Recent Publications by CFE Educators

OBJECTIVES

To describe procedure-specific types, rates, and risk factors for postdischarge (PD) complications occurring within 30 days after 21 groups of inpatient general surgery procedures.

DESIGN

Retrospective cohort study.

SETTING

American College of Surgeons National Surgical Quality Improvement Program 2005 through 2010 Participant Use Data Files.

PATIENTS

A total of 551,510 adult patients who underwent one of 21 groups of general surgery procedures in the inpatient setting.

MAIN OUTCOME MEASURES

Postdischarge complications, reoperation, and mortality.

RESULTS

Of 551,510 patients (mean age, 54.6 years), 16.7% experienced a complication; 41.5% occurred PD. Of the PD complications, 75.0% occurred within 14 days PD. Proctectomy (14.5%), enteric fistula repair (12.6%), and pancreatic procedures (11.4%) had the highest PD complication rates. Breast, bariatric, and ventral hernia repair procedures had the highest proportions of complications that occurred PD (78.7%, 69.4%, and 62.0%, respectively). For all procedures, surgical site complications, infections, and thromboembolic events were the most common. Occurrence of an inpatient complication increased the likelihood of a PD complication (12.5% vs 6.2% without an inpatient complication; P .001). Compared with patients without a PD complication, those with a PD complication had higher rates of reoperation (4.6% vs 17.9%, respectively; P .001) and death (2.0% vs 6.9%, respectively; P .001) within 30 days after surgery; those whose PD complication was preceded by an inpatient complication had the highest rates of reoperation (33.7%) and death (24.7%) (all P .001). After adjustment, PD complications were associated with procedure type, American Society of Anesthesiologists class higher than 3, and steroid use.

CONCLUSIONS

The PD complication rates vary by procedure, are commonly surgical site related, and are associated with mortality. Fastidious, procedure-specific patient triage at discharge as well as expedited patient follow-up could improve PD outcomes.

HYPOTHESIS African American patients exhibit different intraoperative parathyroid hormone (IOPTH) profiles than non-African American patients. DESIGN Retrospective review. SETTING University medical center. PATIENTS Nine hundred ten patients who underwent parathyroidectomy for primary hyperparathyroidism between July 2005 and August 2010. INTERVENTIONS All patients underwent preoperative imaging with ultrasonography and sestamibi; operative exploration; and IOPTH measurement at 2 points preexcision and 5 and 10 minutes postexcision. MAIN OUTCOME MEASURES Preexcision and postexcision IOPTH measurements. RESULTS Of the 910 patients, 734 self-reported their race as white (81%); 91, Latino/other (10%); 56, Asian (6%); and 28, African American (3%). African American patients had significantly higher initial preexcision IOPTH levels compared with white patients (348 vs 202 pg/mL; P = .048) and significantly higher 5-minute postexcision IOPTH levels (151 vs 80 pg/mL; P = .01). The 10-minute postexcision IOPTH levels were similar between the 2 groups (52 vs 50 pg/mL). A similar percentage of white and African American patients had a 50% drop in IOPTH level at 10 minutes postexcision. No differences in IOPTH kinetics were observed in the other racial groups examined. CONCLUSIONS African American patients with primary hyperparathyroidism exhibit significantly higher preincision and 5-minute postexcision IOPTH values when compared with white patients. The 10-minute postexcision IOPTH values did not differ between races. The altered IOPTH kinetics identified in African American patients may reflect the severity of biochemical disease but may also be related to genetically predetermined differences in parathyroid hormone metabolism.

In 2011, an expert panel from the National Heart, Lung, and Blood Institute released recommendations for universal lipid screening and treatment of high cholesterol in children. There is no evidence that universal screening will help children lead longer, healthier lives. These recommendations will, however, fuel the epidemic of overtreatment that is currently threatening our healthcare system and our patients.

