Loren Berman

Necrotizing enterocolitis: an update.

Necrotizing enterocolitis (NEC) is a leading cause of death among patients in the neonatal intensive care unit, carrying a mortality rate of 15-30%. Its pathogenesis is multifactorial and involves an overreactive response of the immune system to an insult. This leads to increased intestinal permeability, bacterial translocation, and sepsis. There are many inflammatory mediators involved in this process, but thus far none has been shown to be a suitable target for preventive or therapeutic measures. NEC usually occurs in the second week of life after the initiation of enteral feeds, and the diagnosis is made based on physical examination findings, laboratory studies, and abdominal radiographs. Neonates with NEC are followed with serial abdominal examinations and radiographs, and may require surgery or primary peritoneal drainage for perforation or necrosis. Many survivors are plagued with long term complications including short bowel syndrome, abnormal growth, and neurodevelopmental delay. Several evidence-based strategies exist that may decrease the incidence of NEC including promotion of human breast milk feeding, careful feeding advancement, and prophylactic probiotic administration in at-risk patients. Prevention is likely to have the greatest impact on decreasing mortality and morbidity related to NEC, as little progress has been made with regard to improving outcomes for neonates once the disease process is underway.

Attracting Surgical Clerks to Surgical Careers: Role Models, Mentoring, and Engagement in the Operating Room

BACKGROUNDnDeclining interest in careers in surgery among medical students has contributed to growing concerns about the surgical workforce. Although the medical student clerkship is likely to play an important role in shaping students impressions of careers in surgery, little is known about the nature of this process. This study was designed to identify those aspects of the clerkship that are associated with medical students expressing an interest in surgery at the end of the clerkship.nnnSTUDY DESIGNnMedical students completed a survey at the end of the surgical clerkship assessing characteristics of the clerkship experience and students level of interest in pursuing a career in surgery. The survey also included open-ended questions about students reasons for having increased or decreased interest in surgery, which were systematically analyzed to complement quantitative findings.nnnRESULTSnStudents who sutured (p = 0.001), drove the camera (p = 0.01), stated that they felt involved in the operating room (p = 0.009), and saw residents (p = 0.03) and attendings (p = 0.0003) as positive role models were more likely to be interested in surgery. After adjusting for covariates, students who sutured in the operating room were 4.8 times as likely to be interested in surgery (95% CI, 1.5 to 14.9) and students who drove the camera were 7.2 times as likely to be interested in surgery (95% CI, 1.1 to 46.8).nnnCONCLUSIONSnStudents who participate actively in the operating room and those who are exposed to positive role models are more likely to be interested in pursuing a career in surgery. To optimize students clerkship experiences and attract top candidates to the field of surgery, clerkship directors should encourage meaningful engagement of students in the operating room and facilitate mentoring experiences.

Defining Surgical Therapy for Pseudomembranous Colitis With Toxic Megacolon

Background Pseudomembranous colitis has increased in incidence and severity over the past 10 years. Toxic megacolon is a rare but reported presentation of severe pseudomembranous colitis. This article reviews the reported cases of Clostridium difficile with toxic megacolon in the literature and introduces an additional case that underscores the importance of early diagnosis in guiding appropriate therapy. Methods A systematic review of the literature was performed to identify previous reports of pseudomembranous colitis presenting with toxic megacolon, and the outcomes of each of these cases was analyzed. The review was focused on atypical presentations in immunocompromised patients. Results Seventeen cases of C. difficile colitis presenting as toxic megacolon were identified. The overall mortality rate was 50% (9/18). Fifteen patients underwent surgery with an associated mortality rate of 50%. Thirteen patients had a subtotal colectomy. Seven of the patients (39%) were taking immunosuppressant medications, and 5 (28%) patients presented with atypical symptoms. Three (76%) of those were immunosuppressed. In several cases, failure to make an early diagnosis of C. difficile colitis resulted in a worse outcome because appropriate therapy was delayed. Conclusions Toxic megacolon is well-established as an unusual presentation of C. difficile colitis. These patients are less likely to present with typical symptoms such as diarrhea or typical risk factors like recent administration of antibiotics, so diagnosis can be a challenge. A patient presenting with toxic megacolon without a history of inflammatory bowel disease should be assumed to have C. difficile colitis until proven otherwise, and medical or surgical therapy administered accordingly.

Informed consent for abdominal aortic aneurysm repair: The patient's perspective.

