Integrated residency is associated with an increase in women among vascular surgery trainees.

BACKGROUND: During the past decade, the proportion of women within graduate medical education has increased. Correspondingly, the proportion of women in almost every specialty has increased, including surgical specialties. We sought to evaluate the effect of establishing vascular surgery integrated residencies (VSIRs) on the proportion of women in vascular surgery training programs. METHODS: Resident data were obtained from the Accreditation Council for Graduate Medical Education (ACGME) Data Resource Book for the academic years 2007 to 2016. Data were collected on overall ACGME residency numbers as well as on the following surgical subspecialties: vascular, general, thoracic, neurologic, orthopedic, otolaryngologic, and urologic surgery. The number and proportion of women per year in VSIRs and vascular surgery fellowships were compared with those in the other surgical specialties. RESULTS: During the study period, the proportion of women in ACGME-accredited residency programs increased from 0.41 (n = 43,695/107,851) to 0.44 (n = 57,130/129,720) of residents. Since the advent of the VSIR, the number of trainees within vascular surgery has increased by 56% from 221 to 501 trainees. The proportion of women in vascular surgery training programs has increased from 0.12 (n = 27/221) to 0.33 (n = 164/501) of trainees. This increase during the 9-year study period was greater than in any other surgical subspecialty and greatest within the VSIR. Compared with fellowship training programs, integrated surgical training programs within the same subspecialty had a higher proportion of women, although variability between surgical subspecialties remained notable. CONCLUSIONS: Although it is lower than the proportion of women within all graduate medical education training programs, an increasing proportion of women have entered vascular surgery training during the study period. This appears to be related to the introduction of VSIRs and exceeds the proportion of women entering almost all other surgical subspecialties at a rate of change faster than in all other surgical subspecialties. Further work to understand surgical specialty preferences and choice of careers after training is warranted.

Comparison of outcomes in women and men following carotid interventions in the Washington state's Vascular Interventional Surgical Care and Outcomes Assessment Program.

BACKGROUND: The benefit for carotid endarterectomy (CEA) to prevent a potential stroke has been shown to be less beneficial for women compared with men and the risk of carotid stenting (CAS) is higher in women than men. We hypothesized that a community-based Washington state registry data would also reveal increased morbidity and mortality for women undergoing carotid interventions. METHODS: Deidentified data for CEA and CAS between 2010 and 2015 were obtained from 19 hospitals participating in the Washington State Vascular-Interventional Surgical Care and Outcomes Assessment Program. Data analysis compared in-hospital composite outcome of stroke and mortality from CEA and CAS between women and men. RESULTS: Over the study period, 3704 individuals underwent CEA (n = 2759; 49.5% symptomatic) and CAS (n = 945; 60.9% symptomatic). Women accounted for 39.5% of the cohort. Women were slightly younger than men (70.0 ± 10.2 vs 71.0 ± 9.6 years respectively; P < .01), less likely to be smokers (70.1% vs 75.6%; P < .01), and less likely to have a diagnosis of coronary artery disease (32.9% vs 46.5%; P < .01). Fewer women underwent CEA for symptomatic carotid disease (46.1% vs 51.8%; P < .01). There were no statistically significant differences in the postoperative in-hospital stroke and mortality among women and men undergoing CEA (asymptomatic, 0.8% vs 1.4% [P = .36]; symptomatic, 1.8% vs 2.2% [P = .58]) and CAS (asymptomatic, 1.4% vs 2.2% [P = .56]; symptomatic, 4.6% vs 2.5% [P = .18]). Hospital duration of stay and discharge disposition were similar for women and men. A subanalysis of the octogenarian cohort undergoing CAS demonstrated a substantial increase in-hospital stroke and mortality among women and men (11.6% [CAS] vs 2.2% [CEA]; P = .024). CONCLUSIONS: In the Washington state Vascular-Interventional Surgical Care and Outcomes Assessment Program registry, hospital composite outcome of stroke and mortality following carotid interventions from 2010 to 2015 were noted to be similar for women and men. The notable exception to this finding was observed in subcohort of women undergoing CAS for symptomatic carotid disease at age 80 years or older. These findings should be taken into account when risk stratifying patients for carotid interventions.

Association of variant arch anatomy with type B aortic dissection and hemodynamic mechanisms.

