Marie A. Hunsinger

Same-day combined endoscopic retrograde cholangiopancreatography and cholecystectomy: Achievable and minimizes costs.

BACKGROUND It is estimated that choledocholithiasis is present in 5% to 20% of patients at the time of laparoscopic cholecystectomy (LC). Several European studies have found decreased length of stay (LOS) when performing LC and intraoperative endoscopic retrograde cholangiopancreatography (ERCP) on the same day for choledocholithiasis. In the United States, common bile duct stones are usually managed preoperatively and typically on a day separate from the day LC was performed. Our aim was to evaluate LOS and total hospital cost for separate-day versus same-day ERCP/cholecystectomy. METHODS This was a retrospective study of patients undergoing ERCP and cholecystectomy during the same admission for the management of choledocholithiasis from 2010 to 2014 at Geisinger Medical Center. The separate-day group underwent ERCP at least 1 day before cholecystectomy and often underwent two separate anesthesia events, while the same-day group had ERCP and cholecystectomy performed on the same day under one general anesthesia event. The primary outcome measured was LOS. RESULTS The study population included 240 patients. There were 175 patients in the separate-day group and 65 patients in the same-day group. Median age was similar between the two groups. The separate-day group had a median of one minor comorbidity compared with zero within the same-day group using the Charlson Comorbidity Index. Overall, LOS for the separate-day group was 5 days compared with 3 days in the same-day group (p < 0.0001). There was no difference in conversion rates to open cholecystectomy between the two groups (14% in the separate-day vs. 12% in the same-day group). Total median hospital cost for the separate-day group was

Severe complicated Clostridium difficile infection: Can the UPMC proposed scoring system predict the need for surgery?

102,537 compared with

Utility of Prophylactic Antibiotics in Nonoperative Facial Fractures.

90,269 in the same-day group (p < 0.0001). CONCLUSION Same-day ERCP and cholecystectomy is feasible and minimizes costs. Same-day procedures decreased hospital LOS by 2 days and had approximately

The Predictive Value of Application Variables on the Global Rating of Applicants to a General Surgery Residency Program

12,000 in cost savings. Future goals include a multidisciplinary protocol to study outcomes in larger numbers. LEVEL OF EVIDENCE Therapeutic study, level IV. Economic study, level III.

Characterizing the Relationship Between Surgical Resident and Faculty Perceptions of Autonomy in the Operating Room

INTRODUCTION Clostridium difficile infection (CDI) is one of the most common health care–associated infections, and it continues to have significant morbidity and mortality. The onset of fulminant colitis often requires total abdominal colectomy with ileostomy, which has a mortality rate of 35% to 57%. University of Pittsburgh Medical Center (UPMC) developed a scoring system for severity and recommended surgical consultation for severe complicated disease. The aim of this study was to evaluate if the UPMC-proposed scoring system for severe complicated CDI can predict the need for surgical intervention. METHODS This is a retrospective review of all patients who developed severe complicated CDI at Geisinger Medical Center between January 2007 and December 2012 as defined by the UPMC scoring system. Main outcomes were the need for surgical intervention and 30-day mortality. RESULTS Eighty-eight patients had severe complicated CDI based on the UPMC scoring system. Fifty-nine patients (67%) required surgery and 29 did not. All patients had a diagnosis of CDI as shown by positive toxin assays. There was no difference between the groups with respect to age, sex, body mass index, or comorbidities. When comparing the surgical group to the nonsurgical cohort, the surgical cohort averaged 20 points on the scoring system compared to 9 in the nonoperative cohort. In patients with severe complicated CDI, 15 or more points predicted the need for surgery 75% of the time. Forty-two percent of the surgical cohort had respiratory failure requiring mechanical ventilation compared to 0% in the nonsurgical cohort (p < 0.0001). Forty-nine percent of the surgical cohort required vasopressors for septic shock before surgery compared to 0% in the nonsurgical cohort (p < 0.0001). Acute kidney injury was present in 92% of the surgical cohort versus 72% within the nonsurgical cohort (p = 0.026). Seventy-six percent of the surgical patients were admitted to the ICU before surgery. Within the nonsurgical cohort, only 24% of patients required ICU stay during admission. Overall, 30-day mortality in the surgical cohort was 30%, and there was no mortality in the nonsurgical cohort. CONCLUSIONS The UPMC scoring system for severe complicated CDI can help us predict patients who need a surgical consult and the need for surgical intervention. In patients with severe complicated CDI, evidence of end-organ failure predicts surgical intervention. LEVEL OF EVIDENCE Prognostic study, level III; therapeutic study, level IV.

