR range = 9.98–44.29 for the 5 procedures), 30-day mortality (RR range, 1.83–3.84), and 1-year mortality (RR range, 1.56–3.14). Conclusions: A recent MI remains a significant risk factor for postoperative MI and mortality following surgery. Strategies such as delaying elective operations for at least 8 weeks and medical optimization should be considered.

Acute Care Surgery Performed by Sleep Deprived Residents: Are Outcomes Affected?

BACKGROUNDnThe Institute of Medicine recently recommended further reductions in resident duty hours, including a 5-h rest time for on-call residents after 16 h of work. This recommendation was purportedly intended to better protect patients against fatigue-related errors made by physician trainees. Yet no data are available regarding outcomes of operations performed by surgical trainees working without rest beyond 16 h in the current 80-h workweek era.nnnMETHODSnA retrospective review of all laparoscopic cholecystectomies (LC) and appendectomies performed by surgery residents at a public teaching hospital from July 2003 through March 2009. Operations after 10 PM were performed by residents who began their shift at 6 AM and had thus been working 16 or more hours. An outcomes comparison between time periods was conducted for operations performed between 6 AM and 10 PM (daytime) and 10 PM and 6 AM (nighttime). Outcome measures were rates of total complications, bile duct injury, conversion to open operation, length of surgery, and mortality.nnnRESULTSnOver the 7-y study period, 2908 LC and 1726 appendectomies were performed. Appendectomies were performed laparoscopically in 73% of cases in patients for both time periods. There were no differences in rates of overall morbidity and mortality for operations when performed in nighttime compared with daytime. On multivariable analysis, there were no differences in outcomes between the two groups.nnnCONCLUSIONnThe two most commonly performed general surgical operations performed at night by unrested residents have favorable outcomes similar to those performed during the day. Instituting a 5-h rest period at night is unlikely to improve the outcomes for these commonly performed operations.

Effect of the 16-hour work limit on general surgery intern operative case volume: a multi-institutional study.

IMPORTANCEnThe 80-hour work-week limit for all residents was instituted in 2003 and studies looking at its effect have been mixed. Since the advent of the 16-hour mandate for postgraduate year 1 residents in July 2011, no data have been published regarding the effect of this additional work-hour restriction.nnnOBJECTIVEnTo determine whether the 16-hour intern work limit, implemented in July 2011, has adversely affected operative experience.nnnDESIGN, SETTING, AND PARTICIPANTSnA retrospective review of categorical postgraduate year 1 Accreditation Council for Graduate Medical Education case logs from the intern class (Nu2009=u200952) (with 16-hour work limit) compared with the 4 preceding years (2007-2010; Nu2009=u2009197) (without 16-hour work limit). A total of 249 categorical general surgery interns from 10 general surgery residency programs in the western United States were included.nnnMAIN OUTCOMES AND MEASURESnTotal, major, first-assistant, and defined-category case totals.nnnRESULTSnAs compared with the preceding 4 years, the 2011-2012 interns recorded a 25.8% decrease in total operative cases (65.9 vs 88.8, Pu2009=u2009.005), a 31.8% decrease in major cases (54.9 vs 80.5, Pu2009<u2009.001), and a 46.3% decrease in first-assistant cases (11.1 vs 20.7, Pu2009=u2009.008). There were statistically significant decreases in cases within the defined categories of abdomen, endocrine, head and neck, basic laparoscopy, complex laparoscopy, pediatrics, thoracic, and soft tissue/breast surgery in the 16-hour shift intern era, whereas there was no decrease in trauma, vascular, alimentary, endoscopy, liver, and pancreas cases.nnnCONCLUSIONS AND RELEVANCEnThe 16-hour work limit for interns, implemented in July 2011, is associated with a significant decrease in categorical intern operative experience. If the 16-hour shift were to be extended to all postgraduate year levels, one can anticipate that additional years of training will be needed to maintain the same operative volume.

Trauma Surgery Performed By “Sleep Deprived” Residents: Are Outcomes Affected?