OBJECTIVE: Congenital aortic arch variations are more common in patients with thoracic aortic disease for reasons unknown. Additionally, little is understood about their relation to type B aortic dissections (TBAD) specifically. We investigated the prevalence of variant aortic arch anatomy in patients with TBAD compared with controls. To understand the implications of how variant aortic arch anatomy may contribute to degenerative aortic disease, we compared flow hemodynamics of three variations of aortic arches using four-dimensional flow magnetic resonance imaging (4D flow MRI). METHODS: Arch anatomy on computed tomography imaging was reviewed and compared between patients with TBAD and age/sex-matched controls free of aortic pathology. Arch variants were defined as follows: common origin of innominate and left common carotid artery (bovine arch), aberrant right subclavian artery, and right-sided aortic arch. Demographics, TBAD characteristics, and follow-up data were abstracted. Patients with TBAD with variant and conventional aortic arches were compared. Additionally, three matched healthy controls with conventional, bovine, and aberrant right subclavian artery arches underwent 4D flow MRI evaluation to assess if there were differences in flow patterns by arch type. Indices of regional hemodynamic wall sheer stress were compared. RESULTS: Computed tomography scans of 185 patients with TBAD (mean age, 58.1 ± 12.4 years; 72.4% males; 71.4% Caucasian) and 367 controls (mean age, 62.5 ± 13.4 years; 67% males; 77.9% Caucasian) were reviewed. Variant arch anatomy was more prevalent in patients with TBAD (40.5% vs 24.5%; P < .001). In patients with TBAD, there were no differences in the mean age of presentation and descending thoracic aorta diameter among those with variant or conventional arch anatomy. Patients with TBAD with variant arch anatomy had a higher percentage of dissection related thoracic aortic repairs (54.7% vs 33.6%; P = .004) with repairs occurring predominantly in the acute phase. 4D flow MRI demonstrated a higher systolic wall shear stress along the inner curve of the bovine arch compared with the conventional aberrant right subclavian artery arches. CONCLUSIONS: Variant aortic arch anatomy is significantly more prevalent in patients with TBAD. patients with TBAD with variant arch anatomy had a higher percentage of dissection-related aortic repair. Preliminary 4D flow MRI data show differences in hemodynamic flow patterns between variant and conventional arches. Studies of long-term outcomes based on arch anatomy may offer additional insight to TBAD genesis and possibly influence management decisions.

Bifurcated-bifurcated aneurysm repair is a novel technique to repair infrarenal aortic aneurysms in the setting of iliac aneurysms.

BACKGROUND: Up to 40% of abdominal aortic aneurysms (AAAs) have coexistent iliac artery aneurysms (IAAs). In the past, successful endovascular repair required internal iliac artery (IIA) embolization, which can lead to pelvic or buttock ischemia. This study describes a technique that uses a readily available solution with a minimally altered off-the-shelf bifurcated graft in the IAA to maintain IIA perfusion. METHODS: From August 2009 to May 2015, 14 patients with AAAs and coexisting IAAs underwent repair with a bifurcated-bifurcated approach. A 22-mm or 24-mm bifurcated main body device was used in the IAA with extension of the "contralateral" limb into the IIA. Intraoperative details including operative time, fluoroscopy time, and contrast agent use were recorded. Outcome measures assessed were operative technical success and a composite outcome measure of IIA patency, freedom from reintervention, and clinically significant endoleak at 1 year. RESULTS: Fourteen patients underwent bifurcated-bifurcated repair during the study period. Technical success was achieved in 93% of patients, with successful treatment of the AAA and IAA and preservation of flow to at least one IIA. The procedure was performed with a completely percutaneous bilateral femoral approach in 92% of patients. Three patients had a type II endoleak on initial follow-up imaging, but none were clinically significant. There were no cases of bowel ischemia or erectile dysfunction. One patient had buttock claudication ipsilateral to IIA coil embolization (contralateral to bifurcated iliac repair and preserved IIA) that resolved by 6-month follow-up. Two patients required reinterventions. One patient presented to his first follow-up visit on postoperative day 25 with thrombosis of the right external iliac limb ipsilateral to the bifurcated iliac repair, which was successfully treated with thrombectomy and stenting of the limb. This same patient presented at 83 months with growth of the preserved IIA to 3.9 cm and underwent coil embolization of the aneurysm. Another patient presented for surveillance 44 months after his original repair with component separation of the mating stent and the iliac bifurcated stent grafts. This was treated with a limb extension and endoanchors to fuse the endografts. Of the 13 patients who underwent bifurcated-bifurcated repair, 100% of the preserved IIAs remained patent at last follow-up. The composite outcome measure of IIA patency and freedom from reintervention and clinically significant endoleak at 1 year was 92% (n = 12/13). CONCLUSIONS: In this small retrospective review, bifurcated-bifurcated aneurysm repair of aortoiliac aneurysms with preservation of perfusion to the IIA is technically feasible and safe with good short-term and midterm results in male patients.

