Sandra R. DiBrito

Engaging clinicians and patients to assess and improve frailty measurement in adults with end stage renal disease

BackgroundThe Fried frailty phenotype, a measure of physiologic reserve defined by 5 components (exhaustion, unintentional weight loss, low physical activity, slow walking speed, and poor grip strength), is associated with poor outcomes among ESRD patients. However, these 5 components may not fully capture physiologic reserve in this population. We aimed to ascertain opinions of ESRD clinicians and patients about the usefulness of thexa0Fried frailty phenotype and interventions to improve frailty in ESRD patients, and to identify novel components to further characterize frailty in ESRD.MethodsClinicians who treat adults with ESRD completed a 2-round Delphi study (nxa0=xa041 and nxa0=xa036, respectively; response ratexa0=xa087%). ESRD patients completed a survey at transplant evaluation (nxa0=xa0460; response ratexa0=xa081%). We compared clinician and patient opinions on the constituent components of frailty.ResultsClinicians were more likely than patients to say that ESRD makes patients frail (97.6% vs. 60.2%). There was consensus among clinicians that exhaustion, low physical activity, slow walking speed, and poor grip strength characterize frailty in ESRD patients; however, 29% of clinicians thought weight loss was not relevant. Patients were less likely than clinicians to say that the 5 Fried frailty components were relevant. Clinicians identified 10 new ESRD-specific potential components including falls (64%), physical decline (61%), and cognitive impairment (39%). Clinicians (83%) and patients (80%) agreed that intradialytic foot-peddlers might make ESRD patients less frail.ConclusionsThere was consensus among clinicians and moderate consensus among patients that frailty is more common in ESRD. Weight loss was not seen as relevant, but new components were identified. These findings are first steps in refining the frailty phenotype and identifying interventions to improve physiologic reserve specific to ESRD patients.

Kidney exchange match rates in a large multicenter clearinghouse

Kidney paired donation (KPD) can facilitate living donor transplantation for candidates with an incompatible donor, but requires waiting for a match while experiencing the morbidity of dialysis. The balance between waiting for KPD vs desensitization or deceased donor transplantation relies on the ability to estimate KPD wait times. We studied donor/candidate pairs in the National Kidney Registry (NKR), a large multicenter KPD clearinghouse, between October 2011 and September 2015 using a competing‐risk framework. Among 1894 candidates, 52% were male, median age was 50 years, 66% were white, 59% had blood type O, 42% had panel reactive antibody (PRA)>80, and 50% obtained KPD through NKR. Median times to KPD ranged from 2 months for candidates with ABO‐A and PRA 0, to over a year for candidates with ABO‐O or PRA 98+. Candidates with PRA 80‐97 and 98+ were 23% (95% confidence interval , 6%‐37%) and 83% (78%‐87%) less likely to be matched than PRA 0 candidates. ABO‐O candidates were 67% (61%‐73%) less likely to be matched than ABO‐A candidates. Candidates with ABO‐B or ABO‐O donors were 31% (10%‐56%) and 118% (82%‐162%) more likely to match than those with ABO‐A donors. Providers should counsel candidates about realistic, individualized expectations for KPD, especially in the context of their alternative treatment options.

Patterns of primary care utilization before and after living kidney donation

Annual visits with a primary care provider (PCP) are recommended for living kidney donors to monitor long‐term health postdonation, yet adherence to this recommendation is unknown.

Interacting with Residents

Interacting with residents can be a rewarding experience. Establishing mutual respect is the key to developing an excellent working relationship. Residents work hard to provide the best patient care possible while learning enough to become a successful attending in a very short time. Treating them with respect will help you develop the best working relationship possible, and behaving in a way that commands their respect will ultimately result in optimal care for your patients.

Using Audience Response Systems for Real-Time Learning Assessments During Surgical Morbidity and Mortality Conference

OBJECTIVEnMorbidity and mortality (M&M) conference is a mainstay of surgical education. However, its effectiveness is poorly described. The purpose of this study was to demonstrate the feasibility of a real-time audience response system for learner assessment during M&M.nnnDESIGNnWe integrated a web-based audience response system into weekly M&M conference. First, this platform collected qualitative responses about the role of M&M. Then, we used the platform to direct questions to attendees in real time. Questions focused on surgical risk estimation and classifying root causes. Responses were grouped by training and compared to a validated risk tools prediction. Root cause assignment concordance was statistically compared using Cohens kappa between the pluralities of faculty responses to that of trainees.nnnSETTINGnGeneral surgical residency program based at a tertiary academic medical center.nnnPARTICIPANTSnAffiliated categorical residents, preliminary residents, and clinical fellows.nnnRESULTSnWe enrolled 110 participants (38 faculty, 31 senior trainees, and 41 trainees). The majority of respondents (75.9%) cited education as the purpose of M&M, and all of respondents stated education as their personal motivation. Audience response questions were integrated into 34 unique case presentations. Mean absolute differences between predicted complication rates and attendees predictions were highest for faculty (-9.4%, pu202f=u202f0.009) and lowest for junior residents (-1.8%, pu202f=u202f0.385). When assigning root cause of each morbidity, concordance between faculty and trainees was low to moderate (Ku202f=u202f0.41).nnnCONCLUSIONSnAssessment of learning during M&M can be performed in real time with discrimination observed by learner experience level. These data support development of this response platform to trend learner performance over time and to monitor targeted educational interventions at future M&Ms.