OBJECTIVEnWhether or not to undergo surgery for abdominal aortic aneurysm (AAA), and whether to have open or endovascular repair (EVAR), is a complex decision that relies heavily on patient preferences, and yet little is known about the patient perspective on informed consent in this context. This study explores patients views on their decision-making processes and the quality of surgeon-patient communication during informed consent for AAA repair.nnnDESIGN OF STUDYnWe conducted in-depth interviews with AAA patients (n = 20) who underwent open AAA repair, endovascular repair, or declined surgery. Data were independently transcribed and analyzed by a team of individuals with diverse backgrounds, using the constant comparative method of analysis and systematic coding procedures.nnnSETTINGnPatients who had seen surgeons from academic, private practice, and VA settings were interviewed.nnnMAIN OUTCOME MEASUREnPatients opinions regarding the nature, scope, and content of informed consent for AAA repair.nnnRESULTSnWe identified four central themes characterizing patients experiences with informed consent for AAA repair: 1) patients did not appreciate the scope of their options; 2) patients demonstrated that they were not adequately informed prior to making a decision; 3) patients differed in the scope and content of information they desired during informed consent; and 4) trust in the surgeon had an impact on the informed consent process.nnnCONCLUSIONnOur research highlights the limitations of the informed consent encounter in the current clinical context, and points to several ways in which informed consent could be improved. Adapting the informed consent encounter to incorporate the patients perspective is critical in order to ensure that the decision regarding AAA repair is consistent with the patients informed preference.

Informed consent for abdominal aortic aneurysm repair: Assessing variations in surgeon opinion through a national survey

OBJECTIVEnInformed consent discussions for elective abdominal aortic aneurysm (AAA) repair should reflect appropriate risks of the open or endovascular repair (EVAR), but few guidelines exist describing what surgeons should discuss. This study examines expert opinion regarding what constitutes informed consent.nnnMETHODSnDesign. We conducted an anonymous, web-based, national survey of vascular surgeons. Associations between surgeon characteristics and opinions regarding informed consent were measured using bivariate statistics; multivariable logistic regression was performed to estimate effects adjusted for covariates. Setting. Academic and private practice surgeons were surveyed. Subjects. United States members of the International Society for Vascular Surgery membership. Main Outcome Measure. Surgeons self-reported opinions regarding the content of informed consent for AAA repair.nnnRESULTSnA total of 199 surgeons completed the survey (response rate 51%). More than 90% of respondents reported that it was essential to discuss mortality risk for both procedures. However, only 60% and 30% of respondents reported that it was essential to discuss the risk of myocardial infarction and stroke, respectively. Opinions varied by procedure regarding the risks of impotence (32% vs 62%; EVAR vs open repair), reintervention (78% vs 17%), and rupture during long-term follow-up (57% vs 17%). Younger and private practice surgeons were more likely to discuss complications compared with older surgeons and those in academic practice. Surgeons who perform predominantly EVAR were more likely to quote higher mortality rates for open repair (odds ration [OR] = 3.1, 95% confidence interval [CI] = 1.4-6.4) and lower reintervention rates for EVAR (OR = 0.3, 95% CI = 0.1-0.7) compared with other surgeons.nnnCONCLUSIONSnThis is the first study of the practice of informed consent for AAA repair. The only risk that the vast majority of surgeons agreed should be included in informed consent for AAA repair was mortality. Significant variation exists regarding whether other complications should be discussed and what complication rates should be quoted. Surgeon characteristics may influence how risks are presented to patients. Further efforts are needed to develop guidelines to ensure consistent communication of appropriate risk during informed consent for AAA repair.

Pilot testing of a decision support tool for patients with abdominal aortic aneurysms

OBJECTIVEnPatients with abdominal aortic aneurysms (AAAs) who are surgical candidates have as many as three options: open surgery, endovascular surgery, or no surgery. As with all treatment decisions, informed patient preferences are critical. Decision support tools have the potential to better inform patients about the risks and benefits associated with each treatment option and to empower patients to participate meaningfully in the decision-making process. The objective of this study was to develop and pilot test a decision support tool for patients with AAAs.nnnMETHODSnWe developed a personalized, interactive, computer-based decision support tool reflecting the most current outcomes data and input from surgeons and patients. We piloted the tool with AAA repair candidates who used the tool prior to meeting with their surgeon. Patients were recruited from a university-based vascular surgery clinic and affiliated VA hospital clinic. To determine feasibility and acceptability, the following outcomes were measured: (1) percent of patients who agreed to participate, (2) length of time required to use the tool, (3) the amount of assistance required to use the tool, and (4) patients opinions on the acceptability of the tool. To assess effectiveness of the tool, we measured change in knowledge and decisional conflict pre- and post-tool using the paired t-test.nnnRESULTSnOne hundred percent of patients who were approached (n = 12) agreed to participate in the study. The tool was administered in a median time of 35 minutes (range, 25-45 minutes), and all patients were able to navigate the program with minor technical assistance. Mean knowledge scores increased from 56% to 90% (P = .005), and decisional conflict scores decreased from 29% to 8% (P = .04). Overall, patients reported that the program content was balanced across treatment options, presented information clearly and concisely, helped them to organize their thoughts about the decision, and prepared them to talk to their surgeon about what mattered most to them.nnnCONCLUSIONSnPreliminary evidence suggests that use of an evidence-based AAA decision support tool is feasible and acceptable to patients, increases knowledge, and decreases decisional conflict. Widespread use of such a tool might improve the content and quality of informed consent for this difficult treatment decision.