A multi-institutional experience in adventitial cystic disease.

BACKGROUND: Adventitial cystic disease (ACD) is an unusual arteriopathy; case reports and small series constitute the available literature regarding treatment. We sought to examine the presentation, contemporary management, and long-term outcomes using a multi-institutional database. METHODS: Using a standardized database, 14 institutions retrospectively collected demographics, comorbidities, presentation/symptoms, imaging, treatment, and follow-up data on consecutive patients treated for ACD during a 10-year period, using Society for Vascular Surgery reporting standards for limb ischemia. Univariate and multivariate analyses were performed comparing treatment methods and factors associated with recurrent intervention. Life-table analysis was performed to estimate the freedom from reintervention in comparing the various treatment modalities. RESULTS: Forty-seven patients (32 men, 15 women; mean age, 43 years) were identified with ACD involving the popliteal artery (n = 41), radial artery (n = 3), superficial/common femoral artery (n = 2), and common femoral vein (n = 1). Lower extremity claudication was seen in 93% of ACD of the leg arteries, whereas patients with upper extremity ACD had hand or arm pain. Preoperative diagnosis was made in 88% of patients, primarily using cross-sectional imaging of the lower extremity; mean lower extremity ankle-brachial index was 0.71 in the affected limb. Forty-one patients with lower extremity ACD underwent operative repair (resection with interposition graft, 21 patients; cyst resection, 13 patients; cyst resection with bypass graft, 5 patients; cyst resection with patch, 2 patients). Two patients with upper extremity ACD underwent cyst drainage without resection or arterial reconstruction. Complications, including graft infection, thrombosis, hematoma, and wound dehiscence, occurred in 12% of patients. Mean lower extremity ankle-brachial index at 3 months postoperatively improved to 1.07 (P < .001), with an overall mean follow-up of 20 months (range, 0.33-9 years). Eight patients (18%) with lower extremity arterial ACD required reintervention (redo cyst resection, one; thrombectomy, three; redo bypass, one; balloon angioplasty, three) after a mean of 70 days with symptom relief in 88%. Lower extremity patients who underwent cyst resection and interposition or bypass graft were less likely to require reintervention (P = .04). One patient with lower extremity ACD required an above-knee amputation for extensive tissue loss. CONCLUSIONS: This multi-institutional, contemporary experience of ACD examines the treatment and outcomes of ACD. The majority of patients can be identified preoperatively; surgical repair, consisting of cyst excision with arterial reconstruction or bypass alone, provides the best long-term symptomatic relief and reduced need for intervention to maintain patency.

Cervical spinal cord injury associated with near-drowning does not increase pneumonia risk or mortality.

Body surfing accidents (BSA) can cause cervical spinal cord injuries (CSCIs) that are associated with near-drowning (ND). The submersion injury from a ND can result in aspiration and predispose to pulmonary complications. We predicted a worse outcome (particularly the development of pneumonia) in patients with CSCIs associated with ND. A retrospective review was performed of patients who were treated at Eastern Virginia Medical School for a CSCI resulting from a blunt mechanism. Data collected included basic demographic data, data regarding injury and in-hospital outcomes, and discharge data, including discharge disposition. Statistics were performed using χ(2) and Student t test. In 2003 to 2008, 141 patients were treated for CSCIs with inclusion criteria. Thirty patients (21%) had an associated ND (BSA) and 111 patients (79%) did not (BLT). The cohorts were similar in mean age (BSA, 45 years; BLT, 50 years; P = 0.16) and male gender distribution (BSA, 93%; BLT, 79%; P = 0.13). The cohorts were similar in injury severity using Injury Severity Score (BSA, 22; BLT, 24; P = 0.65). The cohorts were similar in rates of developing pneumonia (BSA, 3%; BLT, 12%; P = 0.31). The rate of infection was significantly higher in the cohort without an associated near-drowning (BSA, 10%; BLT, 32%; P = 0.033). The mean intensive care unit stay (BSA, 3.5 days; BLT, 11.3 days; P = 0.057) and the rate of mortality were similar (BSA, 10%; BLT, 10% P = 0.99). Those patients with an associated ND had a shorter hospital stay (BSA, 5.7 days; BLT, 22.2 days; P = 0.007) and a better chance of being discharged home (BSA, 57%; BLT, 27%; P = 0.004). CSCIs after a BSA do better than their counterparts without an associated ND. CSCIs associated with ND appear to be isolated injuries with minimal pulmonary involvement despite submersion injuries.