BACKGROUNDnThe Institute of Medicine recently recommended further reductions in resident duty hours, including a 5-hour rest time for on-call residents after 16 hours of work, as a way of providing better protection for patients against fatigue-related errors, yet no data are available regarding outcomes of operations performed by surgical trainees working beyond 16 hours in the current 80-hour workweek era.nnnMETHODSnA retrospective review of all trauma patients who required an urgent/emergent operation by the Trauma Surgery service at a Level 1 trauma center between 2003 and 2009. Operations after 10 pm were performed by residents who began their shift at 6 am, and had thus been working 16 hours. A comparison of morbidity and mortality was performed with operations performed between 6 am and 10 pm (daytime) and 10 pm and 6 am (nighttime).nnnRESULTSnOver the 7-year study period, 1432 trauma patients required an urgent/emergent operation. Eighty-four percent of patients were male and 71% suffered a penetrating injury. The median age for the group was 26 years. The overall complication rate was 18%, with a mortality rate of 12%. On univariate analysis there were a higher proportion of males in the nighttime group versus daytime (87% vs 82%, p = 0.007). The patients in the nighttime group were also younger (25 vs 29 years, p < 0.0001) with a lower injury severity score (ISS) (13 vs 16, p = 0.002) and had a higher proportion of penetrating injuries (81% vs 65%, p < 0.0001). The complication rate was higher in daytime (20% vs 16% for nighttime, p = 0.04), whereas the mortality rates were similar (13.5% for daytime vs 10.6%, p = 0.1). On multivariable analysis, after adjusting for age, male gender, ISS, and penetrating trauma, the time of operation was not a predictor of morbidity (odds ratio [OR] 0.97; 95% confidence interval [CI], 0.7-1.3, p = 0.9) or mortality (odds ratio1.02, 95% confidence interval, 0.7-1.6, p = 0.9).nnnCONCLUSIONSnTrauma surgery performed at night by residents who have worked longer than 16 hours have similar favorable outcomes compared with those performed during the day. Instituting a 5-hour rest period at night is unlikely to improve outcomes of these commonly performed operations.

General Surgery Resident Remediation and Attrition: A Multi-institutional Study

OBJECTIVEnTo determine the rates and predictors of remediation and attrition among general surgery residents.nnnDESIGN, SETTING, AND PARTICIPANTSnEleven-year retrospective analysis of 348 categorical general surgery residents at 6 West Coast programs.nnnMAIN OUTCOME MEASURESnRates and predictors of remediation and attrition.nnnRESULTSnThree hundred forty-eight categorical general surgery residents were included. One hundred seven residents (31%) required remediation, of which 27 were remediated more than once. Fifty-five residents (15.8%) left their programs, although only 2 were owing to failed remediation. Remediation was not a predictor of attrition (20% attrition for those remediated vs 15% who were not [P = .40]). Remediation was most frequently initiated owing to a deficiency in medical knowledge (74%). Remediation consisted of monthly meetings with faculty (79%), reading assignments (72%), required conferences (27%), therapy (12%), and repeating a clinical year (6.5%). On univariate analysis, predictors of remediation included receiving honors in the third-year surgery clerkship, United States Medical Licensing Examination (USMLE) step 1 and/or step 2, and American Board of Surgery In-Training Examination scores at postgraduate years 1 through 4. On multivariable regression analysis, remediation was associated with receiving honors in surgery (odds ratio, 1.9; P = .01) and USMLE step 1 score (odds ratio, 0.9; P = .02). On univariate analysis, the only predictor of attrition was the American Board of Surgery In-Training Examination score at the postgraduate year 3 level (P = .04).nnnCONCLUSIONSnAlmost one third of categorical general surgery residents required remediation during residency, which was most often owing to medical knowledge deficits. Lower USMLE step 1 scores were predictors of the need for remediation. Most remediated residents successfully completed the program. Given the high rates of remediation and the increased educational burden on clinical faculty, medical schools need to focus on better preparing students to enter surgical residency.

Coronary revascularization after myocardial infarction can reduce risks of noncardiac surgery.