Ten Year Projections for US Residency Positions: Will There be Enough Positions to Accommodate the Growing Number of U.S. Medical School Graduates?

AbstractFacial fractures are commonly managed nonoperatively. Patients with facial fractures involving sinus cavities commonly receive 7 to 10 days of prophylactic antibiotics, yet no literature exists to support or refute this practice. The aim of this study was to compare the administration and duration of antibiotic prophylaxis on the incidence of soft tissue infection in nonoperative facial fractures. A total number of 289 patients who were admitted to our level I trauma center with nonoperative facial fractures from the beginning of 2012 to the end of 2014 were studied. Patients were categorized into 3 groups: no antibiotic prophylaxis, short-term antibiotic prophylaxis (1–5 days), and long-term antibiotic prophylaxis (>5 days). The primary outcome was the incidence of facial soft tissue infection and Clostridium difficile colitis. Fifty patients received no antibiotic prophylaxis. Sixty-three patients completed a short course of antibiotic prophylaxis and 176 patients received long-term antibiotics. Ampicillin/sulbactam, amoxicillin/clavulanic acid, or a combination of both were used in 216 patients. Twenty-three patients received clindamycin due to penicillin allergy. Short and long courses of antibiotic prophylaxis were administered more commonly in patients with concomitant maxillary and orbital fractures (P <0.0001). No mortality was found in any group. Soft tissue infection was not identified in any patient. C. difficile colitis was identified in 1 patient who had received a long course of antibiotic prophylaxis (P = 0.7246). There was no difference in the outcome of patients receiving short-term, long-term, and no antibiotic prophylaxis. Prospective randomized studies are needed to provide further clinical recommendations.

Learning preferences of surgery residents: A multi-institutional study

OBJECTIVE Selection of applicants to residency programs can involve a great deal of variability. The purpose of this study was to determine the relationship between different subjective and objective application variables and the global rating score (GRS) of applicants to a general surgery residency program. DESIGN This was a retrospective analysis of data collected from the Electronic Residency Application Service on 188 applicants to a general surgery residency program from 2010 to 2013. Subjective variables including letters of recommendation (LORs), personal statements (PSs), and volunteer work were blindly assessed by raters using a literature-based method of evaluation. Objective data included several variables, such as United States Medical Licensing Examination (USMLE) scores. Each applicant received a GRS, which was a faculty-given numerical value reflecting both interview performance and overall application strength. The effect of subjective and objective variables on the GRS was determined. SETTING The Geisinger Medical Center, a rural moderate-sized general surgery residency program. RESULTS Of all the application variables examined, bivariate analysis indicated that having no prior residency (p = 0.0023), prior medical work (p = 0.0329), higher USMLE Step II Clinical Knowledge scores (p = 0.0021), higher overall PS score (p = 0.0125) and PS Written Expression score (p = 0.0007), and LORs from surgeons in leadership positions (p = 0.0029) have a significant (p < 0.05) effect on the GRS. Of these factors, USMLE Step II Clinical Knowledge score, PS Written Expression score, no prior residency, prior medical work, and LORs from surgeon in lead position had a significant effect on GRS based on multivariate stepwise regression analysis. CONCLUSIONS Our analysis identifies specific surgical resident applicant variables that are predictive of the GRS. Interestingly, most of these factors were objective. This may allow for the development of a more quantitative tool for selection of applicants.

Laparoscopic versus robotic adrenalectomy: a review of the national inpatient sample

OBJECTIVE Characterize the concordance among faculty and resident perceptions of surgical case complexity, resident technical performance, and autonomy in a diverse sample of general surgery procedures using case-specific evaluations. DESIGN A prospective study was conducted in which a faculty surgeon and surgical resident independently completed a postoperative assessment examining case complexity, resident operative performance (Milestone assessment) and autonomy (Zwisch model). Pearson correlation coefficients (r) reaching statistical significance (p < 0.05) were further classified as moderate (r ≥ 0.40), strong (r ≥ 0.60), or very strong (r ≥ 0.80). SETTING This study was conducted in the General Surgery Residency Program at an academic tertiary care facility (Geisinger Medical Center, Danville, PA). PARTICIPANTS Participants included 6 faculty surgeons, in addition to 5 postgraduate year (PGY) 1, 6 midlevel (PGY 2-3), and 4 chief (PGY 4-5) residents. RESULTS In total, 75 surgical cases were analyzed. Midlevel residents accounted for the highest number of cases (35, 46.6%). Overall, faculty and resident perceptions of case complexity demonstrated a strong correlation (r = 0.76, p < 0.0001). Technical performance scores were also strongly correlated (r = 0.66, p < 0.0001), whereas perceptions of autonomy demonstrated a moderate correlation (r = 0.56, p < 0.0001). Subgroup analysis revealed very strong correlations among faculty perceptions of case complexity and the perceptions of PGY 1 (r = 0.80, p < 0.0001) and chief residents (r = 0.82, p < 0.0001). All other intergroup correlations were strong with 2 notable exceptions as follows: midlevel and chief residents failed to correlate with faculty perceptions of autonomy and operative performance, respectively. CONCLUSIONS General surgery residents generally demonstrated high correlations with faculty perceptions of case complexity, technical performance, and operative autonomy. This generalized accord supports the use of the Milestone and Zwisch assessments in residency programs. However, discordance among perceptions of midlevel resident autonomy and chief resident operative performance suggests that these trainees may need more direct communication from the faculty.

