Victor Zaydfudim

The impact of lymph node involvement on survival in patients with papillary and follicular thyroid carcinoma

BACKGROUND The prognostic role of lymph node metastases in well-differentiated thyroid carcinoma remains controversial. We investigated impact of lymph node involvement on survival in patients with well-differentiated thyroid cancer. METHODS We queried the Surveillance, Epidemiology, and End Results registry for patients diagnosed with well-differentiated thyroid carcinoma between 1988 and 2003. Cases were stratified by age (<45 vs >/=45 years) and pathology (papillary/follicular). Four separate Cox regression models were developed to test the effects of demographic and clinical covariates on survival. RESULTS We identified 33,088 patients. 30,504 patients (49% >/=45 years) had papillary carcinoma and 2,584 patients (55% >/=45 years) had follicular carcinoma. Age affected survival in all models (P < .001). In patients with papillary carcinoma <45 years, lymph node disease did not influence survival (P = .535), whereas in patients >/=45 years, lymph node involvement was associated with 46% increased risk of death (P < .001). In patients with follicular carcinoma, lymph node involvement conferred increased risk of death in both age groups (P </= .002). Effects of other covariates varied between models. CONCLUSION Cervical lymph node metastases conferred independent risk in all patients with follicular carcinoma and in those patients with papillary carcinoma aged >/=45 years, but did not affect survival in patients with papillary carcinoma <45 years.

Postoperative neuromuscular blocker use is associated with higher primary fascial closure rates after damage control laparotomy.

BACKGROUND Failure to achieve fascial primary closure after damage control laparotomy (DCL) is associated with increased morbidity, higher healthcare expenditures, and a reduction in quality of life. The use of neuromuscular blocking agents (NMBA) to facilitate closure remains controversial and poorly studied. The purpose of this study was to determine whether exposure to NMBA is associated a higher likelihood of primary fascial closure. METHODS All adult trauma patients admitted between January 2002 and May 2008 who (1) went directly to the operating room, (2) were managed initially by DCL, and (3) survived to undergo a second laparotomy. Study group (NMBA+): those receiving NMBA in the first 24 hours after DCL. Comparison group (NMBA-): those not receiving NMBA in the first 24 hours after DCL. Primary fascial closure defined as fascia-to-fascia approximation by hospital day 7. RESULTS One hundred ninety-one patients met inclusion (92 in NMBA+ group, 99 in NMBA- group). Although the NMB+ patients were younger (31 years vs. 37 years, p = 0.009), there were no other differences in demographics, severity of injury, or lengths of stay between the groups. However, NMBA+ patients achieved primary closure faster (5.1 days vs. 3.5 days, p = 0.046) and were more likely to achieve closure by day 7 (93% vs. 83%, p = 0.023). After controlling for age, gender, race, mechanism, and severity of injury, logistic regression identified NMBA use as an independent predictor of achieving primary fascial closure by day 7 (OR, 3.24, CI: 1.15-9.16; p = 0.026). CONCLUSIONS Early NMBA use is associated with faster and more frequent achievement of primary fascial closure in patients initially managed with DCL. Patients exposed to NMBA had a three times higher likelihood of achieving primary fascial closure by hospital day 7.

Reduction in Corticosteroids Is Associated with Better Health-Related Quality of Life after Liver Transplantation

