Tracy J. Koehler

The drowning whipple: Perioperative fluid balance and outcomes following pancreaticoduodenectomy

Given the high incidence of postoperative morbidity following pancreaticoduodenectomy (PD), efforts at improving patient outcomes are vital. We sought to determine the impact of perioperative fluid balance on outcomes following PD in order to identify a targeted strategy for reducing morbidity.

Physician Retention in the Same State as Residency Training: Data From 1 Michigan GME Institution

BACKGROUND In a time of threats to the funding for graduate medical education (GME) and projected physician shortages, drawing attention to the value of physician training programs may be useful. One approach is to study the number and percentage of physicians who enter practice in the state in which they trained. OBJECTIVE We sought to examine the percentage of graduates from a single Michigan-based GME institution over a 15-year period, who practiced medicine in Michigan during their career. METHODS We performed a retrospective review of historical data for all graduates currently in practice, derived from 18 GME training programs from 2000 through 2014. Practice location data were collected and confirmed using multiple sources for accuracy. RESULTS Data were available for 1168 graduates. The average age at the time of graduation was 32.6 ± 4.4 years (mean and standard deviation [SD]), and 60.2% were men (703 of 1168). There were 546 graduates (46.7%) who practiced in Michigan after graduation. Almost 80% of the graduates (279 of 358) who completed medical school and GME in Michigan also practiced in Michigan. Of those, 87.8% (245 of 279) also completed a bachelors degree in Michigan. CONCLUSIONS The findings show that graduates from our GME programs were highly likely to practice in Michigan if they completed their pre-GME education in Michigan.

Comparison of the expectations of caregivers and children with type 1 diabetes mellitus for independence in diabetes care-related tasks.

OBJECTIVE Children who are given unsupervised responsibility for their diabetes care prior to developmental and/or emotional readiness may have poorer glycemic control. The purpose of this study was to assess the age-related expectations of children and caregivers for independence in diabetes care-related tasks. METHODS A total of 150 participants with type 1 diabetes mellitus (T1DM) receiving multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII) were enrolled in this study. All caregivers and participants older than 10 years of age completed questionnaires evaluating the expected age of independence for different diabetes care-related tasks. RESULTS The participants expected independence with no direct supervision in most diabetes care-related tasks at a younger age than their caregivers (P<.05). The difference was more prominent for those on CSII compared to MDI (P<.01). There was a positive correlation between the age when caregivers expect independence for most of the diabetes-related tasks and the age at diagnosis, regardless of the use of MDI or CSII (P<.01). CONCLUSION Children with T1DM expect to assume independence at a younger age than their caregivers do. The younger the children are at diagnosis, the younger they are expected by their caregivers to be independent, especially those on CSII.

Predicting In-State Workforce Retention After Graduate Medical Education Training

BACKGROUND There is a paucity of literature when it comes to identifying predictors of in-state retention of graduate medical education (GME) graduates, such as the demographic and educational characteristics of these physicians. OBJECTIVE The purpose was to use demographic and educational predictors to identify graduates from a single Michigan GME sponsoring institution, who are also likely to practice medicine in Michigan post-GME training. METHODS We included all residents and fellows who graduated between 2000 and 2014 from 1 of 18 GME programs at a Michigan-based sponsoring institution. Predictor variables identified by logistic regression with cross-validation were used to create a scoring tool to determine the likelihood of a GME graduate to practice medicine in the same state post-GME training. RESULTS A 6-variable model, which included 714 observations, was identified. The predictor variables were birth state, program type (primary care versus non-primary care), undergraduate degree location, medical school location, state in which GME training was completed, and marital status. The positive likelihood ratio (+LR) for the scoring tool was 5.31, while the negative likelihood ratio (-LR) was 0.46, with an accuracy of 74%. CONCLUSIONS The +LR indicates that the scoring tool was useful in predicting whether graduates who trained in a Michigan-based GME sponsoring institution were likely to practice medicine in Michigan following training. Other institutions could use these techniques to identify key information that could help pinpoint matriculating residents/fellows likely to practice medicine within the state in which they completed their training.

Adrenocortical oncocytic neoplasm: A systematic review

Background: Adrenocortical oncocytic neoplasms are rare tumors, generally regarded as benign and hormonally nonfunctional. We performed a systematic review to update the literature on adrenocortical oncocytic neoplasms by reviewing patient and tumor characteristics, as well as management trends, because the literature is composed of predominately single‐case reports. Methods: A systematic search was performed in PubMed, Embase, and Cochrane Library through June 2017. Malignant potential was determined by applying the Lin‐Weiss‐Bisceglia criteria to cases. Results: Included for analysis were 84 citations describing 140 adrenocortical oncocytic neoplasms, including our own case. These were diagnosed predominantly in females (66%), on the left side (64%), and were nonfunctional (66%). Average age at diagnosis was 44 years (2.5–77), and median tumor size was 80 mm (16–285). A total of 35% of adrenocortical oncocytic neoplasms were benign, 41% borderline, and 24% malignant. Male patients were more likely to have a malignant tumor compared with females (36% versus 18%, P = .035). The 5‐year overall survival for benign adrenocortical oncocytic neoplasms was 100%, borderline 88%, and malignant 47%. Hormonal function did not discriminate malignant from benign lesions. Adrenocortical oncocytic neoplasms that stained positive for synaptophysin (50%, P < .001) and negative for vimentin (62%, P = .009) are more often benign. Conclusion: We found that the majority of adrenocortical oncocytic neoplasms (65%) were either malignant or had malignant potential, contrary to the previous literature. The Lin‐Weiss‐Bisceglia criteria are useful in identifying those patients for whom closer surveillance is warranted, because their prognosis is dependent on the Lin‐Weiss‐Bisceglia diagnosis.

