GME Innovations Grant Program at the University of Michigan Health System-Fostering Changes in Education and Clinical Care.

BACKGROUND: Changes in graduate medical education (GME) have resulted in curricula, goals and objectives, and assessment methods becoming more formal, yet there is little financial support for the educational research required to develop better teaching approaches and assessment tools. OBJECTIVE: We sought to encourage the development of new educational tools and assessment methods to improve the overall conduct of GME at the University of Michigan. INTERVENTION: The University of Michigan Health System has recently established a new educational grant that is designed to foster innovative educational research in GME. We describe the experience with a new and robust internal educational grant, including the source of funding, mechanisms for reviewing and assessing the proposals, the types of proposals that have currently been funded, and the effect and results of these studies on GME at the University of Michigan Health System. OUTCOMES: Projects funded by the grant have changed the curriculum in the involved programs, and many have resulted in sustained changes, including new methodologies in the simulation center, the development of an "academy" of faculty physicians with significant teaching expertise, and the creation of web-based teaching and assessment tools for "just in time" learning, and have been disseminated at national meetings and in peer-reviewed journals. CONCLUSIONS: The GME Innovations Grant Program at the University of Michigan Health System has been successful to date, funding 11 proposals during the course of 6 years. Some of these proposals have resulted in permanent changes and additions to residency training programs.

CXC receptor-2 knockout genotype increases X-linked inhibitor of apoptosis protein and protects mice from acetaminophen hepatotoxicity.

UNLABELLED: Although acetaminophen is a commonly used analgesic, it can be highly hepatotoxic. This study seeks to further investigate the mechanisms involved in acetaminophen-induced hepatotoxicity and the role of chemokine (C-X-C motif) receptor 2 (CXCR2) receptor/ligand interactions in the liver's response to and recovery from acetaminophen toxicity. The CXC chemokines and their receptor, CXCR2, are important inflammatory mediators and are involved in the control of some types of cellular proliferation. CXCR2 knockout mice exposed to a median lethal dose of acetaminophen had a significantly lower mortality rate than wild-type mice. This difference was at least partially attributable to a significantly decreased rate of apoptosis in CXCR2 knockout mice versus wild-type mice; there were no differences seen in hepatocyte proliferation in wild-type mice versus knockout mice after this injury. CONCLUSION: The decreased rate of apoptosis in the knockout mice correlated with an almost undetectable and significantly decreased level of activated caspase-3 and significantly increased levels of X-linked inhibitor of apoptosis protein, which also correlated with increased levels of nuclear factor kappa B p52 and decreased levels of c-Jun N-terminal kinase; this provides a possible mechanism for the decrease in apoptosis seen in CXCR2 knockout mice.

An assessment tool for aseptic technique in resident physicians: a journey towards validation in the real world of limited supervision.

PURPOSE: The purpose of this study was to describe the validation process for assessing an instrument to assess residents' aseptic technique skills. METHODS: The validation study entailed comparisons of the performance of aseptic technique procedures between postgraduate year-1 (PGY-1) surgical residents and PGY-2/3 surgical residents. We also compared the performance of PGY-1 surgical residents from 2 different academic years for the same procedures. Finally, we compared the performance of novices (medical students) and experts (operating room nurses) in an effort to determine validity. RESULTS: Our initial analysis found no significant difference between the performance of PGY-1 (mean score, 75.8) and PGY-2/3 (mean score, 75.6) surgical residents for aseptic technique (t((55))  =  0.84, P  =  0.404). Further investigation of validity was obtained to determine whether the no difference results reflected a lack of reliability or validity or a true equivalence between the 2 cohorts. The comparison of novices and experts produced the following findings. For reliability, the internal consistency of the checklist for each of the 2 raters was 0.87 and 0.71 (Cronbach α), interrater reliability was 0.74, with P < 0.001 (intraclass correlation coefficient) for the global scale. (Internal consistency was done within instrument, ie, between items not between raters.) For validity, operating room nurses outperformed students on the global scale (t(14)  =  7.47, P < 0.0001 and t((14))  =  10.66, P < 0.0001 for the 2 raters, respectively) and on several checklist items. The effect size values for raters were large (Cohen d  =  3.0 and 4.4), providing validity evidence for the ability of this assessment to detect difference in performance on this task. CONCLUSION: The validation study showed that the instrument exhibited reliability and evidence for validity, making it useful for the assesment of aseptic technique skills in different specialties. Programs may want to consider using a validated instrument to check competence given that appropriate use of sterile technique frequently occurs in the context of unsupervised activities. Further work is needed to enhance resident skills in the area of aspectic technique because of limited improvement despite additional clinical experience.

