Manuel Castillo-Angeles

Assessing the Accuracy and Readability of Online Health Information for Patients With Pancreatic Cancer

IMPORTANCE The degree to which patients are empowered by written educational materials depends on the texts readability level and the accuracy of the information provided. The association of a websites affiliation or focus on treatment modality with its readability and accuracy has yet to be thoroughly elucidated. OBJECTIVE To compare the readability and accuracy of patient-oriented online resources for pancreatic cancer by treatment modality and website affiliation. DESIGN An online search of 50 websites discussing 5 pancreatic cancer treatment modalities (alternative therapy, chemotherapy, clinical trials, radiation therapy, and surgery) was conducted. The websites affiliation was identified. Readability was measured by 9 standardized tests, and accuracy was assessed by an expert panel. MAIN OUTCOMES AND MEASURES Nine standardized tests were used to compute the median readability level of each website. The median readability scores were compared among treatment modality and affiliation categories. Accuracy was determined by an expert panel consisting of 2 medical specialists and 2 surgical specialists. The 4 raters independently evaluated all websites belonging to the 5 treatment modalities (a score of 1 indicates that <25% of the information is accurate, a score of 2 indicates that 26%-50% of the information is accurate, a score of 3 indicates that 51%-75% of the information is accurate, a score of 4 indicates that 76%-99% of the information is accurate, and a score of 5 indicates that 100% of the information is accurate). RESULTS The 50 evaluated websites differed in readability and accuracy based on the focus of the treatment modality and the websites affiliation. Websites discussing surgery (with a median readability level of 13.7 and an interquartile range [IQR] of 11.9-15.6) were easier to read than those discussing radiotherapy (median readability level, 15.2 [IQR, 13.0-17.0]) (P = .003) and clinical trials (median readability level, 15.2 [IQR, 12.8-17.0]) (P = .002). Websites of nonprofit organizations (median readability level, 12.9 [IQR, 11.2-15.0]) were easier to read than media (median readability level, 16.0 [IQR, 13.4-17.0]) (P < .001) and academic (median readability level, 14.8 [IQR, 12.9-17.0]) (P < .001) websites. Privately owned websites (median readability level, 14.0 [IQR, 12.1-16.1]) were easier to read than media websites (P = .001). Among treatment modalities, alternative therapy websites exhibited the lowest accuracy scores (median accuracy score, 2 [IQR, 1-4]) (P < .001). Nonprofit (median accuracy score, 4 [IQR, 4-5]), government (median accuracy score, 5 [IQR, 4-5]), and academic (median accuracy score, 4 [IQR, 3.5-5]) websites were more accurate than privately owned (median accuracy score, 3.5 [IQR, 1.5-4]) and media (median accuracy score, 4 [IQR, 2-4]) websites (P < .004). Websites with higher accuracy were more difficult to read than websites with lower accuracy. CONCLUSIONS AND RELEVANCE Online information on pancreatic cancer overestimates the reading ability of the overall population and lacks accurate information about alternative therapy. In the absence of quality control on the Internet, physicians should provide guidance to patients in the selection of online resources with readable and accurate information.

Sarcopenia increases risk of long-term mortality in elderly patients undergoing emergency abdominal surgery

BACKGROUND Frailty is associated with poor surgical outcomes in elderly patients but is difficult to measure in the emergency setting. Sarcopenia, or the loss of lean muscle mass, is a surrogate for frailty and can be measured using cross-sectional imaging. We sought to determine the impact of sarcopenia on 1-year mortality after emergency abdominal surgery in elderly patients. METHODS Sarcopenia was assessed in patients 70 years or older who underwent emergency abdominal surgery at a single hospital from 2006 to 2011. Average bilateral psoas muscle cross-sectional area at L3, normalized for height (Total Psoas Index [TPI]), was calculated using computed tomography. Sarcopenia was defined as TPI in the lowest sex-specific quartile. Primary outcome was mortality at 1 year. Secondary outcomes were in-hospital mortality and mortality at 30, 90, and 180 days. The association of sarcopenia with mortality was assessed using Cox proportional hazards regression and model performance judged using Harrells C-statistic. RESULTS Two hundred ninety-seven of 390 emergency abdominal surgery patients had preoperative imaging and height. The median age was 79 years, and 1-year mortality was 32%. Sarcopenic and nonsarcopenic patients were comparable in age, sex, race, comorbidities, American Society of Anesthesiologists classification, procedure urgency and type, operative severity, and need for discharge to a nursing facility. Sarcopenic patients had lower body mass index, greater need for intensive care, and longer hospital length of stay (p < 0.05). Sarcopenia was independently associated with increased in-hospital mortality (risk ratio, 2.6; 95% confidence interval [CI], 1.6–3.7) and mortality at 30 days (hazard ratio [HR], 3.7; 95% CI, 1.9–7.4), 90 days (HR, 3.3; 95% CI, 1.8–6.0), 180 days (HR, 2.5; 95% CI, 1.4–4.4), and 1 year (HR, 2.4; 95% CI, 1.4–3.9). CONCLUSION Sarcopenia is associated with increased risk of mortality over 1 year in elderly patients undergoing emergency abdominal surgery. Sarcopenia defined by TPI is a simple and objective measure of frailty that identifies vulnerable patients for improved preoperative counseling, setting realistic goals of care, and consideration of less invasive approaches. LEVEL OF EVIDENCE Prognostic study, level III.