Limitations of the Outback LTD re-entry device in femoropopliteal chronic total occlusions.

OBJECTIVE: Subintimal recanalization for the treatment of femoropopliteal chronic total occlusions (CTO) occasionally requires re-entry devices to access the true lumen distally, but limited information is available on factors predicting the success or failure of these devices. We evaluated the Outback LTD re-entry device (LuMend, Redwood City, Calif; acquired by Cordis Corp, Miami Lakes, Fla). METHODS: A retrospective review of patients with femoropopliteal CTO from August 2006 to August 2009 was performed. Age, gender, occlusion length, site of re-entry, and the angle of the aortic bifurcation were recorded. Procedural angiograms were used to assign a calcification score (none, mild, moderate, severe) at the re-entry site. Univariate and multivariate logistic regression analyses were used to identify factors predicting failure of re-entry into the true lumen. RESULTS: Of 249 CTOs treated, the re-entry device was used 52 times (20.9%): 47 superficial femoral artery (SFA) occlusions and 5 combined SFA and popliteal artery occlusions (33 TransAtlantic InterSociety Consensus II type C and 18 type D lesions). Of 48 procedures with available angiograms for review, the target re-entry site was at the adductor canal in 30 (62.5%), the above-knee popliteal artery in 13 (27.1%), behind the knee joint in 4 (8.3%), and the mid-SFA in 2 (4.2%). Patients (54% men) were a mean age of 73.1 years. Re-entry was successful in 34 attempts (64.5%). Causes of failure included inability to re-enter the true lumen in 11 (61.1%), difficulty tracking the device over a wire in 3 (16.7%), acute angle of aortic bifurcation in 2 (11.1%), mechanical failure of the device in 1 (5.6%), and difficulty tracking the device through the lesion in 1 (5.6%). Moderate or severe calcification at the site of re-entry was the only significant predictor of failure (odds ratio, 6.3; 95% confidence interval, 1.45-24.48; P = .01). An aortic bifurcation angle ≥40° did trend toward predicting success (odds ratio, 0.23; 95% confidence interval, 0.05-1.02; P = .054). CONCLUSIONS: Although the Outback re-entry device can be successful in extending the applicability of endovascular management to difficult femoropopliteal occlusions, it is not uniformly successful in current clinical practice. Significant calcification at the proposed re-entry site is a strong predictor of failure.

The impact of the 80-hour work week on appropriate resident case coverage.

BACKGROUND: On July 1, 2003, the Accreditation Council for Graduate Medical Education (ACGME) required restriction of resident duty hours. Surgical programs were concerned about an expected decrease in operative experience. In our previous study, resident case coverage remained constant with the institution of the restricted duty hours. Several years later, we hypothesized that the level of resident coverage would be less appropriate. MATERIALS AND METHODS: A retrospective study was performed of elective cases scheduled for an academic general surgery practice over three time periods: 1 y prior to institution of restricted duty hours; 1 y later; 3 y later. Data collected included procedure performed, number of attending surgeons and residents present, and resident level. Resident level was defined as appropriate if it matched or exceeded the complexity of the procedure. RESULTS: From July 2002 to June 2003, 890 records of 1278 scheduled cases were available for review. From July 2004 to June 2005, 961 records of 1182 cases were available. From July 2006 to June 2007, 1029 of 1171 records were available. Case coverage was the same or better in the latest time period overall and for each resident level. An appropriate level resident was available for senior level cases similarly during all periods. During the last period, junior and intermediate level cases were more often covered by a resident at the appropriate level of training. CONCLUSIONS: The restricted duty hours have not negatively affected resident case coverage. The level of resident available for operative cases has remained constant for senior level cases. Junior and intermediate level cases were more often covered by an appropriate level resident.

Carotid angioplasty and stenting in anatomically high-risk patients: Safe and durable except for radiation-induced stenosis.