Evidence for increasing diversity in graduate medical education: the competence of underrepresented minority residents measured by an intern objective structured clinical examination.

OBJECTIVE: Some have commented that the limited number of underrepresented minorities (URMs) in United States' residency programs is due to a lack of qualified candidates. At the University of Michigan, an objective structured clinical examination is administered to incoming residents at the beginning of training to determine baseline competence. In this study we wanted to determine if competence differed for underrepresented minorities when compared to non-URM residents. METHOD: The postgraduate orientation assessment, a 10-station examination, was developed that focused specifically on the knowledge and skills needed in the first 6 to 18 weeks of training. Stations assessed competence in informed consent, aseptic technique, evidence-based medicine, diagnostic images, critical laboratory values, cross-cultural communication, and Joint Commission requirements such as surgical fire safety, pain assessment, and management. We used various assessment measures including standardized patients, computer-based testing, and multiple-choice questions. RESULTS: Our study found no significant differences in overall mean scores between URM residents and all other residents for the 5 years during which we administered the examination, except for 2002. This stands in contrast to the consistently worse performances of URM students on USMLE Step 1 and Step 2 Clinical Knowledge. Also, URM residents did not perform better or worse than their non-URM colleagues on standardized patient stations during the course of 5 years during which the examination was administered. CONCLUSIONS: The postgraduate orientation assessment provides residency program directors with a standard format to measure initial clinical skills. When compared to incoming non-URM residents from a variety of medical schools, URM residents perform as well as other trainees. Our results may aid in the recruitment efforts of URM medical students into academic residency programs such as those at the University of Michigan.

IL-22 is involved in liver regeneration after hepatectomy.

Hepatocyte proliferation following partial hepatectomy is an important component of liver regeneration, and recent in vitro studies have shown that IL-22 is involved in cellular proliferation in a variety of cell types, including hepatocytes. IL-22 functions through IL-10Rbeta and IL-22Ralpha. The goal of this study was to investigate the potential role of IL-22 in liver regeneration after 70% hepatectomy. Following 70% hepatectomy, done under general anesthesia in mice, serum IL-22 and hepatic IL-22Ralpha mRNA were significantly increased. Although administration of exogenous IL-22 prior to hepatectomy did not increase hepatocyte proliferation, administration of anti-IL-22 antibody before hepatectomy did significantly decrease hepatocyte proliferation. Furthermore, IL-22 treatment prior to 70% hepatectomy induced stat-3 activation; no significant changes were seen in ERK1/2 activation, stat-1 activation, or stat-5 activation. IL-22 pretreatment also significantly increased hepatic and serum IL-6 levels. In addition, animals treated with anti-IL-22 antibody also expressed less TGF-alpha. In conclusion, these data suggest that IL-22 is involved in liver regeneration and this may be due to interaction with IL-6 and TGF-alpha cascades.

Stem cell factor and c-kit are involved in hepatic recovery after acetaminophen-induced liver injury in mice.

