Laparoscopic-Assisted Pancreatic Necrosectomy: Technique and Initial Outcomes.

BACKGROUND: Necrotizing pancreatitis (NP) may result de novo or following procedures such as ERCP or partial pancreatectomy (post-procedural), and may require surgical debridement. Video-assisted retroperitoneal debridement (VARD) is a standard approach for NP that employs a 5 cm incision with varying degrees of blind and open debridement. We describe our technique and outcomes of a modified VARD called laparoscopic-assisted pancreatic necrosectomy (LAPN) performed through a single 12 mm incision that uses direct laparoscopic visualization during debridement. METHODS: At one medical center, all LAPN patients (2012-2020) were assessed for demographics, disease factors, and outcomes. Bivariate logistic regression analyses were performed to identify factors independently associated with recovery after LAPN for patients with de novo vs post-procedural necrosum. RESULTS: Over 9 years, 60 patients underwent LAPN for NP. Median age was 57 years (IQR: 47-66) and 43 (69%) were men. Pancreas necrosum was de novo in 39 (63%) patients and post-procedural in 23 (37%). NP resolved with a median of 1 LAPN procedure and median hospitalization was 33 days. The LAPN major morbidity rate and in-hospital mortality rate were 47% and 5%. No significant differences were seen between NP etiology cohorts, although post-procedure NP patients trended towards a faster clinical recovery to baseline compared to de novo patients (193 vs 394 days; p-value = .07). CONCLUSIONS: LAPN offers a smaller incision with excellent visualization and non-inferior outcomes, regardless of etiology, with likely faster recovery for patients with post-procedural vs de novo necrotizing pancreatitis.

Development of Culinary and Self-Care Programs in Diverse Settings: Theoretical Considerations and Available Evidence.

Culinary-based self-care programs are innovative and increasingly utilized models for catalyzing behavior change and improving health and well-being. The content, duration, and delivery of existing programs vary considerably. Between January and August 2019, we developed a teaching kitchen and self-care curriculum, which was administered as part of a year-long worksite well-being program to employees at an academic healthcare system. The curriculum domains included culinary skills, nutrition, physical activity, yoga, stress management, mindful eating, and ethnobotany. An informal systematic literature search was performed to assemble and evaluate key principles and practices related to self-care domains, learning methodologies, and programmatic design considerations. Here, we provide a qualitative summary of the evidence-informed development of the curriculum intervention.

Adherence Patterns and Acceptability of a Perioperative, App-Based Mindfulness Meditation Among Surgical Patients With Chronic Pain.

Identifying barriers to compliance with mindfulness-based interventions (MBIs) during the perioperative period is paramount to the design and implementation of non-pharmacologic, opiate-sparing pain regimens. We prospectively investigated the acceptability and adherence patterns of an app-based MBI amongst surgical patients with chronic pain. Patients were provided a subscription code to a meditation app and encouraged to use the app an average of 10 minutes/day over a 6-week study period. Patients reported a high level of interest in using the app prior to enrollment. 71% used the app at least once, 30% for half the recommended time, and 8% for the recommended amount of time. 88% of respondents enjoyed using the app and agreed it improved mental health and stress levels. Surgical patients with pre-existing pain report a high level of interest in utilizing MBIs perioperatively. Identifying barriers to compliance represents an important area of future investigation.

Flourishing in Healthcare Trainees: Psychological Well-Being and the Conserved Transcriptional Response to Adversity.

While much attention has been paid to healthcare provider and trainee burnout, less is known about provider well-being (i.e., flourishing) or about the effects of well-being on immune function. This study examined the demographic and psycho-social correlates of well-being among healthcare trainees (resident physicians and physician assistant (PA) trainees) and evaluated the association of well-being with the "conserved transcriptional response to adversity" (CTRA) characterized by up-regulated expression of pro-inflammatory genes and down-regulated expression of innate antiviral genes. Participants (n = 58) completed self-reported assessments of sleep disturbance, loneliness, depressive symptoms, anxiety, stress, and well-being (flourishing). Blood sample RNA profiles were analyzed by RNA sequencing to assess the CTRA. Slightly over half (n = 32; 55.2%) of healthcare trainees were categorized as flourishing. Flourishing was less prevalent among primary caregivers, and more prevalent among trainees who exercised more frequently and those with fewest days sick. Loneliness (AOR = 0.75; 95% CI = 0.61, 0.91; p = 0.003) and stress (AOR = 0.65; 95% CI = 0.45, 0.94; p = 0.02) were associated with decreased odds of flourishing when controlling for other variables. Flourishing was associated with down-regulated CTRA gene expression, whereas loneliness was associated with up-regulated CTRA gene expression (both p < 0.05). Assessing these relationships in a larger, multi-site study is of critical importance to inform policy, curricula, and interventions to bolster sustainable trainee well-being.

