Journal of the American College of Surgeons (J AM COLL SURGEONS)

Publications in this journal

• Article: Personal Reflections on the First 50 Years of Cardiovascular Surgery.

  John E Connolly
  Journal of the American College of Surgeons 05/2013;
• Article: Defining Surgical Quality in Gastric Cancer: A RAND/UCLA Appropriateness Study.

  Savtaj Brar, Calvin Law, Robin McLeod, Lucy Helyer, Carol Swallow, Lawrence Paszat, Rajini Seevaratnam, Roberta Cardoso, Matthew Dixon, Alyson Mahar, [......], Norman Marcon, Thomas Miner, Sung Hoon Noh, Geoff Porter, Mitchell C Posner, Vivek Prachand, Takeshi Sano, Cornelis van de Velde, Sandra Wong, Natalie Coburn
  Journal of the American College of Surgeons 05/2013;
• Article: Pediatric Specialist Care Is Associated with a Lower Risk of Bowel Resection in Children with Intussusception: A Population-Based Analysis.

  Jarod P McAteer, Steve Kwon, Cabrini A Lariviere, Keith T Oldham, Adam B Goldin
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  ABSTRACT: BACKGROUND: Although previous studies have shown that radiologic intussusception reduction is more likely at children's hospitals, no study to date has compared outcomes among children advancing to surgical intervention. We hypothesized that rates of bowel resection would differ between hospitals with and without pediatric surgeons. STUDY DESIGN: We conducted a population-based retrospective cohort study using Washington State discharge records. All children younger than 18 years undergoing operative intussusception reduction between 1999 and 2009 were included (n = 327). Data were collected on demographics, disease severity, comorbidities, and concomitant gastrointestinal pathology. Multivariate logistic regression was used to estimate odds of intestinal resection during operative intussusception reduction. RESULTS: Pediatric hospitals treated a smaller proportion of children older than 4 years of age (12.1% vs 44.4%), as well as a greater proportion of Medicaid patients (50.9% vs 42.6%). Patients at pediatric hospitals had a lower prevalence of underlying intestinal anomalies or identifiable mass lesions (14.3% vs 16.7%). "Severe disease" (perforation, ischemia, acidosis) was more common at pediatric hospitals (17.6% vs 9.3%). Overall, bowel resection was more commonly performed at nonpediatric hospitals (59.3% vs 33.0%). On multivariate analysis, the odds of bowel resection were significantly lower at pediatric compared with nonpediatric hospitals (odds ratio [OR] 0.20, p < 0.001), and this association was strongest in younger patients. Adjusted odds of postoperative complications were greater for bowel resection patients (OR 2.83, p < 0.001). CONCLUSIONS: Bowel resection during operative intussusception reduction is more likely at hospitals without pediatric surgeons, and is associated with increased complications. Improved outcomes may be achieved by efforts aimed at standardizing care and decreasing variability in the treatment of pediatric intussusception.
  Journal of the American College of Surgeons 05/2013;
• Article: Health Disparities Analysis of Critically Ill Pediatric Trauma Patients in Milwaukee, Wisconsin.

  Laura D Cassidy, Daphne Lambropoulos, Jessica Enters, David Gourlay, Mina Farahzad, Dave R Lal
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  ABSTRACT: BACKGROUND: Injury is the leading cause of childhood morbidity and mortality in the US. The associated costs exceed $20 billion annually. This study examined disparities in disadvantaged populations of critically injured pediatric patients admitted to a level 1 pediatric trauma center. STUDY DESIGN: A retrospective study was conducted of all trauma patients admitted to the pediatric intensive care unit (PICU) at a level 1 pediatric trauma hospital from 2005 to 2009. RESULTS: Data on 324 patients were analyzed; 45% of patients were Caucasian, 33% were African American, 12% were Hispanic, and 10% were other. There was no difference in age, Glasgow Coma Scale (GCS), or Injury Severity Score (ISS) across ethnic groups. The mortality rate was 12%. A higher percentage of Caucasians were commercially insured and from the highest income quartile than non-Caucasians (p < 0.001). African Americans had the highest rate of penetrating trauma and intentional injury compared with other ethnicities (p < 0.001). Nearly 75% of firearm injuries were clustered in 7 ZIP codes with the lowest median household incomes. The home was the most common location for firearm injuries. Children involved in assaults were more likely to have a single parent (67%) than 2 parents (26%, p < 0.001). Both ethnicity and payer status were significantly associated with mortality. CONCLUSIONS: Significant disparities in socioeconomic status exist in severely injured pediatric patients treated in the PICU. Disparities were associated with adverse outcomes. These results should inform community and public health efforts to identify the areas and populations at highest risk for violence-related injuries.
  Journal of the American College of Surgeons 05/2013;
• Article: The Biopsy-Proven Benign Thyroid Nodule: Is Long-Term Follow-Up Necessary?