Stem cell factor (SCF) and its receptor c-kit are important in hematopoiesis and cellular proliferation. c-kit has also been identified as a cell surface marker for progenitor cells. We have previously shown that there is a large reservoir of hepatic SCF, and this molecule plays a significant role in liver regeneration after 70% hepatectomy. In the current study, we further examined the expression of SCF and c-kit in acetaminophen (APAP)-induced liver injury in C57BL/6J mice or SCF-deficient sl-sld mice and their appropriate wild-type controls. Following APAP-induced liver injury, c-kit mRNA expression increased, with peak levels detected 48 h postinjury. Hepatic SCF mRNA levels after APAP injury were also increased, with peak levels seen 16 h post-APAP. The mortality rate in SCF-deficient mice treated with APAP was significantly higher than that of wild-type mice; furthermore, administration of exogenous SCF significantly reduced the mortality of APAP-treated wild-type mice. Bromodeoxyuridine incorporation experiments showed that SCF significantly increased hepatocyte proliferation at 48 and 72 h in APAP-treated mice. SCF inhibited APAP-induced hepatocyte apoptosis and increased Bcl-2 and Bcl-xL expression, suggesting that this decrease in hepatocyte apoptosis is mediated through Bcl-2 and Bcl-xL. In summary, SCF and c-kit expression was increased after APAP-induced liver injury. Administration of exogenous SCF reduces mortality in APAP-treated mice, increases hepatocyte proliferation, and prevents hepatocyte apoptosis induced by APAP, suggesting that these molecules are important in the liver's recovery from these injuries.

Phase I study of oxaliplatin, full-dose gemcitabine, and concurrent radiation therapy in pancreatic cancer.

PURPOSE: To determine a biweekly dose of oxaliplatin for combination with full-dose gemcitabine and concurrent radiation therapy (RT) in pancreatic cancer. PATIENTS AND METHODS: Patients with previously untreated pancreatic cancer received gemcitabine days 1, 8, and 15, and oxaliplatin days 1 and 15, repeated at 28-day intervals. RT (27 Gy in 1.8-Gy fractions) was administered during cycle 1. Dose escalation was guided using the time-to-event continuous reassessment method. Dose levels 1 to 4 included gemcitabine 1 g/m2 intravenously (IV) during 30 minutes and oxaliplatin 40, 55, 70, or 85 mg/m2 IV during 90 minutes, respectively; for dose levels 5 and 6, oxaliplatin dose remained 85 mg/m2 but infusion time for gemcitabine 1 g/m2 was increased to 65 or 100 minutes, respectively. The trial objective was to determine the dose level associated with dose-limiting toxicity (DLT) through cycle 2 in < or = 20% of patients. RESULTS: Forty-four patients were enrolled (median age, 64 years; 27 men, 17 women) with resectable (n = 12), unresectable (n = 29), and metastatic (n = 3) pancreatic cancer. Ten DLTs occurred in nine patients, including grade 4 platelets (n = 4), decline in performance status (n = 2), GI bleeding (n = 2), and GI toxicity (n = 2). The estimated probability of DLT for dose level 3 was .21 (90% posterior probability interval [PI], .12 to .33); for dose level 4, the estimated probability was .24 (90% PI, .14 to .36). CONCLUSION: The addition of oxaliplatin 85 mg/m2 days 1 and 15 to full-dose gemcitabine and radiation therapy was well tolerated. On the basis of these results, a multi-institutional neoadjuvant phase II study in resectable pancreatic cancer is planned.

Matrix metalloproteinase-9 is an important factor in hepatic regeneration after partial hepatectomy in mice.

Partial hepatectomy triggers hepatocyte proliferation, hepatic matrix remodeling, and hepatocyte apoptosis, all of which are important processes in the regenerating liver. Previous studies have shown an increase in the levels of matrix metalloproteinases gelatinase A (MMP-2) and gelatinase B (MMP-9) after partial hepatectomy. The goal of this study was to investigate the role of MMP-9 in liver regeneration after partial hepatectomy. A 70% hepatectomy or sham laparotomy was performed in wild-type or MMP-9-deficient (MMP-9-/-) mice. Hepatic regeneration was determined by liver weight/total body weight ratios and BrdU staining, which was used to a calculate mitotic index at several times postoperatively. Cytokine and growth factor expression was evaluated by Luminex bead-based ELISA and Western blots. Finally, the effect of MMP-9 on apoptosis was measured using TUNEL and caspase expression. The MMP-9-/- animals had a delayed hepatic regenerative response when compared with wild-type controls. The MMP-9-deficient animals expressed significantly less VEGF, HGF, and TNF-alpha between days 2 and 3 post-hepatectomy. Apoptosis, as measured by TUNEL staining and caspase expression, was decreased in the MMP-9-/-. In conclusion, MMP-9 plays an important role in liver regeneration after partial hepatectomy by affecting matrix remodeling, as well as cytokine, growth factor, and caspase expression.