Pregnancy and Motherhood During Surgical Training

Importance Although family priorities influence specialty selection and resident attrition, few studies describe resident perspectives on pregnancy during surgical training. Objective To directly assess the resident experience of childbearing during training. Design, Setting, and Participants A self-administered 74-question survey was electronically distributed in January 2017 to members of the Association of Women Surgeons, to members of the Association of Program Directors in Surgery listserv, and through targeted social media platforms. Surgeons who had 1 or more pregnancies during an Accreditation Council for Graduate Medical Education–accredited US general surgery residency program and completed training in 2007 or later were included. Important themes were identified using focus groups of surgeons who had undergone pregnancy during training in the past 7 years. Additional topics were identified through MEDLINE searches performed from January 2000 to July 2016 combining the keywords pregnancy, resident, attrition, and parenting in any specialty. Main Outcomes and Measures Descriptive data on perceptions of work schedule during pregnancy, maternity leave policies, lactation and childcare support, and career satisfaction after childbirth. Results This study included 347 female surgeons (mean [SD] age, 30.5 [2.7] years) with 452 pregnancies. A total of 297 women (85.6%) worked an unmodified schedule until birth, and 220 (63.6%) were concerned that their work schedule adversely affected their health or the health of their unborn child. Residency program maternity leave policies were reported by 121 participants (34.9%). A total of 251 women (78.4%) received maternity leave of 6 weeks or less, and 250 (72.0%) perceived the duration of leave to be inadequate. The American Board of Surgery leave policy was cited as a major barrier to the desired length of leave by 268 of 326 respondents (82.2%). Breastfeeding was important to 329 (95.6%), but 200 (58.1%) stopped earlier than they wished because of poor access to lactation facilities and challenges leaving the operating room to express milk. Sixty-four women (18.4%) had institutional support for childcare, and 231 (66.8%) reported a desire for greater mentorship on integrating a surgical career with motherhood and pregnancy. A total of 135 (39.0%) strongly considered leaving surgical residency, and 102 (29.5%) would discourage female medical students from a surgical career, specifically because of the difficulties of balancing pregnancy and motherhood with training. Conclusions and Relevance The challenges of having children during surgical residency may have significant workforce implications. A deeper understanding is critical to prevent attrition and to continue recruiting talented students. This survey characterizes these issues to help design interventions to support childbearing residents.

Weight loss after bariatric surgery in obese adolescents: a systematic review and meta-analysis

Of adolescents in the United States, 20% have obesity and current treatment options prioritize intensive lifestyle interventions that are largely ineffective. Bariatric surgery is increasingly being offered to obese adolescent patients; however, large-scale effectiveness data is lacking. We used MEDLINE, Embase, and Cochrane databases, and a manual search of references to conduct a systematic review and meta-analysis on overall weight loss after gastric band, gastric sleeve, and gastric bypass in obese adolescent patients (age ≤19) and young adults (age ≤21) in separate analyses. We provided estimates of absolute change in body mass index (BMI, kg/m2) and percent excess weight loss across 4 postoperative time points (6, 12, 24, and 36 mo) for each surgical subgroup. Study quality was assessed using a 10 category scoring system. Data were extracted from 24 studies with 4 having multiple surgical subgroups (1 with 3, and 3 with 2 subgroups), totaling 29 surgical subgroup populations (gastric band: 16, gastric sleeve: 5, gastric bypass: 8), and 1928 patients (gastric band: 1010, gastric sleeve: 139, gastric bypass: 779). Mean preoperative BMI (kg/m2) was 45.5 (95% confidence interval [CI]: 44.7, 46.3) in gastric band, 48.8 (95%CI: 44.9, 52.8) in gastric sleeve, and 53.3 (95%CI: 50.2, 56.4) in gastric bypass patients. The short-term weight loss, measured as mean (95%CI) absolute change in BMI (kg/m2) at 6 months, was -5.4 (-3.0, -7.8) after gastric band, -11.5 (-8.8, -14.2) after gastric sleeve, and -18.8 (-10.9, -26.6) after gastric bypass. Weight loss at 36 months, measured as mean (95%CI) absolute change in BMI (kg/m2) was -10.3 (-7.0, -13.7) after gastric band, -13.0 (-11.0, -15.0) after gastric sleeve, and -15.0 (-13.5, -16.5) after gastric bypass. Bariatric surgery in obese adolescent patients is effective in achieving short-term and sustained weight loss at 36 months; however, long-term data remains necessary to better understand its long-term efficacy.