Reliability of Glasgow Coma Score in pediatric trauma patients

BACKGROUNDnDiscordant assessments of Glasgow Coma Score (GCS) following trauma can result in inappropriate triage. This study sought to determine the reliability of prehospital GCS compared to emergency department (ED) GCS.nnnMETHODSnWe conducted a retrospective review of traumas from 01/2000 to 12/2015 at a Level-1 pediatric trauma center. We evaluated reliability between field and ED GCS using Pearsons correlation. We ascertained the difference between prehospital and ED GCS (delta-GCS). Associations between patient characteristics and delta-GCS were modeled using Poisson and linear regression, adjusting for demographic and clinical covariates.nnnRESULTSnWe identified 5306 patients. Pearsons correlation for GCS measurements was 0.57 for ages 0-3, and 0.67-0.77 for other age groups. Mean delta-GCS was highest for age<3years (0.95, SD=2.4). Poisson regression demonstrated that compared to children 0-3years, higher age was associated with lower delta-GCS (RR 0.65 95% CI 0.56-0.74). Linear regression showed that in those with a delta-GCS, more severe injury (higher ISS, worse ED disposition) and older age were associated with a negative change, signifying decline in score.nnnCONCLUSIONSnGCS is generally unreliable in pediatric trauma patients aged 0-3years, particularly the verbal score component. This may impact accuracy of triage priority for pediatric trauma patients.nnnLEVEL OF EVIDENCEnIII, Prognostic.

Outcomes Following Colorectal Resection in Kidney Transplant Recipients

BackgroundKidney transplant recipients (KTR) are at increased risk of requiring colorectal resection compared to the general population. Given the need for lifelong immunosuppression and the physiologic impact of years of renal replacement, we hypothesized that colorectal resection may be riskier for this unique population.MethodsWe investigated the differences in mortality, morbidity, length of stay (LOS), and cost between 2410 KTR and 1,433,437 non-KTR undergoing colorectal resection at both transplant and non-transplant centers using the National Inpatient Sample between 2000 and 2013, adjusting for patient and hospital level factors.ResultsIn hospital, mortality was higher for KTR in comparison to non-KTR (11.1 vs 4.3%, pu2009<u20090.001; adjusted odds ratio [aOR] 2.683.594.81) as were overall complications (38.5 vs 31.5%, pu2009=u20090.001; aOR 1.081.301.56). LOS was significantly longer (10 vs 7xa0days, pu2009<u20090.001; ratio 1.421.531.65) and cost was significantly greater (

Surgical approach, cost, and complications of appendectomy in kidney transplant recipients

23,056 vs

Temporal changes in the composition of a large multicenter kidney exchange clearinghouse: Do the hard-to-match accumulate?

14,139, pu2009<u20090.001; ratio 1.421.541.63) for KTR compared to non-KTR. While LOS was longer for KTR undergoing resection at transplant centers compared to non-transplant centers (aOR 1.68 vs 1.53, pu2009=u20090.03), there were no statistically significant differences in mortality, overall morbidity, or cost by center type.ConclusionsKTR have higher mortality, higher incidence of overall complications, longer LOS, and higher cost than non-KTR following colorectal resection, regardless of center type. Physicians should consider these elevated risks when planning for surgery in the KTR population and counsel patients accordingly.

Living donor postnephrectomy kidney function and recipient graft loss: A dose-response relationship

Kidney transplant recipients (KTRs) have greater morbidity and length of stay (LOS) following certain surgical procedures than non‐KTR. Given that appendectomy is one of the most common surgical procedures, we investigated differences in outcomes between 1336 KTR and 2 640 247 non‐KTR postappendectomy at transplant and nontransplant centers in the United States from 2000 to 2011, using NIS data and adjusting for patient‐level and hospital‐level factors. Postoperative complications were identified using ICD‐9 codes. Among KTR, there were no post‐appendectomy in‐hospital deaths, compared to a 0.2% in non‐KTR (P = .5). Overall complications were similar among KTR and non‐KTR (17.0% vs 11.6%; aOR:0.77 1.121.61). LOS and costs were greater for KTR compared to non‐KTR (LOS ratio 1.191.311.45; cost ratio 1.111.171.26). Only 44.8% of KTR had laparoscopic approach compared to 54.5% of non‐KTR, but had similar complication rates (10.6 vs 8.7%, P = .5). When treated at transplant centers, KTR had similar complications (aOR 0.440.791.43), but longer LOS (ratio 1.211.371.55) and greater hospital‐associated costs (ratio 1.191.291.41) than non‐KTR. Conversely, at nontransplant centers, KTR and non‐KTR had similar complications (aOR 0.751.232.0), LOS (ratio 0.840.961.09), and cost (ratio 0.931.011.10). Contrary to other procedures, KTR did not constitute a high‐risk group for patients undergoing appendectomy.