OBJECTIVE: Carotid angioplasty and stenting (CAS) is used in patients considered high-risk for carotid endarterectomy (CEA). Patients qualify as high-risk because of medical comorbid conditions or for anatomic considerations (previous CEA, radical neck dissection, radiation). We compared the technical feasibility and durability of CAS in medically high-risk patients (MED) vs anatomically high-risk patients (ANAT). METHODS: A retrospective review was performed of all consecutive patients undergoing CAS by a single vascular surgery group. All patients were high risk and evaluated with duplex ultrasound imaging and angiography. Primary end points were technical success, 30-day stroke, myocardial infarction (MI), death, and in-stent restenosis. Standard statistical analysis included Kaplan-Meier life tables. RESULTS: From January 2003 to December 2007, 230 CAS (98 ANAT, 132 MED) procedures were attempted. The ANAT cohort comprised 84 patients with a single anatomic risk factor: 71 with a previous ipsilateral CEA, 6 high lesions, 6 history of neck radiation, and 1 with a tracheostomy. Ten patients had two or three anatomic risk factors: nine with radical neck dissection and radiation and one with neck radiation and ipsilateral CEA. The mean age was 71.1 years for ANAT vs 73.9 years for MED (P = .021). Technical success rates were 98% in ANAT and 98.5% in MED (P = .76). Thirty-day stroke rate was 1.0% in ANAT and 5.3% in MED (P = .14); the mortality rate was 2.0% in ANAT and 0.8% in MED (P = .79). The 2-year survival free from stroke was MED, 93.6% and ANAT, 98.9% (P = .118); and from restenosis was MED, 91.9%; and ANAT, 91.0% (P = .98). Two-year overall survival was significantly better in ANAT (84.6%) vs MED (70.1%; P = .026). Four of the seven restenoses in the ANAT group occurred in patients with previous neck radiation. The restenosis rate for radiation-induced (RAD) stenosis treated with CAS was significantly higher at 22.2% (4 of 18) compared with 3.8% (3 of 78) in ANAT group patients without a history of radiation (non-RAD; P = .028). The 2-year restenosis-free survival was 72.7% in the RAD group vs 95.9% in the non-RAD group (P = .017). CONCLUSION: CAS is as technically feasible, safe, and durable in anatomically high-risk patients as in medically high-risk patients, with similar rates of periprocedural stroke and death and late restenosis. However, patients with radiation-induced stenosis appear to be at an increased risk for restenosis.

Outpatient minimally invasive parathyroidectomy is safe for elderly patients.

BACKGROUND: Elderly patients with primary hyperparathyroidism (PHPT) are often not referred for surgical intervention because of concern of comorbid conditions that may increase perioperative complications. Because PHPT is more common in the elderly, we sought to compare indications and complications of minimally invasive parathyroidectomy in patients 70 years of age and older (elderly) with their younger counterparts. STUDY DESIGN: A review was conducted of a prospectively collected database of all patients undergoing parathyroidectomy on our endocrine surgery service. Data collected included patient demographic, biochemical pathologic, and operative findings. Wilcoxon rank sum and chi-square tests were used for comparisons. RESULTS: Three hundred eighty-eight patients with PHPT recently underwent parathyroidectomy over a 3-year period (elderly, n=101; younger, n=287). The elderly cohort had significantly higher median preoperative creatinine (elderly, 2.0 mg/dL; younger,1.0 mg/dL; p=0.002) and parathyroid hormone (elderly, 145 pg/mL; younger, 123 pg/mL; p=0.026) levels. The elderly cohort also had more severe osteoporosis, with a significantly worse median bone mineral density T-score (elderly, -2.5; younger, -1.8; p<0.001). The rate of postoperative complications was similarly low in both groups (elderly, 5.9%; younger, 3.5%; p=0.38). CONCLUSIONS: Minimally invasive parathyroidectomy for PHPT can be performed as safely in elderly patients as in their younger counterparts. Elderly patients with PHPT are more likely to have osteoporosis and higher creatinine levels at the time of surgical referral. Additional study of the role of earlier intervention is warranted.

Intraoperative endoleak during EVAR: frequency, nature, and significance.

OBJECTIVE: Endoleaks are critical complications of endovascular abdominal aortic aneurysm repair (EVAR). This study sought to determine the frequency and nature of intraoperative endoleaks and their impact on postoperative endoleak-related events. METHODS: A retrospective chart review was performed of all patients who underwent EVAR at our institution. The impact of intraoperative endoleaks on postoperative endoleak rates and endoleak-related reintervention rates were assessed. RESULTS: From December 18, 1996, to May 21, 2003, 241 patients underwent EVAR. An endoleak was observed during 126 (52.3%) procedures. Type I endoleaks were observed in 63 (26.1%) cases: 35 proximal and 31 distal endoleaks (3 cases at both attachments). Angioplasty, additional cuff placement, or stenting corrected 59 (89.4%) of these endoleaks. A total of 71 type II intraoperative endoleaks (29.5%) and 8 type IV endoleaks (3.3%) were observed without any attempted corrective maneuvers. Ten type III endoleaks (4.2%) occurred but all resolved with angioplasty or additional cuff placement. In all, 86 (35.7%) endoleaks persisted on completion angiogram. Patients with a type I or type II intraoperative endoleak were more likely to have an endoleak at 1.5 years (31.4% vs. 21.6%, P=.018). Reinterventions were required more often after an intraoperative type I endoleak (10% vs. 4%, P=.003). Patients with intraoperative endoleaks demonstrated a trend toward less postoperative aneurysm diameter reduction at 2 years (43.8% vs. 74.5%, P=.104). CONCLUSION: The presence of a type I or a type II endoleak during EVAR significantly increases the likelihood of a postoperative endoleak and should prompt a high degree of suspicion during follow-up.