Results of a longitudinal study of rigorous manuscript submission guidelines designed to improve the quality of clinical research reporting in a peer-reviewed surgical journal

BACKGROUND/PURPOSEnIn an effort to improve the reporting quality of clinical research, the Journal of Pediatric Surgery instituted specific reporting guidelines for authors beginning June 2006. This study was conducted to evaluate whether these guidelines improved reporting of observational studies.nnnMETHODSnThe Guidelines for the Reporting of Clinical Research Data (Guidelines) included 23 criteria in 3 subcategories: Methods, Results, and More than one treatment group. Reporting quality was evaluated by determining the percentage of criteria met. Seventy-three articles before implementation and 147 articles after implementation were independently assessed by 2 reviewers.nnnRESULTSnMean global composite scores increased from 72.2 pre-Guidelines to 80.1 post-Guidelines (P < .0001). Scores increased in each subcategory: Methods, 71.9 to 78.6 (P < .0001); Results, 77.2 to 83.0 (P = .002); and More than one treatment group, 40.0 to 70.6 (P = .0003). Post-Guidelines implementation scores have increased over time.nnnCONCLUSIONSnThe introduction of the Guidelines resulted in significant improvement in the quality of reporting in the Journal. The low cost vs the benefit suggests that the Guidelines can be an effective way to improve reporting quality in nonrandomized studies. We encourage further efforts to increase inclusion of reporting criteria as well as evaluation and improvement of the Guidelines. We suggest that editors of other surgical publications consider implementing analogous guidelines.

Computer-Based Endoscopy Simulation: Emerging Roles in Teaching and Professional Skills Assessment

Advances in endoscopy simulation are reviewed with emphasis on applications in teaching and skills assessment. Endoscopy simulation has only been realized recently in a computer-based fashion because of advances in technology, but several studies have been performed both to validate computer-based endoscopy simulators and to assess their potential role in training. Multiple studies have shown that simulators can distinguish between clinicians at different skill levels and also have shown improvement in clinician skill, particularly at the early stages of training. This article summarizes those studies. The cost versus benefit of endoscopic simulators is also discussed, as well as the upcoming role of simulators in judging competence and as a tool in the credentialing process.

Serous cystadenoma in communication with the pancreatic duct: an unusual radiologic and pathologic entity.

Cross-sectional imaging is frequently used in the diagnosis of pancreatic cysts, but there can be overlap in radiographic appearance. We present a case of a patient with presumed intraductal papillary mucinous neoplasm (IPMN) who was ultimately found to have a serous cystadenoma in communication with the pancreatic duct. A literature search for serous cystadenoma communicating with the pancreatic duct was performed and the data was reviewed in the context of this case report. Three reports of patients with serous cystadenoma communicating with the pancreatic duct were identified. Review of current data revealed that endoscopic ultrasound (EUS) has an important role in distinguishing between pancreatic cystic lesions preoperatively. Distinguishing between serous and mucinous cystadenomas and IPMN is essential to guide appropriate management. Although communication with the pancreatic duct is usually pathognomonic of IPMN, rarely this may be a misdiagnosis of a serous cystadenoma and EUS may be necessary for further evaluation. If EUS cannot be performed, resection is favored to avoid undertreating a premalignant lesion.

The paradoxical effect of medical insurance on delivery of surgical care for infants with congenital anomalies

OBJECTIVEnCaring for neonates with major congenital anomalies has significant financial implications for the treating institution, which can be positive or negative depending on whether the patient has insurance. We hypothesized that insured affected neonates born in non-childrens hospitals would be more likely to be treated on site, whereas uninsured neonates would be more likely to be transferred.nnnPATIENTS AND METHODSnWe used the Kids Inpatient Database to study neonates with congenital anomalies who were born in US non-childrens hospitals. We performed bivariate analysis using the chi(2) test and adjusted for covariates with multiple logistic regression.nnnRESULTSnUninsured patients were 2.57 (95% confidence interval, 1.83-3.62) times more likely to be transferred compared with patients with private insurance or Medicaid, after adjusting for patient and hospital characteristics. This trend increased over time between 1997 and 2006.nnnCONCLUSIONSnThe current reimbursement structure in the United States incentivizes non-childrens hospitals to retain insured patients with congenital anomalies and transfer uninsured patients with these same anomalies. This places a disproportionate financial burden on childrens hospitals while paradoxically causing insured infants to be cared for at hospitals that may not be best equipped to provide complex care.