BACKGROUND Corticosteroid use during post-transplant immunosuppression contributes to documented long-term complications in liver transplant recipients. However, the effects of steroids on post-transplant physical and mental health-related quality of life (HRQOL) have not been established. We aimed to test the association between steroid-based immunosuppression and post-transplant HRQOL in liver transplant recipients. STUDY DESIGN We performed a retrospective analysis of prospective, longitudinal HRQOL measured using the Short Form 36 Health Survey physical and mental component summary scores, Beck Anxiety Inventory, and Center for Epidemiologic Studies Depression Scale. Steroid use (none, low [<10 mg/d], high [≥10 mg/d]) and temporally associated acute rejection (within previous 6 weeks, previous 7 to 12 weeks, and never or >12 weeks before HRQOL measurement) were determined at every post-transplant HRQOL data point. Linear mixed-effects models tested the effects of contemporaneous steroid use and dosing on post-transplant HRQOL. RESULTS The sample included 186 adult liver transplant recipients (mean age 54 ± 8 years, 70% male) with pre- and at least 1 post-transplant HRQOL data point. Individual follow-up post-transplant averaged 21 ± 18 months (range 1 to 74 months). After controlling for pre-transplant HRQOL, time post-transplant, pre-transplant diagnosis group, and temporally associated episodes of rejection, post-transplant high-dose steroid use (≥10 mg/d) was associated with lower physical component summary (p < 0.001) and mental component summary (p = 0.049) scores and increased Beck Anxiety Inventory (p = 0.015) scores. Low-dose steroid use (<10 mg/d) was not associated with post-transplant HRQOL in any model (all p ≥ 0.28). CONCLUSIONS High-dose steroid use for post-transplant immunosuppression in liver transplant recipients was associated with reduced physical and mental HRQOL, and increased symptoms of anxiety. There was an association between better HRQOL and steroid reduction to <10 mg/d in liver transplant recipients during a broad follow-up period.

Exsanguination protocol improves survival after major hepatic trauma

BACKGROUND Hepatic injury remains an important cause of exsanguination after major trauma. Recent studies have noted a dramatic reduction in mortality amongst severely injured patients when trauma exsanguinations protocols (TEP) are employed. We hypothesised that utilisation of our institutions TEP at the initiation of hospital resuscitation would improve survival in patients with significant hepatic trauma. PATIENTS AND METHODS All patients who (1) sustained intra-abdominal haemorrhage with Grades III-V hepatic injury and (2) underwent immediate operative intervention between February 2004 and January 2008 were included in the study. TEP was instituted in February 2006, and all subsequent patients who met inclusion criteria and were treated with TEP constituted the study group. Patients who met inclusion criteria, were treated before introduction of TEP, and received at least 10 units packed red blood cells in the first 24h constituted pre-TEP comparison group. Univariate and multivariate analyses evaluated the effects of TEP on the study population. RESULTS Seventy-five patients were included in the study: 39 in the pre-TEP cohort (31% 30-day survival) and 36 in the TEP cohort (53% 30-day survival). There were no differences in demographics, extent of hepatic injury, or operative approach between the patient groups (all p > or = 0.27). Injury Severity Scores were significantly higher in the TEP group (41+/-18 vs. 28+/-15, p<0.01). TEP patients received more plasma and platelets during operative intervention and significantly less crystalloid (all p<0.01). Occurrence of cardiac dysfunction and abdominal compartment syndrome was significantly lower in TEP patients who survived 24-h post-injury (both p < or = 0.04). After adjusting for the significant negative effects of Grade V injury and involvement of major hepatic vasculature (both p < or = 0.02), TEP significantly improved 30-day survival: OR=0.22, 95% CI: 0.06-0.81, p=0.02. CONCLUSIONS TEP allows for an effective use of plasma and platelets during intra-operative management of severe hepatic injury. Utilisation of TEP is associated with significant reductions of cardiac dysfunction and development of abdominal compartment syndrome, as well as, significant improvement in 30-day survival.

Pre-transplant overweight and obesity do not affect physical quality of life after kidney transplantation.

BACKGROUND Recent studies demonstrate that obesity does not affect survival after kidney transplantation. However, overweight and obesity impair health-related quality of life (HRQOL) in patients with chronic illnesses. We wished to examine the effects of pre-transplant overweight and obesity on post-transplant physical HRQOL in kidney transplant recipients. STUDY DESIGN Patient-reported HRQOL data were systematically collected in kidney transplant recipients receiving post-transplant follow-up at Vanderbilt Transplant Center. Patients who received kidney transplants between 1998 and 2008, had at least 1 post-transplant physical component summary (PCS) measurement, and did not receive other solid organ transplants were included in this retrospective cohort study. Pre-transplant body mass index was stratified as normal, overweight, obese class I, and obese class II/extremely obese. HRQOL was measured primarily with the PCS scale of the Medical Outcomes Study Short Form 36 Health Survey. Multivariate linear and logistic regression models were used to test the effects of body mass index and demographic and clinical covariates on post-transplant HRQOL. RESULTS The study cohort included 464 adults (mean body mass index 27.5 +/- 5.1; range 18.5 to 47.4). After controlling for gender (p = 0.148), pre-transplant dialysis (p = 0.003), previous kidney transplantation (p = 0.255), donor type (p = 0.455), steroid avoidance immunosuppression (p = 0.070), and follow-up time (p = 0.352), there was no effect of pre-transplant overweight or obesity on post-transplant PCS (all p > or = 0.112). Kidney transplant recipients who did not require dialysis pre-transplant and those who were managed with steroid avoidance after transplantation were more likely to achieve post-transplant PCS scores at or above the general population average (both p < or = 0.011). CONCLUSIONS Pre-transplant overweight and obesity do not affect physical quality of life after kidney transplantation.