Analyzing the Impact of Compliance with National Guidelines for Pancreatic Cancer Care Using the National Cancer Database

OBJECTIVE Recently, a multitude of new U.S. medical schools have been established and existing medical schools have expanded their enrollments. The National Residency Match Program (NRMP) reports that in 2016 there were 23,339 categorical residency positions offered in the match and 26,836 overall applicants with 17,789 (66.29%) of the total candidates being U.S. allopathic graduates. In view of the rapid growth of medical school graduates, the aim of this study is to determine if current trends suggest a shortage of residency positions within the next ten years. DESIGN The total number of graduates from U.S. medical schools was obtained from the Association of American Medical Colleges (AAMC) for 2005-2014 academic years and was trended linearly for a 10-year prediction for the number of graduates. The yearly number of categorical positions filled by U.S. graduates for calendar years 2006-2015 was obtained from the NRMP and was trended longitudinally 10 years into the future. Analysis of subspecialty data focused on the comparison of differences in growth rates and potential foreseeable deficits in available categorical positions in U.S. residency programs. RESULTS According to trended data from AAMC, the total number of graduates from U.S. medical schools has increased 1.52 percent annually (15,927 in 2005 to 18,705 in 2014); with a forecast of 22,280 U.S. medical school graduates in 2026. The growth rate of all categorical positions available in U.S. residency programs was 2.55 percent annually, predicting 29,880 positions available in 2026. In view of these results, an analysis of specific residencies was done to determine potential shortages in specific residencies. With 17.4 percent of all U.S. graduates matching into internal medicine and a 3.17 percent growth rate in residency positions, in 2026 the number of internal medicine residency positions will be 9,026 with 3,874 U.S. graduates predicted to match into these positions. In general surgery, residency positions note a growth rate of 1.55 percent. Of all U.S. graduates, 5.6 percent match into general surgery. Overall this projects 1,445 general surgery residency positions in 2026 with 1,257 U.S. graduates matching. In orthopedics with a growth rate of 1.35 percent and a match rate of 3.75 percent, there are projected to be 827 positions available with 836 U.S. graduates projected to match. CONCLUSIONS Despite the increasing number of medical school graduates, our model suggests the rate of growth of residency positions continues to be higher than the rate of growth of U.S. medical school graduates. While there is no apparent shortage of categorical positions overall, highly competitive subspecialties like orthopedics may develop a shortage within the next ten years.

External Validation of a Survival Nomogram for Non-Small Cell Lung Cancer Using the National Cancer Database

Background. The VARK model categorizes learners by preferences for 4 modalities: visual, aural, read/write, and kinesthetic. Previous single‐institution studies found that VARK preferences are associated with academic performance. This multi‐institutional study was conducted to test the hypothesis that the VARK learning preferences of residents differ from the general population and that they are associated with performance on the American Board of Surgery In‐Training Examination (ABSITE). Methods. The VARK inventory was administered to residents at 5 general surgery programs. The distribution of the VARK preferences of residents was compared with the general population. ABSITE results were analyzed for associations with VARK preferences. χ2, Analysis of variance, and multiple linear regression were used for statistical analysis. Results. A total of 132 residents completed the VARK inventory. The distribution of the VARK preferences of residents was different than the general population (P < .001). The number of aural responses on the VARK inventory was an independent predictor of ABSITE percentile rank (P = .03), percent of questions correct (P = .01), and standard score (P = .01). Conclusion. This study represents the first multi‐institutional study to examine VARK preferences among surgery residents. The distribution of preferences among residents was different than that of the general population. Residents with a greater number of aural responses on VARK had greater ABSITE scores. The VARK model may have potential to improve learning efficiency among residents.