Randomized, wait-list-controlled pilot study of app-delivered mindfulness for patients reporting chronic pain.

INTRODUCTION: Chronic pain creates economic burden and exerts profound individual and societal harm. Mobile application (app)-delivered mindfulness meditation may be an important approach to self-management of chronic pain. OBJECTIVES: We examined the feasibility, acceptability, and impact of app-delivered mindfulness meditation on pain cognition and daily functioning among patients reporting chronic pain. METHODS: We used a longitudinal, randomized, and wait-list-controlled design (NCT03495726) to evaluate changes in self-reported pain severity, pain catastrophizing, and social and physical functioning among participants randomized to 6 weeks of app-delivered mindfulness meditation, compared with participants randomized to a wait-list control group. RESULTS: Although most participants randomized to the mindfulness group used the app at least once, fewer than half adhered to the instructed program. Participants who did not use the app scored higher on the helplessness component of pain catastrophizing at the start of the study and were less likely to have completed 4 years of college. Participants who reported feeling pressured to enroll in the study were also less likely to adhere to the intervention. Compared with participants randomized to wait-list, those in the mindfulness group reported significant improvements in social functioning, even after controlling for pain severity. Participants randomized to the mindfulness intervention also reported significant improvements in helplessness. App usage was not significantly correlated with changes in social functioning or helplessness scores. CONCLUSIONS: These results suggest that app-delivered mindfulness meditation is beneficial to patients with chronic pain. Identifying characteristics of patients who were adherent highlights important considerations for clinical settings.

Impact of App-Delivered Mindfulness Meditation on Functional Connectivity, Mental Health, and Sleep Disturbances Among Physician Assistant Students: Randomized, Wait-list Controlled Pilot Study.

BACKGROUND: Health care provider and trainee burnout results in substantial national and institutional costs and profound social effects. Identifying effective solutions and interventions to cultivate resilience among health care trainees is critical. Although less is known about the mental health needs of physician assistants (PAs) or PA students, accumulating research indicates that they experience similarly alarming rates of burnout, depression, and emotional exhaustion. Mobile app-delivered mindfulness meditation may be an effective part of salubrious programming to bolster long-term resilience and health among PA students. OBJECTIVE: This study aims to examine the impact of app-delivered mindfulness meditation on self-reported mental health symptoms among PA students. A secondary aim is to investigate changes in brain connectivity to identify neurobiological changes related to changes in mental health symptoms. METHODS: We recruited PA students enrolled in their third semester of PA school and used a longitudinal, randomized, wait-list-controlled design. Participants randomized to the mindfulness group were provided 1-year subscriptions to the 10% Happier app, a consumer-based meditation app, and asked to practice every day for 8 weeks. Before randomization and again after completion of the 8-week program, all participants completed resting-state functional magnetic resonance imaging as well as self-report assessments of burnout, depression, anxiety, and sleep impairment. App use was acquired as a measure of mindfulness practice time. RESULTS: PA students randomized to the mindfulness group reported improvements in sleep impairment compared with those randomized to the wait-list control group (ηp2=0.42; P=.01). Sleep impairment decreased significantly in the mindfulness group (19% reduction; P=.006) but not in the control group (1% reduction; P=.71). There were no other significant changes in mental health for those randomized to app-delivered mindfulness. Across all students, changes in sleep impairment were associated with increased resting-state functional connectivity between the medial prefrontal cortex (a component of the default mode network) and the superior temporal gyrus, as well as between areas important for working memory. Changes in connectivity predicted categorical conversion from impaired to nonimpaired sleep in the mindfulness group. CONCLUSIONS: This pilot study is the first to examine app-based mindfulness for PA students' mental health and investigate the impact of mindfulness on PA students' brain function. These findings suggest that app-delivered mindfulness may be an effective tool to improve sleep dysfunction and that it may be an important part of the programming necessary to reduce the epidemic of suffering among health profession trainees.