The independent effect of emergency general surgery on outcomes varies depending on case type: A NSQIP outcomes study

BACKGROUND Emergency general surgery (EGS) is an independent risk factor for morbidity and mortality, and seven procedures account for 80% of the National burden of operative EGS. We aimed to characterize the excess morbidity and mortality attributable to these procedures based on the level of procedural risk. METHODS Retrospective analysis of the ACS National Surgical Quality Improvement Project (ACS-NSQIP) database. (2005-2014). Seven EGS procedures were stratified as high risk and low risk. Primary outcomes were overall mortality, overall morbidity, major morbidity. Multivariable logistic regression was performed. RESULTS There were 619,174 patients identified. Comparing EGS to non-EGS in high-risk cases the OR for overall mortality was 1.39(1.33,1.45), overall morbidity 1.07 (0.98, 1.16), and major morbidity 1.15(1.03,1,27). In low-risk cases the OR for overall mortality was 1.03 (0.89, 1.19) overall morbidity 1.35 (1.23, 1.48), and major morbidity 2.18(1.90, 2.50). CONCLUSIONS Using a Nationally representative clinical database we identified significant heterogeneity in the outcomes of EGS depending on procedural risk. Risk stratification and benchmarking strategies need to account for the inherent heterogeneity of EGS.

Prevention and Management of Complications of Pancreatic Surgery

Abstract Mortality after pancreatic resection has greatly decreased in comparison with historical series, from 33% following Whipples initial reports to currently less than 2% in most high-volume centers, resulting in the recognition that assessment of surgical quality for these high-acuity patients warrants further refinement. The impact of hospital volume on actual operative mortality is significant for pancreatic cancer resections, but these two measures accounted for only half of the hospital-level variation in mortality. The three most common complications after pancreatectomy are delayed gastric emptying, wound infection, and pancreatic fistula. This chapter will also discuss postpancreatectomy hemorrhage. Initial efforts to better understand perioperative mortality after pancreatic resection demonstrated the impact of hospital volume on outcome and an ongoing survival benefit (6% at 2 years) for patients undergoing pancreatic cancer resection at a high-volume institution. However, great effort has since been expended to better define, describe, and categorize postpancreatectomy complications, as well as to understand risk factors for the complications and management strategies. This chapter will focus on technical and clinical means of preventing and managing pancreatic surgical complications, but the import of surgeon and hospital volume, as well as experience, on complications and overall outcome after pancreatic resection should not be lost on the reader.

Failure to rescue and disparities in emergency general surgery

BACKGROUND Racial and socioeconomic disparities are well documented in emergency general surgery (EGS) and have been highlighted as a national priority for surgical research. The aim of this study was to identify whether disparities in the EGS setting are more likely to be caused by major adverse events (MAEs) (e.g., venous thromboembolism) or failure to respond appropriately to such events. METHODS A retrospective cohort study was undertaken using administrative data. EGS cases were defined using International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes recommended by the American Association for the Surgery of Trauma. The data source was the National Inpatient Sample 2012-2013, which captured a 20%-stratified sample of discharges from all hospitals participating in the Healthcare Cost and Utilization Project. The outcomes were MAEs, in-hospital mortality, and failure to rescue (FTR). RESULTS There were 1,345,199 individual patient records available within the National Inpatient Sample. There were 201,574 admissions (15.0%) complicated by an MAE, and 12,006 of these (6.0%) resulted in death. The FTR rate was therefore 6.0%. Uninsured patients had significantly higher odds of MAEs (adjusted odds ratio, 1.16; 95% confidence interval, 1.13-1.19), mortality (1.28, 1.16-1.41), and FTR (1.20, 1.06-1.36) than those with private insurance. Although black patients had significantly higher odds of MAEs (adjusted odds ratio, 1.14; 95% confidence interval, 1.13-1.16), they had lower mortality (0.95, 0.90-0.99) and FTR (0.86, 0.80-0.91) than white patients. CONCLUSIONS Uninsured EGS patients are at increased risk of MAEs but also the failure of health care providers to respond effectively when such events occur. This suggests that MAEs and FTR are both potential targets for mitigating socioeconomic disparities in the setting of EGS.