A multi-institutional phase II trial of preoperative full-dose gemcitabine and concurrent radiation for patients with potentially resectable pancreatic carcinoma.

BACKGROUND: We report the results of a multi-institutional phase II trial that used preoperative full-dose gemcitabine and radiotherapy for patients with potentially resectable pancreatic carcinoma. METHODS: Patients were treated before surgery with three cycles of full-dose gemcitabine (1000 mg/m2 intravenously), with radiation during the second cycle (36 Gy in daily 2.4-Gy fractions). Patients underwent surgery 4 to 6 weeks after the last gemcitabine infusion. RESULTS: There were 10 men and 10 women, with a median age of 58 years (range, 50-80 years). Nineteen patients (95%) completed therapy without interruption, and one experienced grade 3 gastrointestinal toxicity. The mean weight loss after therapy was 4.0%. Of 20 patients taken to surgery, 17 (85%) underwent resections (16 pancreaticoduodenectomies and 1 distal pancreatectomy). The complication rate was 24%, with an average length of stay of 13.5 days. There were no operative deaths. Pathologic analysis revealed clear margins in 16 (94%) of 17 and uninvolved lymph nodes in 11 (65%) of 17 specimens. One specimen contained no residual tumor, and three specimens revealed only microscopic foci of residual disease. With a median follow-up of 18 months, 7 (41%) of the 17 patients with resected disease are alive with no recurrence, 3 (18%) are alive with distant metastases, and 7 (41%) have died. CONCLUSIONS: Preoperative gemcitabine/radiotherapy is well tolerated and safe when delivered in a multi-institutional setting. This protocol had a high rate of subsequent resection, with acceptable morbidity. The high rate of negative margins and uninvolved nodes suggests a significant tumor response. Preliminary survival data are encouraging. This regimen should be considered in future neoadjuvant trials for pancreatic cancer.

Capecitabine and radiation therapy preceded and followed by combination chemotherapy in advanced pancreatic cancer.

PURPOSE: The primary objective of this study was to evaluate the tolerance and toxicity of radiation therapy (RT) and capecitabine in patients with advanced, unresectable pancreatic carcinoma. To control micrometastatic disease, combination chemotherapy (gemcitabine and cisplatin) before and after combined modality therapy (CMT) was planned. METHODS AND MATERIALS: Patients with unresectable or metastatic pancreatic cancer were eligible. Gemcitabine 1000 mg/m2 and cisplatin 35 mg/m2 were administered on Days 1 and 8 of a 21-day cycle for two cycles. RT was then given to a dose of 50.4 Gy in 1.8 Gy fractions. Patients were treated with capecitabine 1330 mg/m2 daily during RT. After CMT, two additional cycles of gemcitabine and cisplatin completed the treatment. RESULTS: Twenty-three patients were treated. Eighteen patients completed CMT. One patient was removed from study during CMT for toxicity issues. Treatment delays and dose reductions were common during the final two cycles of gemcitabine and cisplatin as a result of myelosuppression. Median survival was 10.1 months (95% confidence interval [CI] = 7.6, 13.7) for all 23 patients and 12.8 months (95% CI = 8.2, 18.9) for 18 patients without metastasis. CONCLUSION: Combined modality therapy with RT and capecitabine was well tolerated. Chemotherapy after CMT was difficult to complete owing to cumulative myelosuppression. Survival, response, and toxicity were comparable to infusional 5-fluorouracil and RT.

Initial use of a novel instrument to measure professionalism in surgical residents.