  Sukhyung Lee, Thomas S Skelton, Feibi Zheng, Katherine A Schwartz, Nancy D Perrier, Jeffrey E Lee, Roland L Bassett, Salmaan Ahmed, Savitri Krishnamurthy, Naifa L Busaidy, Elizabeth G Grubbs
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  ABSTRACT: BACKGROUND: Thyroid nodules are common, and of those biopsied by fine-needle aspiration (FNA), the majority will be benign colloid nodules (BCN). Current guidelines suggest these BCN should be followed by ultrasonographic examination (US) every 3 years, with no endpoint specified. This study evaluated if long-term follow-up of benign thyroid nodules was associated with change in treatment or improvement in diagnosing a missed malignancy compared with short-term follow-up. STUDY DESIGN: All patients with FNA-based diagnosis of BCN at our institution from 1998 to 2009 were identified. Patients observed after the diagnosis were divided into short-term follow-up (<3years) and long-term follow-up (≥3years). Rates of repeat FNA, thyroidectomy, and malignancy detection were compared. RESULTS: Of 738 patients with BCN, 92 patients underwent thyroid resection after the initial US. Six hundred forty-six patients were observed, of which 366 returned for 1 or more follow-up US: 226 in the short-term group (median 13 months) and 140 in the long-term group (median 57 months). There were more follow-up US in long-term vs short-term (medians 4 vs 2, p < 0.01), more repeat FNAs in the long-term group (18 of 140 vs 8 of 226, p < 0.01); but no difference in interval thyroidectomies (13 of 140 vs 31 of 226, p = 0.25) or malignant final pathology (0 of 13 vs 2 of 31, p > 0.99). For all patients undergoing surgery, pathology was malignant in 2 of 136 (1.5%). CONCLUSIONS: Long-term follow-up of patients with BCN is associated with increased repeat FNA and US without improvement in the malignancy detection rate. After 3 years of follow-up, consideration should be given to ceasing long-term routine follow-up of biopsy-proven BCN.
  Journal of the American College of Surgeons 05/2013;
• Article: Predicting Lymph Node Metastases in Early Esophageal Adenocarcinoma Using a Simple Scoring System.

  Lawrence Lee, Ulrich Ronellenfitsch, Wayne L Hofstetter, Gail Darling, Timo Gaiser, Christiane Lippert, Sebastien Gilbert, Andrew J Seely, David S Mulder, Lorenzo E Ferri
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  ABSTRACT: BACKGROUND: Endoscopic resection is an organ-sparing option for early esophageal adenocarcinoma, but should be used only in patients with a negligible risk of lymph node metastases (LNM). The objective was to develop a simple scoring system to predict LNM in T1 esophageal adenocarcinoma. STUDY DESIGN: All primary esophagectomies performed for T1 esophageal adenocarcinoma without neoadjuvant therapy at 5 university institutions from 2000 to 2011 were analyzed. Patient and pathologic characteristics were compared between patients with LNM at the time of surgical resection and those without. Univariate and multivariate analyses were performed to establish a simple scoring system that estimated the risk of LNM, using variables from the final surgical pathology. RESULTS: A total of 258 patients were included for analysis (mean age 65.2 years [SD 10.3 years], 88% male). The incidence of LNM was 7% (9 of 122) for T1a and 26% (35 of 136) for T1b. Tumor size (odds ratio [OR] 1.35 per cm, 95% CI 1.07 to 1.71) and lymphovascular invasion (OR 7.50, 95% CI 3.30 to 17.07) were the strongest independent predictors of LNM. A weighted scoring system was devised from the final multivariate model and included size (+1 point per cm), depth of invasion (+2 for T1b), differentiation (+3 for each step of dedifferentiation), and lymphovascular invasion (+6 if present). Total number of points estimated the probability of LNM (low risk [0 to 1 point], ≤2%; moderate risk [2 to 4 points], 3% to 6%; and high risk [5+ points], ≥7%). CONCLUSIONS: We devised a simple scoring system that accurately estimates the risk of LNM to aid in decision-making in patients with T1 esophageal adenocarcinoma undergoing endoscopic resection.
  Journal of the American College of Surgeons 05/2013;
• Article: Late Recurrence in Melanoma: Clinical Implications of Lost Dormancy.