An evidence-based intraoperative communication tool for emergency general surgery: a pilot study

BACKGROUND Emergency general surgery (EGS) is characterized by high rates of morbidity and mortality. Though checklists and associated communication-based huddle strategies have improved outcomes, these tools have never been specifically examined in EGS. We hypothesized that use of an evidence-based communication tool aimed to trigger intraoperative discussion could improve communication in the EGS operating room (OR). MATERIALS AND METHODS We designed a set of discussion prompts based on modifiable factors identified from previously published studies aimed to encourage all team members to speak up and to centralize awareness of patient disposition and intraoperative transfusion practices. This tool was pilot-tested using OR human patient simulators and was then rolled out to EGS ORs at an academic medical center. The perceived effect of our tools implementation was evaluated through mixed-methodologic presurvey and postsurvey analysis. RESULTS Preimplementation and postimplementation survey-based data revealed that providers reported the EGS-focused discussion prompts as improving team communication in EGS. A trend toward shared awareness of intraoperative events was observed; however, nurses described cultural impedance of discussion initiation. Providers described a need for further reinforcement of the tool and its indications during implementation. CONCLUSIONS Use of a discussion-based communication tool is perceived as supporting team communication in the EGS OR and led to a trend toward improving a shared understanding of intraoperative events. Analyses suggest the need for enhanced reinforcement of use during implementation and improvement of team-based education regarding EGS. Furthermore work is needed to understand the full impact of this evidence-based tool on OR team dynamics and EGS patient outcomes.

Using Individual Clinical Evaluations to Assess Residents’ Clinical Judgment; Feasibility and Residents’ Perception

OBJECTIVE In surgical training, most assessment tools focus on advanced clinical decision-making or operative skill. Available tools often require significant investment of resources and time. A high stakes oral examination is also required to become board-certified in surgery. We developed Individual Clinical Evaluation (ICE) to evaluate intern-level clinical decision-making in a time- and cost-efficient manner, and to introduce the face-to-face evaluation setting. DESIGN Intern-level ICE consists of 3 clinical scenarios commonly encountered by surgical trainees. Each scenario was developed to be presented in a step-by-step manner to an intern by an attending physician or chief resident. The interns had 17 minutes to complete the face-to-face evaluation and 3 minutes to receive feedback on their performance. The feedback was transcribed and sent to the interns along with incorrect answers. Eighty percent correct was set as a minimum to pass each scenario and continue with the next one. Interns who failed were retested until they passed. Frequency of incorrect response was tracked by question/content area. After passing the 3 scenarios, interns completed a survey about their experience with ICE. SETTING Beth Israel Deaconess Medical Center, an academic tertiary care facility located in Boston, Massachusetts. PARTICIPANTS All first-year surgery residents in our institution (n = 17) were invited to complete a survey. RESULTS All 2016-2017 surgical interns (17) completed the ICEs. A total of

Factors Associated With Residency and Career Dissatisfaction in Childbearing Surgical Residents

171 (US) was spent conducting the ICEs, and an average of 17 minutes was used to complete each evaluation. In total, 5 different residents failed 1 scenario, with the most common mistake being: failing to stabilize respiration before starting management. After completing the 3 clinical scenarios, more than 90% of respondents agreed or strongly agreed that the evaluations were appropriately challenging for training level, and that the evaluations helped to identify personal strengths and weaknesses in skill and knowledge. The majority believed their knowledge improved as a result of the ICE and felt better prepared to manage these scenarios (88% and 76%, respectively). CONCLUSIONS The ICE is an inexpensive and time efficient way to introduce interns to board type examinations and assess their preparedness for perioperative patient care issues. Common errors were identified which were able to inform educational efforts. ICEs were well accepted by residents. Next steps include extension of the ICE to PGY2 and PGY3 residents.