BACKGROUND: No universally accepted method to measure professionalism exists. We developed an instrument to measure specific aspects of professionalism in surgical residents. METHODS: Professionalism was deconstructed into 15 domains. Behavioral descriptors were determined for extreme and selected intermediate anchors. It became evident that residents could "go too far" in some professional behaviors. Therefore, although a 7-point continuous ordinal scale forms the framework, a score of 7 does not necessarily indicate the ideal. This characteristic minimizes the problem of inflated ratings. RESULTS: The instrument was utilized by attending faculty to evaluate residents and also by residents as a self-evaluation. Calculated from ordinal values, mean (SD) of the ratings across domains for faculty evaluations of residents was 4.95 (0.38) while mean for self-evaluations was 4.95 (0.39). Reliability was high (coefficient alpha 0.85). CONCLUSIONS: This instrument provides a means to measure professional behaviors during surgical residency. Repeated use will be required to thoroughly establish validity and reliability.

Common celiacomesenteric trunk: aneurysmal and occlusive disease.

Eighteen patients (14 men, 4 women), ages 24 to 77 years, with a common celiacomesenteric trunk (CMT) were treated between 1965 and 2004 at the University of Michigan. Four patients had CMT aneurysmal or occlusive disease that led to operative treatment. Pertinent arteriographic findings in these 4 patients included a CMT aneurysm (n = 2), an occluded proximal CMT (n = 1), and a type III aortic dissection that was compressing the CMT (n = 1). Therapy in these 4 patients included placement of a polytetrafluoroethylene bypass graft from the supraceliac aorta to the CMT (n = 2) or a Dacron bypass graft from a thoracoabdominal bypass to the CMT (n = 1), and endovascular fenestration of the septum between the true and false lumens of an aortic dissection at the level of the CMT (n = 1).

Attending, house officer, and medical student perceptions about teaching in the third-year medical school general surgery clerkship.

BACKGROUND: There has been declining interest in surgery among medical students and one reason might be the third-year clerkship experience. The aim of this study was to clarify the perceptions and expectations of attendings, residents, and medical students on the clerkship experience. STUDY DESIGN: A survey was distributed to all general surgery attendings, the entire general surgery house staff, and an entire third year medical school class inclusive of the 2001-2002 academic year at a single institution. Statistic analysis consisted of chi-square and Kruskal-Wallis-ANOVA on ranks with Dunn's test for multiple comparisons. A p < 0.05 was significant. RESULTS: Responses were obtained from 59 attending surgeons (50%), 38 surgical residents (32%), and 107 medical students (66%). Of this student cohort, 35% were planning to choose a surgical specialty as a career. Agreement was high among faculty, students, and residents about factors considered important in evaluation, expectations of skills, and level of skills needed before the clerkship. Medical students desired more hours of instruction, believed they performed fewer procedures per week, and thought that feedback was poor compared with the opinions of faculty and residents (p < 0.002). Nearly 50% of medical students believed they were an inconvenience to the service; 30% of house officers and 27% of faculty (p < 0.001) believed this also. Almost all faculty and residents, however, wanted medical students on the service (> 95%). Faculty believed residents did a better job teaching than either the students or residents themselves did (p < 0.001), and students thought that residents were the primary source of education in patient care. CONCLUSIONS: Considerable differences exist between faculty, surgical resident, and medical student perceptions and expectations of medical student education. Structured direct faculty contact, definition of medical student roles on the surgical team, and more consistent feedback can be rapidly improved.

National trends in the use and outcomes of hepatic resection.