The Impact of App-Delivered Mindfulness Meditation on Functional Connectivity and Self-Reported Mindfulness Among Health Profession Trainees.

Objectives: Previous research indicates that mindfulness meditation reduces anxiety and depression and enhances well-being. We examined the impact of app-delivered mindfulness meditation on resting state functional MRI (fMRI) connectivity among physician assistant (PA) students and surgery residents. Methods: PA students and residents were randomized to receive a popular meditation app or to wait-list control group. Before and after the 8-week meditation period, we acquired fMRI scans of participants' resting state, and participants completed a self-report measure of mindfulness. We used a 2 × 2, within- and between-group factorial design and leveraged a whole-brain connectome approach to examine changes in within- and between-network connectivity across the entire brain, and to examine whether changes in connectivity were associated with app use or to changes in self-reported mindfulness. Results: Meditation practitioners exhibited significantly stronger connectivity between the frontoparietal network and the left and right nucleus accumbens and between the default mode (DMN) and salience networks, among other regions. Mindfulness practice time was correlated with increased connectivity between the lateral parietal cortex and the supramarginal gyrus, which were also positively correlated with increased scores on the "Describing" subscale of the Five Facet Mindfulness Questionnaire between baseline and post-meditation. These findings are consistent with previous research indicating that mindfulness-based interventions alter functional connectivity within the DMN and between the DMN and other networks both during meditation and at rest, as well as increased connectivity in systems important for emotion and reward. Conclusions: Recent commentaries call for healthcare provider and trainee wellness programs that are sustainable and preventive in nature rather than reactive; these data indicate that even brief sessions of app-delivered mindfulness practice are associated with functional connectivity changes in a dose-dependent manner.

Frailty assessment in the acute care surgery population - the agreement and predictive value on length of stay and re-admission of 3 different instruments in a prospective cohort.

BACKGROUND: We compared the Emergency General Surgery Specific Frailty Index (EGSFI), Risk Analysis Index (RAI-C) and the Katz Index (KI) at assessing frailty in acute care surgery (ACS). METHODS: A prospective cohort of ACS patients was stratified into frail or non-frail by the EGSFI, RAI-C and KI. The agreement between scales were compared. RESULTS: Of 272 eligible patients, 72, 75, and 56 were categorized as frail by the EGSFI, RAI-C, and KI respectively. There was weak to no agreement between instruments and consensus among all three scales was 59.4%. CONCLUSION: Between 21 and 28% of patients seen in this ACS cohort were categorized as frail using the EGSFI, RAI-C and KI. These frailty tools have different measures of what constitutes frailty and there was poor agreement between them. Only the KI definition of frailty was associated with a longer LOS. The KI may be more useful for assessing ACS patients in a tertiary care facility.

Ethanol Lock Therapy Markedly Reduces Catheter-Related Blood Stream Infections in Adults Requiring Home Parenteral Nutrition: A Retrospective Study From a Tertiary Medical Center.

BACKGROUND: The use of central venous catheter (CVC) access for home parenteral nutrition (HPN) is associated with catheter-related bloodstream infections (CRBSIs). There are limited data on the use of ethanol lock therapy (ELT) to prevent CRBSI in adult HPN patients. Our aim was to determine whether the routine institution of ELT decreased the incidence of CRBSI compared with historic controls at Emory University Hospital (EUH) in Atlanta, Georgia, USA. METHODS: EUH medical records of adult HPN patients discharged with a tunneled, silicone CVC on ELT were retrospectively studied during a pre-hoc determined 14-month observation period (n = 87; 13,386 catheter days) and compared with clinically similar HPN patients from the same institution before institution of the ELT protocol for all appropriate patients. The ELT protocol involved instilling 2 mL of 70% ethanol into each catheter lumen daily after the HPN cycle, following initial flushing with normal saline. RESULTS: Only 5 of 87 patients (5.7%) who received ELT were diagnosed with a CRBSI (0.45/1000 catheter days) during observation. We compared these data with our previously published clinically matched patient population from EUH (n = 22) receiving HPN via a silicone CVC without ELT. Of these historical controls, 45.5% were diagnosed with 1 or more CRBSIs (8.7/1000 catheter days) during observation (P < .001 vs the current ELT cohort). CONCLUSIONS: In this retrospective study with historical controls from the same academic center, institution of ELT in adults requiring HPN via a silicone CVC was associated with a marked (19-fold) reduction in CRBSI.