  Mark B Faries, Shawn Steen, Xing Ye, Myung Sim, Donald L Morton
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  ABSTRACT: BACKGROUND: For patients with melanoma, if there has been no recurrence of disease 10 years after initial treatment, additional disease is believed to be very unlikely. However, such late recurrences are known to occur. The frequency of this phenomenon and its clinical significance are not well characterized due to the difficulty in obtaining relevant data. We examined a large, mature, institutional database to evaluate late recurrence. STUDY DESIGN: The late recurrence cohort was defined as having a disease-free interval of 10 or more years after potentially curative treatment and was compared with an early recurrence cohort recurring within 3 years. Actuarial late recurrence frequency and factors associated with late recurrence were examined. Post-recurrence overall and melanoma-specific survival and prognostic variables were analyzed. RESULTS: Among all patients, 408 exhibited late recurrence (mean disease-free interval 15.7 years). For patients who received primary treatment at our institution with 10 or more years follow-up, 327 of 4,731 (6.9%) showed late recurrence. On an actuarial basis, late recurrence rates were 6.8% and 11.3% at 15 and 20 years, respectively, for those with no recurrence at 10 years. Late recurrence was associated with both tumor (thin, non-ulcerated, non-head/neck, node negative) and patient (younger age, less male predominant) characteristics. Multivariate analysis confirmed younger age, thinner and node negative tumors in the late recurrence group. Late recurrences were more likely to be distant, but were associated with better post-recurrence survival on univariate and multivariate analyses. CONCLUSIONS: Late melanoma recurrence is not rare. It occurs more frequently in certain clinical groups and is associated with improved post-recurrence survival.
  Journal of the American College of Surgeons 05/2013;
• Article: Management of appendicitis and cholecystitis.

  Brendan J Carroll
  Journal of the American College of Surgeons 05/2013; 216(5):1026.
• Article: Fluid resuscitation for burn patients at risk for abdominal complications.

  Tetsuji Fujita
  Journal of the American College of Surgeons 05/2013; 216(5):1027.
• Article: Reply.

  Nephtali Gomez, Carlos A Garberoglio
  Journal of the American College of Surgeons 05/2013; 216(5):1026.
• Article: Reply.

  John Alfred Carr
  Journal of the American College of Surgeons 05/2013; 216(5):1028.
• Article: Predictors of Chronic Groin Discomfort after Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair.

  Shahzad M Ali, Benjamin Zendejas, Siddhant Yadav, Roberto C Hernandez-Irizarry, Christine M Lohse, David R Farley
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  ABSTRACT: BACKGROUND: Chronic groin discomfort is an undesired complication of laparoscopic totally extraperitoneal (TEP) inguinal hernia repairs. We examined whether perioperative factors may be associated with an increased risk of developing this problem and if their recognition could lead to preventive strategies. STUDY DESIGN: We performed a retrospective review of 1 surgeon's experience with 1,479 TEP repairs on 976 patients from 1995 to 2009. A mailed survey, which included a groin discomfort questionnaire (Carolinas Comfort Scale), was distributed to all patients. Symptom severity grading (range 0, none to 5, severe) was used to sort individual responses. Perioperative factors were compared between asymptomatic and symptomatic patients with varying levels of discomfort. RESULTS: There were 691 patients (71%) who provided complete responses to the questionnaire. Median follow-up was 5.7 years (range 0 to 14.4 years). The majority (n = 543, 79%) denied any symptoms of mesh sensation, pain, or movement limitation. In the remaining 148 (21%) patients, symptoms were most often mild (n = 108), followed by mild but bothersome (n = 25), and 15 patients (2%) had moderate or severe symptoms. Symptomatic patients were younger (median age 52 vs 57 years, p = 0.002) and were more likely to have had the TEP repair for recurrent hernias (24% vs 17%, p = 0.035). Operative diagnosis, bilateral exploration, mesh fixation techniques, perioperative complications, American Society of Anesthesiologists grade, and length of hospital stay were not associated with chronic groin discomfort. CONCLUSIONS: The majority of patients are asymptomatic after a laparoscopic TEP inguinal hernia repair. Most of the symptomatic patients do not have any bothersome symptoms. Given that younger age and a repair for recurrent hernia were predictors of chronic groin discomfort, we counsel these patients about their increased risks.
  Journal of the American College of Surgeons 04/2013;
• Article: A Negative Urinalysis Rules Out Catheter-Associated Urinary Tract Infection in Trauma Patients in the Intensive Care Unit.