BACKGROUND: Hepatic resection is increasingly performed for primary and metastatic tumors. Reports from tertiary care centers show improved outcomes over time with lower operative mortality rates. The objective of this investigation was to characterize trends in the use and outcomes of hepatic resection in the US during a recent 13-year period. STUDY DESIGN: Adult patients with a procedures code for hepatic resection in the Nationwide Inpatient Sample (NIS) from 1988 to 2000 were included. The Nationwide Inpatient Sample is a 20% representative sample of all discharges in the US. Outcomes variables included in-hospital mortality and length of stay. High volume hospitals performed 10 or more (>50th percentile) procedures per year. RESULTS: During the 13-year period, 16,582 patients underwent hepatic resection. The number of procedures performed increased nearly twofold, from 820 per year in 1988 to 1,420 per year in 2000. Similar changes in use were seen for each indication for operation. The overall mortality rate declined from 10.4% (1988 to 1989) to 5.3% (1999 to 2000) during the study period (p < 0.001). The mortality rate was lower at high volume centers than at lower volume centers (5.8% versus 8.9%, p < 0.001), and the decline in mortality over time was greater at high volume centers (10.1% to 3.9%, p < 0.001) compared with to low volume centers (10.6% to 7.4%, p = 0.01). CONCLUSIONS: The number of hepatic resections performed in the US has increased significantly. Short-term outcomes have also improved over the same time period, with more improvement seen at higher volume centers than in lower volume centers.

Hospital teaching status and outcomes of complex surgical procedures in the United States.

HYPOTHESIS: Complex operations performed in teaching hospitals have similar outcomes as those performed in nonteaching hospitals. DESIGN: Observational cohort study with clinical patient data obtained from the Nationwide Inpatient Sample. The Nationwide Inpatient Sample data were linked to the American Hospital Association hospital survey data for 1997 to determine hospital characteristics. Hospitals were considered high volume if they performed more than the median (50th percentile) number of procedures per year. SETTING: Nationally representative sample of hospitals during 1996 and 1997. PATIENTS: Individuals undergoing esophageal resection (n = 1247), hepatic resection (n = 2073), or pancreatic resection (n = 3337) in Nationwide Inpatient Sample hospitals during 1996 and 1997 were included. MAIN OUTCOMES MEASURES: Unadjusted and adjusted in-hospital mortality and prolonged length of stay (>75th percentile). RESULTS: None of the procedures had higher operative mortality rates at teaching hospitals. In unadjusted analyses, pancreatic resection (4.0% vs 8.8%; P<.001), hepatic resection (5.3% vs 8.0%; P =.03), and esophageal resection (7.7% vs 10.2%; P =.10) had lower operative mortality rates at teaching compared with nonteaching hospitals. However, after adjusting for hospital volume in the multivariate analysis, hospital teaching status was no longer a predictor of operative mortality. CONCLUSIONS: Teaching hospitals have lower operative mortality rates for complex surgical procedures. However, the lower mortality rates at teaching hospitals can be explained by higher procedural volume.

Surgical resection following radiation therapy with concurrent gemcitabine in patients with previously unresectable adenocarcinoma of the pancreas.

The combination of gemcitabine with concurrent radiation therapy (Gem/RT) is a promising new approach that is being investigated in patients with unresectable pancreatic cancer. However, substantial toxicity with this combination has also been observed. This review was conducted to determine whether Gem/RT could be safely delivered in the neoadjuvant setting, based on our experience with this combined therapy in a cohort of patients with previously unresectable pancreatic cancer, who subsequently underwent surgical resection. Between July 1996 and June 2001, a total of 67 patients with locally unresectable pancreatic cancer, without distant metastatic disease, received Gem/RT at our institution. Seventeen patients (25%) underwent exploratory surgery following Gem/RT, and nine underwent standard Whipple resection. Thus 9 (52%) of 17 patients who had exploratory operations or 9 (13%) of 67 patients, underwent surgical resection. Thirty-day mortality after resection was 0%, and there were no major surgical complications. Median length of hospital stay was 14 days (range 11 to 19 days). With a median follow-up of 32 months, median survival for the resected patients was 17.6 months (95% confidence interval 12.6 to 37.3 months). Median survival for the remaining 58 patients was 11.9 months (95% confidence interval 9.6 to 14.7 months, P=0.013). We conclude that surgical resection may be safely performed after Gem/RT in a select group of patients initially considered to have unresectable pancreatic cancer. The use of Gem/RT in a neoadjuvant setting is currently being investigated in a multi-institutional phase II trial.

Hospital volume and surgical outcomes for elderly patients with colorectal cancer in the United States.