Visceral Kaposi Sarcoma Presenting as Small Bowel Intussusception: A Rare Presentation and Call to Action.

Surgical emergencies related to visceral involvement of Kaposi sarcoma (KS) are rare complications of the disease. In this report, we describe a case of visceral KS causing small bowel intussusception in a young, previously undiagnosed human immunodeficiency virus (HIV)-positive patient. Southern surgeons should be particularly attentive to HIV/AIDS-related disease as a cause of surgical pathology, particularly in the southeast, and can play a significant advocacy role for improved access to HIV/AIDS diagnostic and treatment services.

Individualized, Single Session Yoga Therapy to Reduce Physical and Emotional Symptoms in Hospitalized Hematological Cancer Patients.

Objective: Inpatient treatment of hematological cancer is among the most physically and mentally arduous cancer treatments, and it is associated with a number of common physical, emotional, and social symptoms that can negatively affect quality of life (QOL) for years following treatment. While treating symptoms during hospitalization holds promise for improving long-term QOL, successful approaches likely require multidisciplinary interventions. In this article, we describe a 4-year effort in program enhancement that incorporated an adjunctive single yoga therapy session during treatment for hematological malignancies. Methods: Hospitalized patients receiving treatment for hematological cancer (N = 486) were provided a 40-minute individualized yoga therapy session. We evaluated feasibility and acceptance by quantifying the percentage of patients who discontinued the yoga session due to pain, discomfort, or another reason, and by comparing the intervention population to the demographic makeup of the unit more generally. Patient-reported symptoms were obtained before and after each session, and we evaluated acute symptom change for the entire sample and in subsamples that are less likely to use mindfulness-based interventions such as yoga. Results: The majority of sessions (87%) were completed, and the majority of unfinished sessions were interrupted by a medical procedure or because the patient fell asleep. No session was stopped early due to patients' reported pain. Significant decreases were reported in all symptoms, with the greatest decrease in fatigue and anxiety. Conclusions: Yoga therapy was a feasible and effective nondrug adjunct intervention for hospitalized patients receiving treatment for hematological cancer, including bone marrow transplantation.

Definitive surgical treatment of enterocutaneous fistula: outcomes of a 23-year experience.

OBJECTIVE: To analyze postoperative outcomes, morbidity, and mortality following enterocutaneous fistula (ECF) takedown. DESIGN, SETTING, AND PATIENTS: Retrospective review of the complete medical records of patients who presented to a single tertiary care referral center from December 24, 1987, to June 18, 2010, and subsequently underwent definitive surgical treatment for ECF originating from the stomach, small bowel, colon, or rectum. MAIN OUTCOME MEASURES: Postoperative fistula recurrence and mortality. RESULTS: A total of 153 patients received operative intervention for ECF. Most ECFs were referred to us from outside institutions (75.2%), high output (52.3%), originating from the small bowel (88.2%), and iatrogenic in cause (66.7%). Successful ECF closure was ultimately achieved in 128 patients (83.7%). Six patients (3.9%) died within 30 days of surgery, and overall 1-year mortality was 15.0%. Postoperative complications occurred in 134 patients, for an overall morbidity rate of 87.6%. Significant risk factors for fistula recurrence were numerous, but postoperative ventilation for longer than 48 hours, organ space surgical site infection, and blood transfusion within 72 hours of surgery carried the most considerable impact (relative risks, 4.87, 4.07, and 3.91, respectively; P < .05). Risk of 1-year mortality was also associated with multiple risk factors, the most substantial of which were postoperative pulmonary and infectious complications. Closure of abdominal fascia was protective against both recurrent ECF and mortality (relative risks, 0.47 and 0.38, respectively; P < .05). CONCLUSIONS: Understanding risk factors both associated with and protective against ECF recurrence and postoperative morbidity and mortality is imperative for appropriate ECF management. Closure of abdominal fascia is of utmost importance, and preventing postoperative complications must be prioritized to optimize patient outcomes.