Gender-specific data focused on cardiovascular disease (CVD) are becoming increasingly available. This is of great importance, given that CVD has become the number 1 killer of women, and unlike for men, mortality rates do not seem to be declining. Many factors are cited as the causes of sex-based differences, including delays in recognizing symptoms, underutilization of diagnostic tests and treatments, as well as anatomic, physiological, and genetic factors. Evidence of fundamental biological differences in vascular function and the underlying pathologic processes is only beginning to elucidated, motivated by growing evidence of differences in clinical presentations and outcomes between men and women. The good news is that we are starting to see improvements in outcomes for women, such as after coronary revascularization; decrease in complication rates with the advent of new techniques, such as radial access for cardiac catheterizations; as well as increased participation of women in clinical trials. The underlying mechanisms of ischemic heart disease remain to be elucidated, and will help guide therapy and ultimately may explain the higher prevalence of : subendocardial myocardial infarctions, spontaneous arterial dissections, plaque erosion, increased vasospastic disorders, such as coronary microvascular disease, and pulmonary hypertension in women compared with men. We have made great progress in understanding gender-related differences in CVDs, but much remains to be done to optimize the prevention of CVD for both men and women.

BACKGROUND

Minimally invasive follicular thyroid cancer (MIFC) is an encapsulated follicular tumor of low malignant potential. To date, histological criteria are still under debate, and there are no population-level data regarding characteristics and outcomes of patients with MIFC.

METHODS

Patients diagnosed with MIFC in the Surveillance, Epidemiology, and End Results (SEER) database from 2000 to 2009 were included. Summary statistics were utilized to analyze patient characteristics; Kaplan-Meier analysis, and one-sample log-rank test were performed.

RESULTS

A total of 1,200 patients with MIFC and 4,208 with widely invasive follicular thyroid cancer (WIFC) were identified over 10 years of follow-up. MIFC was more common than WIFC in younger patients (mean age 49 vs. 52.3 years; p 0.001). More patients with MIFC were alive at the end of follow-up (96.8 vs. 86.5% WIFC; p 0.001). Patients diagnosed with MIFC were less likely than those with WIFC to have lymph nodes involved and distant metastases (0.9 vs. 3.6% and 0.5 vs. 8.9%, respectively; both p 0.001). Only 2 of 1,200 patients died of disease-specific causes; overall survival was comparable to the general US population (p = 0.16). Total thyroidectomy and RAI ablation were not associated with improvement in patient outcomes (p = 0.2 and 0.443, respectively).

CONCLUSIONS

MIFC is associated with survival comparable to that of the normative US general population. Thyroid lobectomy alone may be considered adequate treatment in these patients.

Endoscopic resection, including polypectomy, endoscopic mucosal resection, and endoscopic submucosal dissection, is the preferred treatment method of large colorectal polyps. Its safety and efficacy have been shown. Endoscopic removal techniques are important because they provide a resection specimen for precise histopathologic staging to further direct diagnosis, prognosis, and management decisions. Used according to its indications, it provides curative resection and obviates the higher morbidity, mortality, and cost associated with alternative surgical treatment.