Cutaneous melanoma in Asian-Americans.

BACKGROUND: There is little information available on melanoma in non-white populations. Our objective was to characterize melanoma in Asian-Americans (AsA) and compare patient demographics and tumor characteristics with the non-Hispanic White (NHW) population. METHODS: 483,050 cutaneous melanoma patients diagnosed between 1986 and 2005 were identified using the National Cancer Data Base (NCDB); 1,237 were AsA, and 409,564 were NHW. Age, gender, site, histologic type, tumor thickness, AJCC stage, and survival were compared. RESULTS: AsA were more likely to be diagnosed with acral lentiginous tumors (6.7%) than NHW (0.8%, P < 0.001). A greater proportion of AsA were diagnosed with T4 tumors (15.6%) than NHW (8.5%, P < 0.001). AsA presented with fewer early stage I-II tumors and more late stage III-IV tumors than NHW (P < 0.001). Survival was similar for AsA and NHW. CONCLUSIONS: This is the largest study to date on melanoma in AsA. Compared to NHW, AsA are more likely to have acral lentinginous tumors, thick tumors, and higher stage. Despite this, their survival is similar to the NHW population.

The cuff leak test is not predictive of successful extubation.

In intubated patients the presence of a cuff leak (CL) is used as a predictor of successful extubation. CL is proposed to indicate laryngeal edema and predict which patients may develop complications such as postextubation stridor and eventual reintubation. Our objective was to evaluate the reliability of CL in our population of critically ill trauma patients. A retrospective chart review was performed of patients admitted to the trauma service who required mechanical ventilation. All patients undergo the CL test by a single respiratory therapist team before attempted extubation. Data collected included body mass index (BMI), endotracheal tube (ETT) size, length of time of mechanical ventilation, tidal volumes (Vt), and the size of the patient's trachea based on CT scan. The test is performed by the respiratory therapists and involves measuring expired Vt before and after the ETT cuff has been deflated and listening for an audible leak. A positive test result is defined as a CL greater than 10 per cent of Vt or, when volumes are not available, as audible air expired. From October 2005 to May 2006, 150 mechanically ventilated patients were identified and 49 charts were available for review. Forty-one patients had a cuff leak (+CL), whereas eight did not (-CL). The two cohorts were similar in age (+CL = 36.5 years, -CL = 38.1 years, P = 0.82), male gender (+CL = 70%, -CL = 50%, P = 0.25) ETT size (+CL = 7.4, -CL = 7.4, P = 0.57), and BMI (+CL = 28 kg/m2, -CL = 27 kg/m2, P = 0.71). The average tracheal diameter (+CL = 17.4 mm, -CL = 17.5 mm, P = 0.90) as well as the ratio of ETT and tracheal diameter was similar for the two cohorts (+CL = 0.65, -CL = 0.64, P = 0.73). Four patients (10%) in the +CL cohort failed extubation, whereas none of the -CL cohort failed (0%) (P = 0.40). The CL test does not reliably identify those patients who will require reintubation in our trauma population. In addition, the ratio of ETT and tracheal diameter is not predictive of successful extubation.

Effect of the 80-hour work week on resident case coverage: corrected article.

BACKGROUND: On July 1, 2003, residency training programs were required to institute restricted duty hours as mandated by the Accreditation Council for Graduate Medical Education. A major concern,voiced by both surgical residents and faculty, was an expectation that this would result in a decrease in operative experience. We hypothesized that implementing restricted duty hours would decrease case coverage by resident trainees. STUDY DESIGN: A retrospective study was per formed of operative and endoscopic cases scheduled for a single general surgery practice for a year before and after July 1, 2003. Data collected included operation per formed, number of attending surgeons present, whether a resident was present,and level of resident. RESULTS: From July 2002 to June 2003, there were 1,278 cases scheduled; 890 records were available. From July 2004 to June 2005, there were 1,182 cases scheduled; 960 records were available. Before institution of the restricted duty hours, 24.6% of junior-level (PGY1 and 2) cases, 21.7%of intermediate-level (PGY3) cases, and 6.2% of senior-level (PGY4 and 5) cases were not covered by residents. After restricted duty hours were implemented, 27.3% of junior-level cases,15.9% of intermediate-level cases, and 8.1% of senior-level cases were not covered by residents. Overall 20.8% (185 of 890) and 20.4% (196 of 960) of cases were not covered by residents before and after instituting restricted duty hours, respectively. No difference in case coverage was statistically significant in each category or overall. CONCLUSIONS: Restricted duty hours have not affected resident case coverage.