The negative effect of pretransplant overweight and obesity on the rate of improvement in physical quality of life after liver transplantation.

BACKGROUND Recent studies suggest that obesity does not affect survival after liver transplantation. Overweight and obesity, however, impair health-related quality of life (HRQOL) in patients with chronic illnesses. We tested the effect of pretransplant body weight on HRQOL in liver transplant recipients. METHODS Prospective, longitudinal HRQOL data were collected using the SF-36 health survey. Pretransplant body weight was stratified based on body mass index (BMI), as follows: normal (18.5-24.9), overweight (25.0-29.9), and obese (> or =30.0). Linear mixed-effects models were used to test the effects pretransplant BMI category on the trajectory of HRQOL after liver transplantation. RESULTS The sample included 154 adults who underwent liver transplantation. Thirty-one percent had normal BMI, 41% were overweight, and 28% were obese pretransplant. The mean pretransplant physical HRQOL did not differ by BMI group (P > or = .697). Physical and mental HRQOL improved (P < .001) in all groups after transplantation, but the rate of improvement in physical HRQOL was significantly greater during the first year posttransplant in the normal BMI compared with the overweight and obese patients (P < or = .032). There was no effect of BMI on the rate of improvement in mental HRQOL. CONCLUSION Excess pretransplant body weight hinders the rate of improvement in physical quality of life during the first year after liver transplantation.

The impact of tumor extent (T stage) and lymph node involvement (N stage) on survival after surgical resection for gallbladder adenocarcinoma

INTRODUCTION Tumor extent (T stage) and lymph node involvement (N stage) have a known combined negative effect on survival in patients with gallbladder adenocarcinoma, but the independent effects of these factors have been less well described. We investigated whether T stage and N stage independently predict survival after surgery for gallbladder adenocarcinoma. METHODS We queried the Surveillance, Epidemiology and End Results database for patients treated with surgical resection for gallbladder adenocarcinoma between 1988 and 2004. Cases were stratified by disease severity based on tumor extent and nodal involvement. Kaplan-Meier and Cox regression methods were used to test the effect of disease severity and to develop multivariate models of the effects of demographic and clinical covariates on survival. Univariate and multivariate models were tested in the entire cohort and in a subsample with pathologically confirmed lymph node status. RESULTS Four thousand and forty-eight patients who survived the immediate perioperative period comprised the full cohort. The subsample with pathologically confirmed lymph node status included 1298 patients. Age, gender, radiation treatment, tumor grade, tumor extent and lymph node status had statistically significant independent effects on survival in both models (all p<0.03). After accounting for T by N stage interactions, both tumor extent (1.21 < or = HR < or = 3.81, all p < or = 0.005) and lymph node involvement (1.80 < or = HR < or = 2.84, p<0.001) had independent effects on survival. CONCLUSIONS Tumor extent and lymph node metastases are independent predictors of survival after surgical resection for gallbladder adenocarcinoma. Tumor penetration of the gallbladder wall and pathologically confirmed lymph node involvement each carry poor prognosis.

International medical graduates in general surgery: increasing needs, decreasing numbers.