The cellular response to DNA damage is mediated through multiple pathways that regulate and coordinate DNA repair, cell cycle arrest, and cell death. We show that the DNA damage response (DDR) induced by ionizing radiation (IR) is coordinated in breast cancer cells by selective mRNA translation mediated by high levels of translation initiation factor eIF4G1 (eukaryotic initiation factor 4γ1). Increased expression of eIF4G1, common in breast cancers, was found to selectively increase translation of mRNAs involved in cell survival and the DDR, preventing autophagy and apoptosis [Survivin, hypoxia inducible factor 1α (HIF1α), X-linked inhibitor of apoptosis (XIAP)], promoting cell cycle arrest [growth arrest and DNA damage protein 45a (GADD45a), protein 53 (p53), ATR-interacting protein (ATRIP), Check point kinase 1 (Chk1)] and DNA repair [p53 binding protein 1 (53BP1), breast cancer associated proteins 1, 2 (BRCA1/2), Poly-ADP ribose polymerase (PARP), replication factor c2-5 (Rfc2-5), ataxia telangiectasia mutated gene 1 (ATM), meiotic recombination protein 11 (MRE-11), and others]. Reduced expression of eIF4G1, but not its homolog eIF4G2, greatly sensitizes cells to DNA damage by IR, induces cell death by both apoptosis and autophagy, and significantly delays resolution of DNA damage foci with little reduction of overall protein synthesis. Although some mRNAs selectively translated by higher levels of eIF4G1 were found to use internal ribosome entry site (IRES)-mediated alternate translation, most do not. The latter group shows significantly reduced dependence on eIF4E for translation, facilitated by an enhanced requirement for eIF4G1. Increased expression of eIF4G1 therefore promotes specialized translation of survival, growth arrest, and DDR mRNAs that are important in cell survival and DNA repair following genotoxic DNA damage.

OBJECTIVE

To assess the frequency and associations of barrier protection use during sexual activity in a population of women who have sex with women (WSW).

METHODS

WSW were invited to participate in an international internet-based survey. Information regarding ethnodemographics, sexual health, and barrier use during sexual activities was collected.

RESULTS

The study cohort comprised 1557 participants. Barrier use was least prevalent during digital genital stimulation (11.3% ever used barriers) and most prevalent during stimulation with a sex toy (34.4% ever used barriers). Univariate analysis revealed that women in non-monogamous relationships were more likely than monogamous women to always use barrier protection for sexual activity (14.3% vs 3.5%). On multivariate analysis, there was no association between barrier use and frequency of casual sexual activity or history of sexually transmitted infection. Small associations were noted between barrier use and certain sexual activities, age, race, and number of partners.

CONCLUSION

Many WSW do not use barrier protection during sexual activity, even in the context of potentially risky sexual behaviors. Safer-sex practices among WSW merit increased attention from healthcare providers and public health researchers.

BACKGROUND

Debates about the difficult job market for young endocrine surgeons are ongoing. This study aimed to analyze the practice patterns and work-related satisfaction levels of recently trained endocrine surgeons.

METHODS

An anonymous survey was utilized. Participants were divided into 3 groups: "Young" (3 years in practice), "middle" (3-5 years), and "older" (>5 years).

RESULTS

Fifty-six of 78 surgeons (72%) responded to the survey. Time in practice ranged from 1 to 9 years (mean, 3.9 ± 0.28). Forty-five (80%) described their practice as academic. Participants performed 244.1 ± 17.8 operations within the last year; 75.4 ± 3.3% were endocrine cases. More surgeons in the "young" group have academic practices (92%) and joined established endocrine surgery groups (54%) versus older surgeons (67% and 42%; P = .05). Of surgeons in the "young" group, 4% started their own practice versus 33% in the "older" group (P = .04). Level of satisfaction with financial compensation (3.2 on a 4-point scale versus 2.9) and lifestyle (3.6 vs 3.1) was also higher in the younger group (P = .009).

CONCLUSION

Despite widespread speculation about scarcity of academic jobs after fellowship, recently trained endocrine surgeons are more likely to practice in academic settings and join established endocrine surgery practices when compared with older surgeons. Overall satisfaction level is higher among recently trained surgeons.

Spinal cord infections pose urgent diagnostic and management issues. This article outlines a clinical approach to potential spinal cord infection based on demographic risk factors and both central nervous system (CNS) and extra-CNS clinical clues. The spectrum of disease in vulnerable patient groups, such as transplant and chemotherapy recipients, patients infected with the human immunodeficiency virus, and international travelers, is discussed. Serologic and cerebrospinal fluid investigations for bacterial, viral, and parasitic spinal cord infections are outlined with accompanying characteristic magnetic resonance imaging and other images. Clinical, epidemiologic, and initial management strategies for important spinal cord infections conclude the discussion.