Effect of the 80-hour work week on resident case coverage.

BACKGROUND: On July 1, 2003, residency training programs were required to institute restricted duty hours as mandated by the Accreditation Council for Graduate Medical Education. A major concern, voiced by both surgical residents and faculty, was an expectation that this would result in a decrease in operative experience. We hypothesized that implementing restricted duty hours would decrease case coverage by resident trainees. STUDY DESIGN: A retrospective study was performed of operative and endoscopic cases scheduled for a single general surgery practice for a year before and after July 1, 2003. Data collected included operation performed, number of attending surgeons present, whether a resident was present, and level of resident. RESULTS: From July 2002 to June 2003, there were 1,278 cases scheduled; 890 records were available. From July 2004 to June 2005, there were 1,182 cases scheduled; 960 records were available. Before institution of the restricted duty hours, 24.6% of junior-level (PGY1 and 2) cases, 21.7% of intermediate-level (PGY3) cases, and 6.2% of senior-level (PGY4 and 5) cases were not covered by residents. After restricted duty hours were implemented, 27.3% of junior-level cases, 15.9% of intermediate-level cases, and 8.1% of senior-level cases were not covered by residents. Overall 20.8% (185 of 890) and 20.4% (196 of 960) of cases were not covered by residents before and after instituting restricted duty hours, respectively. No difference in case coverage was statistically significant in each category or overall. CONCLUSIONS: Restricted duty hours have not affected resident case coverage.

Early glucose normalization does not improve outcome in the critically ill trauma population.

Strict control of serum glucose in critically ill patients decreases morbidity and mortality. The objective of this study was to evaluate the effect of early normalization of glucose in our burn and trauma intensive care unit. From January 2002 to June 2005, 290 patients were admitted with serum glucose 150 mg/dL or greater and 319 patients with serum glucose less than 150 mg/dL. The patients with hyperglycemia were more severely injured and more often required operative intervention within the first 48 hours. The patients with hyperglycemia were at increased risk for infection and mortality. Of those 290 patients in the hyperglycemic cohort, 125 patients had early normalization of serum glucose, whereas 165 patients required more than 24 hours to normalize. The early normalization cohort was younger in mean age than the late group, but these 2 groups were similar in injury severity. Correspondingly, there was no difference in the rate of infection. Although hyperglycemia on admission appears to correlate with a worse outcome, early glucose normalization did not affect morbidity and mortality in our critically ill population.

Serum biomarkers to differentiate benign and malignant mammographic lesions.

BACKGROUND: Mammographic screening has increased detection of earlier-stage breast cancers and has decreased mortality from breast cancer. A Breast Imaging-Reporting and Data System (BIRADS) 4 classification prompts a biopsy that most often reveals benign disease. Our objective was to determine if serum protein-expression profiles could be used to differentiate between benign and malignant mammographic lesions. STUDY DESIGN: After IRB approval, women undergoing an image-guided biopsy for a BIRADS category 4 lesion were recruited. Serum was collected prebiopsy and labeled retrospectively after final pathology was reviewed. Serum was incubated with weak cation exchange magnetic beads and assayed in duplicate for analysis on matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) instrumentation (Bruker Daltonics). Spectra were analyzed using ClinProTools 2.0 software (Bruker Daltonics), and classifications determined using a genetic-clustering algorithm. RESULTS: In a 14-month period, 260 subjects were recruited into this study. Sera from 92 subjects were randomly selected to form benign (n = 46) and cancer (n = 46) cohorts. The MALDI-TOF spectra analysis yielded 273 peaks, with 14 peaks expressed differentially (p < 0.05) between the cancer and benign cohorts. A genetic algorithm model was generated, yielding a sensitivity of 88.3% and specificity of 85.8%. CONCLUSIONS: MALDI-TOF protein-expression profiles generated from BIRADS 4 sera could be used to distinguish between benign and malignant mammographic lesions.

Infectious complications after the Nuss repair in a series of 863 patients.