BACKGROUND The current residency training system in the United States (US) has inherent dependence on the international medical graduate (IMG). This article discusses the physician workforce shortage, especially related to general surgery, and examines the distribution of IMGs in general surgery ranks. STUDY DESIGN We performed a cross-sectional study using the American Medical Association Masterfile database of physicians licensed to practice in at least 1 state and determined the number and location of general surgeons in practice. We then stratified the distribution of these practicing surgeons, both IMGs and non-IMGs, according to rural urban commuting areas into small rural, large rural, or urban areas. RESULTS There were 17,727 general surgeons. IMGs were older (52 +/- 8 years versus 47 +/- 8 years; p < 0.001), more likely to be male (93% versus 82%; p < 0.001), and more likely to be further out of training (46% versus 28% > or =20 years out of training; p < 0.001). There were 2,216 IMGs in urban cores, constituting 15% of general surgeons in these areas. Large rural areas contained 223 IMGs (12% of general surgeons in these cores) and small rural areas contained 163 IMG general surgeons (16% of total general surgeons in these cores). CONCLUSIONS General surgeons are in high demand, and until now have remained inherently dependent on IMGs to reinforce their ranks. Current numbers of IMGs in practice are declining. This decline, coupled with inadequate numbers of trainees in domestic general surgery programs, creates a crisis of urgency.

Don't forget the posters! Quality and content variables associated with accepted abstracts at a national trauma meeting.

BACKGROUND: As a primary venue for presenting research results, abstracts selected for presentation at national meetings should be of the highest scientific merit and research quality. It is uncertain to what degree this is achieved as the methodological quality of abstracts submitted to national surgical meetings has not been previously described. The objective of this study was to evaluate abstracts presented at a leading trauma meeting for methodological quality. METHODS: All abstracts accepted for the 2009 American Association for the Surgery of Trauma meeting were reviewed and scored for methodological quality based on 10 criteria (scores, 0–10; 10 being the highest). Criteria were based on nationally published methodology guidelines. Two independent reviewers who were blinded to institution, region, and author reviewed each abstract. RESULTS: A total of 187 abstracts were accepted for presentation (67 oral and 120 posters). The most frequent clinical topics were shock/transfusion (23%), abdomen (12%), and nervous system (11%). Shock/transfusion abstracts were more common in the oral presentations (31% vs. 19%; p = 0.06). Abstracts from the northeast and south regions were the most common in both oral (26% and 29%) and posters (25% and 24%). Basic science accounted for 12% of accepted studies, while 51% were clinical and 28% were health services/outcomes. Only 8% of abstracts presented randomized data and only 11% reported null findings. Overall abstract scores ranged from 3 to 10 (median, 7; mean, 7.4). Abstracts selected for poster presentation had an overall higher score than those selected for oral presentation (7.4 ± 1.7 vs. 6.8 ± 1.7; p = 0.02). CONCLUSION: Although oral presentations traditionally receive the most attention and interest, the methodological quality of abstracts accepted for poster presentation equals (and sometimes exceeds) that of oral abstracts. Attendees of these national meetings should reconsider their time spent in viewing and visiting these poster sessions as with the oral presentations. In light of our findings, we highly encourage that all members and guests attend the American Association for the Surgery of Trauma Poster Rounds at each years scientific assembly.

Hyperkalemia Following Massive Transfusion in Trauma

BACKGROUND Large-volume blood transfusions have been implicated in the development of hyperkalemia. The purpose of the current study was to determine whether critically injured patients receiving massive transfusions are at an increased risk of hyperkalemia. METHODS Massive transfusion (MT) cohort, all trauma patients (02/2004-01/2008) taken directly to the OR and receiving >or=10 units of RBC in first 24h. Comparison cohort (No-RBC), all patients (02/2004-01/2008) transported directly to the OR who received no blood products in the first 24h. Hyperkalemia defined as K+ > 5.5 mEq/L. RESULTS There were 266 MT patients, 237 No-RBC patients. MT patients were more likely to have hyperkalemia in the immediate postoperative setting (1.8% versus 4.6%, P = 0.049). However, linear regression did not identify intraoperative blood transfusions as a predictor of postoperative K+ values (P = 0.417). Logistic regression identified only preop K+ (OR 1.79, P = 0.021) and postop pH (OR 0.009, P = 0.001), but not MT, as independent risk factors for postop hyperkalemia. CONCLUSIONS Despite concerns of hyperkalemia following MT, we found less than a 5% incidence of postop K+ (>5.5 mEq/L). After adjusting for the significant effects of preop K+ and postop pH, MT patients were at no higher risk of hyperkalemia than those who received no blood products.