Michael J. Cahalane

Whither biliary sludge

A mong the growing list of pathogenic events implicated in the formation of human gallstones, gelation of gallbladder mucin with entrapment of “particulate matter” nucleated from bile, also known as biliary sludge, is unquestionably assuming a pivotal role (1,2). The peculiar phrase “biliary sludge” is, of course, jargon. In classic American fashion, the notion is borrowed from sanitary engineering (“sludge thickening tanks”) and, presumably because of its graphic pungency, seems to have become firmly entrenched in both radiologic and surgical nomenclature. Our intent is not to proscribe this appellation, but rather to anoint it. What follows is an attempt to place this common form of biliary tract dysfunction in pathophysiologic context. We will probe the metabolic and physicalchemical origins of biliary sludge, explore how Lee and colleagues, in a recent issue of this journal (3), have furthered our knowledge of its origins and fate, and attempt to provide a unifying hypothesis for further investigation of biliary sludge in the pathogenesis and possible prevention of human gallstones. In our understanding of the evolution of macroscopic cholesterol gallstones, many pieces of the jigsaw puzzle have been fitted into place over the past 20 yr (4). Investigators from diverse disciplines now continue to focus upon the earliest identifiable evolutionary events, such as the metabolic origin (57) and physical-chemical nature (8) of cholesterolsupersaturated bile, gallbladder mucin accumulation and gelation (g-12), biliary nucleation (13,14) and antinucleation factors (l5-l8), nucleation stages, physical chemistry and kinetics (19-21), and gallbladder dysmotility (11,22-29). But the picture is still incomplete; we have broad brush strokes of the secondary colors without a palette that displays the primary colors. Both in gallstone-prone American Indians in the United States and in western populations, gallstones are distinctly rare before the third decade of life (4) yet, during early adolescence, the lipid composition of bile changes from being unsaturated with cholesterol to being supersaturated with cholesterol (30,31). This alteration is most dramatic in women and correlates with enhanced urinary output of endogenous estrogens (3 1). Contrary to previously held beliefs (32) that this resulted generally from hyposecretion of bile salts beginning in adolescence, it is now becoming clear that hypersecretion of biliary cholesterol is the major cause of supersaturated bile in both obese and nonobese humans in the western hemisphere (5,33-35). The pathogenic wisdom of the 1970s was that deficient secretion of bile salts from a contracted bile salt pool was the causative cornerstone in the formation of lithogenic bile (reviewed in Reference 36). This belief now requires reexamination. Hyposecretion of bile salts into the upper small intestine in earlier secretion studies apparently resulted from suboptimal cholecystokinin release during formula perfusion of the duodenum, with diversion of hepatic bile into a partially relaxed gallbladder (37). Furthermore, the presence of gallstones per se in the gallbladder results in an apparent contraction of the bile salt pool when measured by isotope-labeled bile salt dilution kinetics (38). Nevertheless, adult American Indians in the United States may be a genetic and biologically distinct group in this regard. Pima Indians, in addition to being hypersecretors of cholesterol, exhibit true enterohepatic bile salt deficiency before the formation of cholesterol gallstones (39). Hypersecretion of biliary cholesterol is caused by many factors (5). These putatively include the following.

Screening inpatient quality using post-discharge events.

BACKGROUND Decreasing hospital lengths of stay (LOS) hamper efforts to detect and to definitively treat complications of care. Patients leave before some complications are identified. OBJECTIVES To develop a computerized method to screen for hospital complications using readily available administrative data from outpatient and nonacute care within 90 days of discharge. DESIGN We developed the Complications Screening Program for Outpatient data (CSP-O) by using diagnosis and procedure codes from Medicare Part A and B claims to define 50 complication screens. Seventeen apply to specific procedural cases, and 33 apply to all adult, acute, medical, or surgical hospitalizations. The CSP-O algorithm examined outpatient, physician office, home health agency, and hospice claims within 90 days following discharge. SUBJECTS Seven hundred thirty nine thousand, two hundred and forty eight discharges of Medicare beneficiaries (age range, > or = 65 years) were admitted to 515 hospitals nationwide in 1994. RESULTS Complete 90-day, post-discharge windows were present for 62.8% of all and 68.5% of procedural cases. The 33 general screens flagged 13.6% of all cases; only 1.8% of procedural cases were flagged by the 17 procedural screens. When we allowed the CSP-O algorithm to scan information from acute hospital readmissions, flag rates rose to 32.8% for general and 8.7% for procedural complications. Controlling for patient and hospital characteristics, flag rates were considerably higher among the very old and at small and for-profit institutions. CONCLUSIONS Whereas several CSP-O findings have construct validity, limitations of claims raise concerns. Regardless of the CSPOs ultimate utility, examining post-discharge experiences to identify inpatient complications remains important as LOSs fall.

The Certifying Examination of the American Board of Surgery: The Effect of Improving Communication and Professional Competency: Twenty-Year Results

PURPOSE In 1985, a small research group identified variables affecting applicant success on the oral Certifying Examination (CE) of the American Board of Surgery (ABS). This led to the design of an oral examination course first taught in 1991. The success of and need for this program led to its continuation. The results from the first 10 years were presented at the 2001 Association of Program Directors in Surgery annual meeting.(1) We now report the outcomes for the course of the second 10 years as measured by success on the CE. METHODS Thirty-six courses were held over 20 years. There were 57 invited faculty from 27 general surgery programs throughout the United States and Canada. The participant-to-faculty ratio ranged from 16:7 to 5:1 in the newer 3-day format (2007). Courses were offered at sites that replicated the actual examination setting. Each course included (1) pretest and posttest examinations, (2) analysis of case presentation skills, (3) measurement of communication apprehension, (4) 1:1 faculty feedback, (5) small-group practice sessions, (6) individual videotaping, (7) didactic review of specific behaviors on examinations, (8) a debrief session with two faculty members, and (9) a written evaluative summary that included an improvement strategy. RESULTS There were 36 courses with 326 participants (30-54 years). Follow-up data are available for 225 participants. Trends were analyzed between 1991-2001 and 2002-2011. As resident performance on the CE increased in importance, applicant profiles changed from those who had previously failed (1991-2001) to residents identified by program directors as needing assistance (52%). Since 2002, most course participants (69%) who had failed the CE had completed at least 1 other review course. Participants reported more significant stressors (2002-2011) 9%, but communication apprehension remained the same. As a result, individual counseling for anger and family stressors was integrated into the course. The perception of knowledge deficits was associated with those who enrolled in fellowship training and delayed their examination. The recent groups exhibited more professionalism and articulation issues related to performance. Five surgeons (2002-2011) were asked not to return to the course because of severe knowledge deficiencies or ethical/behavioral issues based on faculty evaluations. Although complete follow-up of all participants was not possible (only 225/326), the success rate among those providing follow-up was 97% for those who followed their remediation plan, giving 218/326, a worse-case pass rate of 67%. CONCLUSION Communication and professionalism deficits are still common in those struggling with the CE, Early identification of those at risk of failing by program directors who are documenting the competencies may promote earlier interventions and thus lead to success. This program continues to be effective at identifying behaviors that interfere with success on the CE of the ABS.