PURPOSE: A nemesis of surgical implants is infection. We evaluated the various infectious complications after Nuss repair of pectus excavatum in 863 patients over 18 years. METHODS: After institutional review board approval, a retrospective review of a prospectively gathered database of patients was performed who underwent minimally invasive repair of pectus excavatum and developed an infection. All patients received intravenous antibiotics before surgery continuing until discharge. Patients with a persistent fever after operation were discharged with oral antibiotics. RESULTS: From January 1987 to September 2005, 863 patients underwent a minimally invasive pectus excavatum repair and 13 (1.5%) developed postoperative infections. These included 6 bar infections, 4 cases of cellulitis, and 3 stitch abscesses. Cellulitis was defined as erythema and warmth which responded to a single course of antibiotics. Bar infections were defined as an abscess in contact with the bar. Surgical drainage and long-term antibiotics resolved 3 of these abscesses, whereas 3 patients required early bar removal (1 after 3 months and 2 after 18 months). Cultures identified a single organism in each case and Staphylococcus aureus was the most common organism (83%) identified, and all being methicillin sensitive. All infections occurred on the side of the stabilizer if a stabilizer had been placed. CONCLUSIONS: Infectious complications after Nuss repair are uncommon and occurred in 1.5% of our patients. Published rates of postoperative infection range from 1.0% to 6.8%. Superficial infections responded to antibiotics alone. Bar infection occurred in only 0.7% and required surgical drainage and long-term antibiotics. Only 3 of these (50% of bar infections and 0.34% overall) required early bar removal at 3 and 18 months because of recurring infections. Early bar removal should be a rare morbidity with the Nuss repair.

Effects of sentinel lymph node biopsy on surgical residency training.

Axillary node dissection (AND) is an integral part of surgical training. Sentinel lymph node biopsy (SLN) was introduced into our residency in 1997. Our purpose in this study was to evaluate the impact of SLN on AND experience. AND/SLN operative experience of residents and attendings at our residency was reviewed using resident case-logs and questionnaires from 2002 and 2005. The perception of performing and teaching AND was assessed. Thirty-three residents and 24 attendings participated. Graduating chiefs from the class of 2000 performed no SLN, which increased to 4.25 in 2002 and to 8.5 in 2005. In contrast, graduating chiefs performed 25 AND in 2000, which decreased to 16.5 in 2002 and to 13.25 in 2005. The majority of the residents felt that AND was a senior level case (56% postgraduate year [PGY] I and II and 87% PGY III-V). The majority of the residents felt that SLN was a junior level case (89% PGY I and II and PGY III-V). Fifty-six per cent of PGY III-V felt that SLN introduction negatively impacted their ability to perform AND. Attendings cited 15 and 24 AND before feeling comfortable performing and teaching the procedure to a resident. Since the introduction of SLN into our residency, the number of AND has decreased, with senior residents feeling that SLN has decreased their ability to perform AND. As fewer AND are performed than our attendings cite to feel comfortable, future residents may not be competent to perform or teach AND.

Follow-up recommendations for benign breast biopsies.

Histologically proven benign breast disease increases a woman's relative risk for subsequent cancer development. Yet follow-up guidelines for mammogram and clinical breast examination after a benign breast biopsy are lacking. Our objective was to determine if increased surveillance is indicated following a benign breast biopsy. Following institutional review board approval, a retrospective database review was conducted of prospectively gathered patients who had a benign breast biopsy (core or excisional) for an abnormality detected on mammogram, ultrasound, or clinical breast examination. Follow-up, for all subjects, was a clinical breast examination and mammogram or ultrasound at 6 months, 1 year, and 2 years after benign breast biopsy by a breast surgeon. End points were the need for additional biopsies or cancer detection. Statistical analysis was performed using chi-squared analysis. From January 2000 to July 2003, 156 patients age 18-86 years had a benign breast biopsy. During the 2 year follow-up, 20 patients (13%) required a subsequent biopsy. No significant difference was observed in mean age, race, menarche, menopause, parity, age at first live birth, use of oral contraceptives, history of prior biopsy, or the pathology of the initial lesion between those who needed a subsequent biopsy and those who did not. Seven excisional biopsies were performed (one at 6 months, four at 1 year, and two at 2 years follow-up) for growth of the benign breast biopsy lesion, and pathology remained concordant with the original diagnosis. Thirteen biopsies were done for new findings on mammogram or ultrasound. Three of these (1.9%) yielded a cancer diagnosis (one at 6 months, one at 1 year, and one at 2 years follow-up). No new lesions were identified on follow-up by clinical breast examination alone. Increased surveillance following a benign breast biopsy is necessary because of the increased need for subsequent biopsy or risk of cancer development. This should include imaging (mammography or ultrasound) and a clinical breast examination 6 months, 1 year, and 2 years after a benign breast biopsy.