BACKGROUND: Recent emphasis has been placed on the quality of surgical care in the United States. As such, patients, providers, and payers are increasingly aware of the outcomes of surgical care as a marker of quality. The objective of this study was to determine the impact of hospital volume on mortality for patients of different age groups to determine whether elderly patients would derive more benefit from selective referral policies. METHODS: Data from the Nationwide Inpatient Sample for all patients undergoing surgery for colorectal cancer during 1997 were obtained (N = 20,862). Differences in mortality associated with increasing age and hospital volume quartiles were determined. Risk-adjusted analyses of mortality were performed using multiple logistic regression. RESULTS: The overall mortality rate was 3.1% for the 842 hospitals included. Patient age breakdown was the following: age <50, 7%; age 50 to 64, 19%; age 65 to 80, 51%; and age >80, 22%. Increasing age was associated with higher mortality rates: age <50, 0.8%; age 51 to 65, 1.3%; age 66 to 80, 2.9%; and >80, 6.9%. Overall, the highest volume hospitals (HVH) (>150/year) had lower mortality than the lowest volume hospitals (LVH) (<55/year) (2.5% vs. 3.7%; P = 0.006). However, the effect of volume on mortality was primarily due to differences in older patients. For patients greater than 65 years old, the mortality rate was 3.1% at HVH and 4.5% at LVH (P = 0.03). For patients greater than 80 years old, the mortality rate was 4.6% at HVH and 7.3% at LVH (P = 0.04). The results were unchanged after adjustment for patient demographics, comorbid disease, site of cancer, and type of resection. CONCLUSIONS: The majority of deaths after surgery for colorectal cancer occur in older patients. Hospitals that perform higher volumes of colorectal resection have lower mortality rates, especially for older patients. In the absence of other information about the quality of surgical care, provider volumes are a useful marker of postoperative outcomes for older patients in need of surgery for colorectal cancer.

Presentation and treatment of venomous snakebites at a northern academic medical center.

Poisonous snakebites are relatively rare in the United States. The incidence of venomous snakebites is comparatively high in the southern states compared with the northern states and reports of these accidents from northern states is particularly uncommon. We report the experience with treatment of venomous snakebites at the University of Michigan over a 25-year period from 1976 to 2001. Six cases were identified and are described in detail. All patients were male and all were bitten in the upper extremity by pit vipers. One patient suffered a moderate envenomation and was treated with antivenin. Four other cases of mild envenomation occurred and two of these cases required antivenin therapy. One case was considered to represent a "dry" bite and required only 24-hour observation. There were no severe envenomations and no mortalities. On short-term follow-up all patients recovered without sequelae. This report demonstrates that venomous snakebites can be treated effectively at low-volume centers.

Unusual causes of benign biliary strictures with cholangiographic features of cholangiocarcinoma.

Focal strictures occurring at the hepatic duct confluence, or within the common hepatic duct or common bile duct in patients without a history of prior surgery in that region or stone disease, are usually thought to represent cholangiocarcinoma until proved otherwise. However, not uncommonly, patients undergo surgical exploration for a preoperative diagnosis of cholangiocarcinoma, based on the cholangiographic appearance of the lesion, only to find histologically that the stricture was benign in nature. Despite sophisticated radiographic, endoscopic, and histologic studies, it is often impossible before laparotomy to distinguish malignant from benign strictures when they have the characteristic radiographic appearance of cholangiocarcinoma. Even at the risk of overtreating some benign cases, most agree that aggressive surgical resection is the treatment of choice, given the serious consequences resulting from a failure to diagnose and adequately treat cholangiocarcinoma. Four patients who presented to our institution between February 1991 and June 2000 underwent laparotomy for a preoperative diagnosis of biliary tract malignancy based on clinical presentation and cholangiographic findings. The final pathology report in all patients showed marked fibrosis and inflammation of the biliary duct without evidence of malignancy. A review of the patient data and the relevant literature identified benign causes of focal extrahepatic biliary strictures associated with concomitant disease processes in two of the four patients. We present these cases and discuss the benign etiologies with emphasis on the role of surgery in both diagnosis and treatment.