  Robert T Stovall, James B Haenal, Timothy C Jenkins, Gregory J Jurkovich, Fredric M Pieracci, Walter L Biffl, Carlton C Barnett, Jeffrey L Johnson, Denis D Bensard, Ernest E Moore, Clay Cothren Burlew
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  ABSTRACT: BACKGROUND: Urinary tract infection (UTI) in trauma patients is associated with increased mortality. Whether the urinalysis (UA) is an adequate test for a urinary source of fever in the ICU trauma patient has not been demonstrated. We hypothesized that the UA is a valuable screen for UTI in the febrile, critically ill trauma patient. STUDY DESIGN: All trauma ICU patients in our surgical ICU who had a fever (temperature >38.0°C), urinary catheter, UA, and a urine culture between January 1, 2011 and December 13, 2011 were reviewed. A positive UA was defined as positive leukocyte esterase, positive nitrite, WBC > 10/high power field, or presence of bacteria. A positive urine culture was defined as growth of ≥10(5) colony forming units (cfu) of an organism irrespective of the UA result or ≥10(3) cfu in the setting of a positive UA. A UTI was defined as positive urine culture without an alternative cause of the fever. RESULTS: There were 232 UAs from 112 patients that met criteria. The majority (75%) of patients were men; the mean age was 40 (±16) years. Of the 232 UAs, 90 (38.7%) were positive. There were 14 UTIs. The sensitivity, specificity, positive predictive value, and negative predictive value of the UA for UTI were 100%, 65.1%, 15.5%, and 100%, respectively. CONCLUSIONS: A negative UA reliably excludes a catheter-associated UTI in the febrile, trauma ICU patient with a 100% negative predictive value, and it can rapidly direct the clinician toward more likely sources of fever and reduce unnecessary urine cultures.
  Journal of the American College of Surgeons 04/2013;
• Article: Outcomes with Split Liver Transplantation Are Equivalent to Those with Whole Organ Transplantation.