BACKGROUNDnRecent studies suggest that preoperative coronary revascularization overall does not improve outcomes after noncardiac surgery. It is not known whether this holds true for high-risk patients with a history of recent MI. Our objective was to determine whether preoperative revascularization improves outcomes after noncardiac surgery in patients with a recent MI.nnnSTUDY DESIGNnUsing the California Patient Discharge Database, we retrospectively analyzed patients with a recent MI who underwent hip surgery, cholecystectomy, bowel resection, elective abdominal aortic aneurysm repair, and lower extremity amputation from 1999 to 2004 (n = 16,478). Postoperative 30-day reinfarction and 30-day and 1-year mortality were compared for patients who underwent preoperative revascularization (percutaneous transluminal coronary angioplasty, coronary stenting, or coronary artery bypass graft) and those who were not revascularized using univariate analyses and multivariate logistic regression. Relative risks with 95% confidence intervals were estimated using bootstrapping with 1,000 repetitions.nnnRESULTSnPatients with a recent MI who were revascularized before surgery had an approximately 50% decreased rate of reinfarction (5.1% versus 10.0%; p < 0.001) and 30-day (5.2% versus 11.3%; p < 0.001) and 1-year mortality (18.3% versus 35.8%; p < 0.001) compared with those who were not. Stenting within 1 month of surgery was associated with a trend toward increased reinfarction (relative risk: 1.36; 95% CI, 0.96-1.97), and coronary artery bypass graft was associated with a decreased risk (relative risk: 0.70; 95% CI, 0.55-0.95).nnnCONCLUSIONSnThis large sample representing real world practice suggests that patients with a recent MI can benefit from preoperative revascularization. Coronary artery bypass graft can improve outcomes more than stenting, especially when surgery is necessary within 1 month of revascularization, but additional prospective studies are indicated.

The Electronic Residency Application Service Application Can Predict Accreditation Council for Graduate Medical Education Competency-Based Surgical Resident Performance

OBJECTIVEnProgram directors often struggle to determine which factors in the Electronic Residency Application Service (ERAS) application are important in the residency selection process. With the establishment of the Accreditation Council for Graduate Medical Education (ACGME) competencies, it would be important to know whether information available in the ERAS application can predict subsequent competency-based performance of general surgery residents.nnnMETHODSnThis study is a retrospective correlation of data points found in the ERAS application with core competency-based clinical rotation evaluations. ACGME competency-based evaluations as well as technical skills assessment from all rotations during residency were collected. The overall competency score was defined as an average of all 6 competencies and technical skills.nnnRESULTSnA total of77 residents from two (one university and one community based university-affiliate) general surgery residency programs were included in the analysis. Receiving honors for many of the third year clerkships and AOA membership were associated with a number of the individual competencies. USMLE scores were predictive only of Medical Knowledge (p = 0.004). Factors associated with higher overall competency were female gender (p = 0.02), AOA (p = 0.06), overall number of honors received (p = 0.04), and honors in Ob/Gyn (p = 0.03) and Pediatrics (p = 0.05). Multivariable analysis showed honors in Ob/Gyn, female gender, older age, and total number of honors to be predictive of a number of individual core competencies. USMLE scores were only predictive of Medical Knowledge.nnnCONCLUSIONSnThe ERAS application is useful for predicting subsequent competency based performance in surgical residents. Receiving honors in the surgery clerkship, which has traditionally carried weight when evaluating a potential surgery resident, may not be as strong a predictor of future success.

Outcomes of brachial artery-basilic vein fistula.

Increasing the creation of arteriovenous fistulas in the maintenance of hemodialysis patients is of great importance to the nephrology community. The creation of the brachial artery–basilic vein fistula is an important option in patients with unsuccessful or failing forearm accesses for hemodialysis. The aim of this study is to review reported outcomes of brachial artery–basilic vein fistulas regarding patency and primary failure rates in comparison with other types of fistulas and grafts in the published literature. We have also described the variations in the surgical technique during creation and the potential influence on outcomes. Based on our review of the literature, the rate of primary failure is approximately 15–20% with a range of 0–40%. The mean 1‐year primary patency rate is approximately 72% with a range of 23–90%, and the 2‐year primary patency rate is approximately 62% with a range from 11% to 86%. The number of required interventions to maintain patency is lower with brachial artery–basilic vein fistula compared to arteriovenous grafts.