The danger zone: Injuries and conditions associated with immediately fatal motorcycle crashes in the state of Michigan

BACKGROUND Immediately fatal motorcycle crashes have not been well characterized. This study catalogues injuries sustained in fatal motorcycle crashes and assesses the impact of crash conditions on injury patterns. METHODS Autopsy records from the office of the medical examiner of Kent County, MI and publicly available traffic reports were queried for information pertaining to motorcyclists declared dead on-scene between January 1, 2007, and December 31, 2016. RESULTS A total of 71 autopsies of on-scene motorcycle crash fatalities were identified. The two most prevalent injuries were traumatic brain injury (TBI) (85%) and rib fractures (79%). The majority of fatalities occurred in daylight hours (54.3%) and in a 55 mph speed limit zone (63.8%). CONCLUSIONS This study provides a catalogue of the injuries sustained in immediately fatal motorcycle crashes and the associated conditions. Advocacy efforts that highlight the risks associated with motorcycle riding and that promote safe riding practices are warranted.

Continuous hemoglobin monitoring in pediatric trauma patients with solid organ injury

BACKGROUND/PURPOSE Hemoglobin monitoring is required in pediatric trauma patients with solid organ injury. We hypothesized that noninvasive hemodynamic monitoring (NIHM) represents an effective, safe alternative to laboratory hemoglobin (LabHb) monitoring in clinically stable patients. METHODS A retrospective cohort study was conducted regarding pediatric trauma patients (<18 years old) with blunt solid organ injury over six consecutive months. Continuous NIHM was initiated at the time of admission, and LabHb measurements were obtained per institutional guidelines. Measurements were correlated within two hours of assessment and patient outcomes were analyzed. RESULTS Twenty-one patients met inclusion criteria and had evaluable data. Blunt trauma was the exclusive mechanism of injury, and mean injury severity score was 16.6 for the cohort. Bland Altman analysis showed an average deviation of 0.80 g/dL between NIHM and LabHb values for all data pairs. Measurement trends were highly correlated in patients with stable hemoglobin levels and those requiring blood transfusion. CONCLUSIONS NIHM demonstrated clinically acceptable accuracy when following hemoglobin trends in the defined pediatric trauma patient population. Slight variances between NIHM and LabHb values were occasionally noted, but did not affect clinical management. Continuous NIHM represents a potentially valuable adjunct to traditional laboratory hemoglobin monitoring. LEVEL OF EVIDENCE RATING IV.

Differences in parental involvement in the care of children and adolescents with type 1 diabetes mellitus on multiple daily insulin injections versus continuous subcutaneous insulin infusion

Abstract Background: Assessing the degree of involvement of caregivers for children with type 1 diabetes mellitus (T1DM) in their diabetes care, differences in the degree of involvement based on the method of insulin administration (multiple daily injections: MDI/continuous subcutaneous insulin infusion: CSII), and its effect on glycemic control. Methods: This was a cross-sectional study with T1DM patients, ages 6–13 years using a six question survey derived from the Diabetes Family Responsibility Questionnaire (DFRQ). All caregivers (n=140) and participants between ages 11 and 13 (n=60) completed the survey. Results: Significant differences between MDI and CSII caregiver responses were found for responsibility for giving insulin boluses, as well as for rotation of infusion/injection sites (p<0.001 and p=0.03, respectively). A sub-analysis of caregiver responses for caregiver versus child responsibility for giving infusion boluses (excluding shared responsibility) showed that 36% of children in the CSII group had primary responsibility for giving insulin boluses, compared to 17% in the MDI group (p<0.001). The median agreement for all questions combined between participants and caregivers for ages 11–13 (n=60 pairs) was “poor” (κ=0.18). No significant effect of parental involvement on last 2-year average HbA1C was found for CSII or MDI groups (p>0.20). Conclusions: Caregiver reported diabetes care responsibility (mostly parent, mostly child, shared between parent and child) varies for certain aspects of diabetes related care for children ages 6–13, depending upon the mode of insulin administration. Based on the reported degree of parental collaboration, HbA1C did not differ significantly. However, long-term effects are yet to be determined in longitudinal studies.

A matched cohort study of laparoscopic biliopancreatic diversion with duodenal switch and sleeve gastrectomy performed by one surgeon

SETTING Spectrum Blodgett and Mercy Health St. Marys hospitals in Grand Rapids, Michigan OBJECTIVE: To compare the 30-day outcomes of laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) to laparoscopic sleeve gastrectomy (SG). BACKGROUND Laparoscopic BPD/DS has been shown to be superior to SG in terms of excess weight loss. Despite this superiority, BPD/DS accounts for a small percentage of all metabolic surgeries due partly to the perception that BPD/DS has a higher complication rate than SG. METHODS Retrospective review of all patients who underwent BPD/DS or SG from January 2008 to August 2014 by 1 surgeon was completed. These patients were used to construct cohorts matched via propensity score matching and compared by surgical type. Data collected included patient demographic characteristics; hospital length of stay (LOS); and 30-day rates of leak, bleed, reoperation, readmission, and mortality. RESULTS Of the 741 patients who underwent BPD/DS or SG, 2 cohorts of 167 patients each were matched for age, sex, and BMI. LOS was longer in the BPD/DS cohort (2.5±.9 days versus 2.1±.7 days, P<.001). There were no significant differences between the groups in relation to 30-day postoperative rates of leak (.3% versus .6%, P>.99), bleed (0% versus .3%, P>.99), reoperation (1.2% versus .6%, P>.99), or readmission (3% versus 1.2%, P = .45). There were no mortalities. CONCLUSION After matching for age, sex, and BMI, BPD/DS found no significant differences from SG with regard to 30-day postoperative rates of leak, bleed, reoperation, readmission, or mortality.