  M B Majella Doyle, Erin Maynard, Yiing Lin, Neeta Vachharajani, Surendra Shenoy, Christopher Anderson, Mark Earl, Jeffrey A Lowell, William C Chapman
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  ABSTRACT: BACKGROUND: Split liver transplantation is an excellent option for expansion of the donor organ pool. However, reports of increased morbidity in split liver recipients may limit use of this technique. STUDY DESIGN: This was a single center retrospective analysis investigating split liver transplantation. Between August 1, 1995 and March 30, 2012, 53 of 1,261 (4.2%) recipients received split liver grafts. RESULTS: The 1-, 5-, and 10-year patient and graft survivals in adult recipients of split grafts were 95.5%, 89.5%, and 89.5%, respectively. Survival was similar to that of whole organ recipients (p = 0.15). Twenty-three adults received split grafts: 18 (78%) were right trisegment grafts, 4 (17.4%) were right lobes, and 1 (4.3%) was a left lobe. The mean cold ischemic time was 5.7 hours (±2.4 hours [SD]) and warm ischemic time was 36 minutes (±5.5 minutes). Four (17%) recipients required hepatic artery reconstruction; 5 (21.7%) required a caval-venous patch, and 5 (21.7%) had Roux-en-Y reconstruction of the bile duct. No venous conduits were required. Thirty children received split grafts (median age 1.2 years, range 0.1 to 16.4 years) and had a median weight of 8.6 kg (range 3.6 to 45 kg). Pediatric split 1-, 5-, and 10-year overall and graft survival rates were 96.7%, 80.0%, 80.0%, and 93.3%, 76.8, and 76.8%, respectively. Complications included retransplantation in 3 (10.0%), bile leak in 5 (16.7%), hepatic arterial thrombosis in 2 (6.7%), bowel perforation in 2 (6.7%), and bleeding in 2 (6.7%). The mean donor age was 22.4 months (±8.9) months and body mass index was 22.8 kg/m(2) (±3.3 kg/m(2)). CONCLUSIONS: We demonstrated excellent outcomes in adult and pediatric recipients using carefully selected donors for liver splitting. We recommend escalation of the use of split liver transplants to expand the donor pool for cadaveric liver transplantation.
  Journal of the American College of Surgeons 04/2013;
• Article: Analysis of the Efficacy of Portal Vein Embolization for Patients with Extensive Liver Malignancy and Very Low Future Liver Remnant Volume, Including a Comparison with the Associating Liver Partition with Portal Vein Ligation for Staged Hepatectomy Approach.

  Junichi Shindoh, Jean-Nicolas Vauthey, Giuzeppe Zimmitti, Steven A Curley, Steven Y Huang, Armeen Mahvash, Sanjay Gupta, Michael J Wallace, Thomas A Aloia
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  ABSTRACT: BACKGROUND: The primary reported indication for the associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) technique is in patients with very low future liver remnant volumes. Given the elevated incidence of major morbidity (40%) and liver-related mortality (12%) with ALPPS, we sought to determine the safety and efficacy of percutaneous portal vein embolization (PVE) in a similar patient population. STUDY DESIGN: Tumor resectability and morbidity and mortality rates were reviewed for 144 consecutive liver tumor patients with future liver remnant to body weight ratios (LR/BW) less than 0.5%. All patients were referred for preoperative percutaneous right plus segment IV PVE using embolic microspheres, with planned reassessment of the LR/BW 30 days after PVE. Post-PVE outcomes were compared with reported outcomes for ALPPS. RESULTS: Percutaneous PVE was successfully performed in 141 of the 144 study patients (97.9%). Adequate regeneration was observed in 139 patients (98.5%) with median post-PVE LR/BW rising from 0.33% to 0.52% (p < 0.0001), representing a per-patient median regeneration rate of 62% (range 0.3% to 379%). In total, 104 patients underwent extended right hepatectomy (n = 102) or right hepatectomy (n = 2). The remaining 40 patients (27.8%) were not resectable due to short-interval disease progression (27 patients, 18.5%), insufficient liver regeneration (5 patients, 3.5%), and medical comorbidities (8 patients, 5.6%). After resection, the following outcomes were observed: major morbidity: 33.0% (34 of 104), liver insufficiency: 12.5% (13 of 104), and 90-day liver-related mortality: 5.8% (6 of 104). These oncologic and technical results compare favorably with those of ALPPS. CONCLUSIONS: Based on its ability to select oncologically resectable patients and superior safety and efficacy profiles, percutaneous right + segment IV PVE and interval surgery remains the standard of care for patients with very low future liver remnant volumes.
  Journal of the American College of Surgeons 04/2013;
• Article: Preoperative Axillary Ultrasound in Breast Cancer: Safely Avoiding Frozen Section of Sentinel Lymph Nodes in Breast-Conserving Surgery.

  Irada Ibrahim-Zada, Clive S Grant, Katrina N Glazebrook, Judy C Boughey
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  ABSTRACT: BACKGROUND: The American College of Surgeons Oncology Group Z0011 trial results provided convincing evidence that completion axillary lymph node dissection (CALND) was unnecessary in selected patients with 1 to 2 positive sentinel lymph nodes (SLNs). We hypothesized that preoperative axillary ultrasound (AUS) with fine-needle aspiration is sufficiently sensitive to detect worrisome macrometastasis to preclude the need for frozen-section pathology of SLNs. STUDY DESIGN: We conducted a retrospective single-institution study at a tertiary academic referral center. A total of 1,140 T1 to 2 breast cancer patients who underwent SLN biopsy with or without CALND from January 1, 2007 to December 31, 2010 were reviewed. All patients had negative preoperative AUS with or without fine-needle aspiration. RESULTS: One hundred forty-four (13%) patients were node positive at surgery. Mean age, tumor size, histology, and estrogen receptor and progesterone receptor status were similar comparing 996 SLN-negative with 144 (13%) SLN-positive patients. Of the SLN-positive patients, 25% were premenopausal, 9% were estrogen receptor-negative, and 19% had additional lymph nodes at CALND. Only 19 (2%) patients had SLN metastasis ≥6 mm, 10 (1%) had metastasis >7 mm, and only 1 patient had ≥3 positive SLNs. CONCLUSIONS: The addition of preoperative AUS with or without fine-needle aspiration to management of patients who meet American College of Surgeons Oncology Group Z0011 trial eligibility criteria reduced the risk of macrometastasis measuring ≥6 mm to only 2%; very few of these patients would be premenopausal, have estrogen receptor-negative tumors, or ≥3 positive SLNs. With the addition of AUS with or without fine-needle aspiration, we endorse the conclusions of the American College of Surgeons Oncology Group Z0011 trial to avoid CALND, and see marginal gain in frozen-section analysis of SLNs.
  Journal of the American College of Surgeons 04/2013;
• Article: Aspiration, Localized Pulmonary Inflammation, and Predictors of Early-Onset Bronchiolitis Obliterans Syndrome after Lung Transplantation.

  P Marco Fisichella, Christopher S Davis, Erin Lowery, Luis Ramirez, Richard L Gamelli, Elizabeth J Kovacs
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  ABSTRACT: BACKGROUND: We hypothesized that immune mediator concentrations in the bronchoalveolar fluid (BALF) are predictive of bronchiolitis obliterans syndrome (BOS) and demonstrate specific patterns of dysregulation, depending on the presence of acute cellular rejection, BOS, aspiration, and timing of lung transplantation. STUDY DESIGN: We prospectively collected 257 BALF samples from 105 lung transplant recipients. The BALF samples were assessed for absolute and differential white blood cell counts and 34 proteins implicated in pulmonary immunity, inflammation, fibrosis, and aspiration. RESULTS: There were elevated BALF concentrations of interleukin (IL)-15, IL-17, basic fibroblast growth factor, tumor necrosis factor-α, and myeloperoxidase, and reduced concentrations of α1-antitrypsin, which were predictive of early-onset BOS. Patients with BOS had an increased percentage of BALF lymphocytes and neutrophils, with a reduced percentage of macrophages (p < 0.05). The BALF concentrations of IL-1β; IL-8; interferon-γ-induced protein 10; regulated upon activation, normal T-cell expressed and secreted; neutrophil elastase; and pepsin were higher in patients with BOS (p < 0.05). Among those with BOS, BALF concentrations of IL-1RA; IL-8; eotaxin; interferon-γ-induced protein 10; regulated upon activation, normal T-cell expressed and secreted; myeloperoxidase; and neutrophil elastase were positively correlated with time since transplantation (p < 0.01). Those with worse grades of acute cellular rejection had an increased percentage of lymphocytes in their BALF (p < 0.0001) and reduced BALF concentrations of IL-1β, IL-7, IL-9, IL-12, granulocyte colony-stimulating factor, granulocyte-macrophage colony-stimulating factor, interferon-γ, and vascular endothelial growth factor (p ≤ 0.001). Patients with aspiration based on detectable pepsin had increased percentage of neutrophils (p < 0.001) and reduced BALF concentrations of IL-12 (p < 0.001). CONCLUSIONS: The BALF levels of IL-15, IL-17, basic fibroblast growth factor, tumor necrosis factor-α, myeloperoxidase, and α1-antitrypsin at 6 to 12 months after lung transplantation are predictive of early-onset BOS, and those with BOS and aspiration have an augmented chemotactic and inflammatory balance of pulmonary leukocytes and immune mediators. These data justify the surgical prevention of aspiration and argue for the refinement of antirejection regimens.
  Journal of the American College of Surgeons 04/2013;
• Article: Improving Clinical Productivity in an Academic Surgical Practice Through Transparency.

  Charles R Scoggins, Timothy Crockett, Lex Wafford, Robert M Cannon, Kelly M McMasters
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  ABSTRACT: BACKGROUND: Patient care revenue is becoming an increasingly important source of funding to support the academic surgery department missions of research and education. Transparency regarding productivity metrics will improve clinical productivity among members of an academic surgical practice. STUDY DESIGN: Clinical productivity-related data were collected and compared between 2 time periods. Data were stratified by pretransparency and post-transparency time periods. Comparisons were made using the Wilcoxon-Mann-Whitney test, and p values ≤0.05 were considered significant. RESULTS: The faculty compensation plan remained the same across both time periods; faculty members were paid a base salary plus practice plan income based on individual collections minus practice overhead and academic program support taxes. Before 2006, clinical productivity data were not made public among faculty members. In 2006, the departmental leadership developed a physician scorecard that led to transparency with regard to productivity. After publication of the scorecard, clinical productivity increased, as did the number of partners producing a threshold number of work relative value units (RVU) (6,415 wRVU = 1.0 full time equivalent [FTE]). This occurred during a time of reduced collections per RVU. There was no change in the work assignments (percent effort for clinical service, research, and teaching) for the physicians between the 2 time periods, or the overall effort assigned to the Veterans Affairs hospital. CONCLUSIONS: Clinical productivity can be improved by making productivity metrics transparent among faculty members. Additional measures must be taken to ensure that research and teaching activities are appropriately incentivized.
  Journal of the American College of Surgeons 04/2013;
• Article: Development and Validation of a Necrotizing Soft-Tissue Infection Mortality Risk Calculator Using NSQIP.

  Iris Faraklas, Gregory J Stoddard, Leigh A Neumayer, Amalia Cochran
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  ABSTRACT: BACKGROUND: Necrotizing soft-tissue infections (NSTI) are a group of uncommon, rapidly progressive infections requiring prompt surgical debridement and systemic support. A previous attempt to define risk factors for mortality from NSTI had multiple limitations. The objective of this study was to develop and validate a 30-day postoperative mortality risk calculator for patients with NSTI using NSQIP. STUDY DESIGN: The NSQIP Participant Use Files (2005-2010) were used as the primary data source. Patients diagnosed with NSTI were identified by ICD-9 codes. Multiple logistic regression analysis identified key preoperative variables predicting mortality. Bootstrap analysis was used to validate the model. RESULTS: In 1,392 identified NSTI cases, demographics were as follows: 42% were female, median age was 55 years (interquartile range 46 to 63 years), and median body mass index was 32 kg/m(2) (interquartile range 26 to 40 kg/m(2)). Thirty-day mortality was 13%. Seven independent variables were identified that correlated with mortality: age older than 60 years (odds ratio [OR] = 2.5; 95% CI 1.7-3.6), functional status (partially dependent: OR = 1.6; 95% CI 1.0-2.7; totally dependent: OR = 2.3; 95% CI 1.4-3.8), requiring dialysis (OR = 1.9; 95% CI 1.2-3.1), American Society of Anesthesiologists class 4 or higher (OR = 3.6; 95% CI 2.3-5.6), emergent surgery (OR = 1.6; 95% CI 1.0-2.3), septic shock (OR = 2.4; 95% CI 1.6-3.6), and low platelet count (<50K/μL: OR = 3.5; 95% CI 1.6-7.4; <150K/μL but >50K/μL: OR = 1.9; 95% CI 1.2-2.9). The receiver operating characteristic area was 0.85 (95% CI 0.82-0.87), which indicated a strong predictive model. Using bootstrap validation, the optimism-corrected receiver operating characteristic area was 0.83 (95% CI 0.81-0.86), which represents the model performance in future patients. The model was used to develop an interactive risk calculator. CONCLUSIONS: This risk calculator has excellent predictive ability for mortality in patients with NSTI. This simple interactive tool can aid physicians and patients in the decision-making process.
  Journal of the American College of Surgeons 04/2013;