Fellowship training in Acute Care Surgery: from inception to current state.

Recognizing the need for urgent and emergent surgical care across America, the American Association for the Surgery of Trauma developed and implemented, and oversees, the Acute Care Surgery Fellowship Training Program. Now in its 10th year, the fellowship has become an established post-General Surgery Fellowship Training Program, with 20 approved programs and 82 fellows trained. Consistent with the desire to have this non-Accreditation Council for Graduate Medical Education (ACGME) fellowship one with the highest standards, several educational improvements have occurred since its origin. The following is an account of the background and evolution of what has become a significant educational contribution to surgery

Body mass index, abdominal fatness, fat mass and the risk of atrial fibrillation: a systematic review and dose–response meta-analysis of prospective studies

Different adiposity measures have been associ- ated with increased risk of atrial fibrillation, however, results have previously only been summarized for BMI. We therefore conducted a systematic review and meta- analysis of prospective studies to clarify the association between different adiposity measures and risk of atrial fibrillation. PubMed and Embase databases were searched up to October 24th 2016. Summary relative risks (RRs) were calculated using random effects models. Twenty-nine unique prospective studies (32 publications) were included. Twenty-five studies (83,006 cases, 2,405,381 participants) were included in the analysis of BMI and atrial fibrillation. The summary RR was 1.28 (95% confidence interval: 1.20–1.38, I 2 = 97%) per 5 unit increment in BMI, 1.18 (95% CI: 1.12–1.25, I 2 = 73%, n = 5) and 1.32 (95% CI: 1.16–1.51, I 2 = 91%, n = 3) per 10 cm increase in waist and hip circumference, respectively, 1.09 (95% CI: 1.02–1.16, I 2 = 44%, n = 4) per 0.1 unit increase in waist- to-hip ratio, 1.09 (95% CI: 1.02–1.16, I 2 = 94%, n = 4) per 5 kg increase in fat mass, 1.10 (95% CI: 0.92–1.33, I 2 = 90%, n = 3) per 10% increase in fat percentage, 1.10 (95% CI: 1.08–1.13, I 2 = 74%, n = 10) per 5 kg increase in weight, and 1.08 (95% CI: 0.97–1.19, I 2 = 86%, n = 2) per 5% increase in weight gain. The association between BMI and atrial fibrillation was non- linear, p nonlinearity \ 0.0001, with a stronger association at higher BMI levels, however, increased risk was observed even at a BMI of 22–24 compared to 20. In conclusion, general and abdominal adiposity and higher body fat mass increase the risk of atrial fibrillation

A Primer on Quality Assurance and Performance Improvement for Interprofessional Chronic Kidney Disease Care: A Path to Joint Commission Certification.

Interprofessional care for chronic kidney disease facilitates the delivery of high quality, comprehensive care to a complex, at-risk population. Interprofessional care is resource intensive and requires a value proposition. Joint Commission certification is a voluntary process that improves patient outcomes, provides external validity to hospital administration and enhances visibility to patients and referring providers. This is a single-center, retrospective study describing quality assurance and performance improvement in chronic kidney disease, Joint Commission certification and quality outcomes. A total of 440 patients were included in the analysis. Thirteen quality indicators consisting of clinical and process of care indicators were developed and measured for a period of two years from 2009-2017. Significant improvements or at least persistently high performance were noted for key quality indicators such as blood pressure control (85%), estimation of cardiovascular risk (100%), measurement of hemoglobin A1c (98%), vaccination (93%), referrals for vascular access and transplantation (100%), placement of permanent dialysis access (61%), discussion of advanced directives (94%), online patient education (71%) and completion of office visit documentation (100%). High patient satisfaction scores (94-96%) are consistent with excellent quality of care provided

Secular Trends in Cardiovascular Disease in Kidney Transplant Recipients: 1994 to 2009

Cardiovascular events are a major cause of morbidity and mortality in kidney transplant recipients. We conducted a retrospective study using healthcare databases in Ontario, Canada to determine whether the incidence of cardiovascular events has changed from 1994 to 2009 in 4954 kidney transplant recipients. Our primary endpoint was a 3-year composite outcome of post-transplant death or cardiovascular event (myocardial infarction, percutaneous coronary intervention, coronary artery bypass graft, or stroke). Recipients were older and had more baseline co-morbidity in recent eras (1994-1997 vs. 2006-2009: median age 45 vs. 53 years; coronary artery disease 22% vs. 37%). A total of 445 recipients (9.0%) died or experienced a cardiovascular event within 3 years. There was no significant change in the composite outcome or death-censored cardiovascular events (p=0.41 and 0.92, respectively) over time. Despite transplant centers accepting recipients who are older with more co-morbidities, the incidence of death or cardiovascular event has remained stable

Editor's Choice - Delays to Surgery and Procedural Risks Following Carotid Endarterectomy in the UK National Vascular Registry.

OBJECTIVE: Guidelines recommend that patients suffering an ischaemic transient ischaemic attack (TIA) or stroke caused by carotid artery stenosis should undergo carotid endarterectomy (CEA) within 14 days. METHOD: The degree to which UK vascular units met this standard was examined and whether rapid interventions were associated with procedural risks. The study analysed patients undergoing CEA between January 2009 and December 2014 from 100 UK NHS hospitals. Data were collected on patient characteristics, intervals of time from symptoms to surgery, and 30-day postoperative outcomes. The relationship between outcomes and time from symptom to surgery was evaluated using multilevel multivariable logistic regression. RESULTS: In 23,235 patients, the median time from TIA/stroke to CEA decreased over time, from 22 days (IQR 10-56) in 2009 to 12 days (IQR 7-26) in 2014. The proportion of patients treated within 14 days increased from 37% to 58%. This improvement was produced by shorter times across the care pathway: symptoms to referral, from medical review to being seen by a vascular surgeon, and then to surgery. The spread of the median time from symptom to surgery among NHS hospitals shrank between 2009 and 2013 but then grew slightly. Low-, medium-, and high-volume NHS hospitals all improved their performance similarly. Performing CEA within 48 h of symptom onset was associated with a small increase in the 30-day stroke and death rate: 3.1% (0-2 days) compared with 2.0% (3-7 days); adjusted odds ratio 1.64 (95% CI 1.04-2.59) but not with longer delays. CONCLUSIONS: The delay from symptom to CEA in symptomatic patients with ipsilateral 50-99% carotid stenoses has reduced substantially, although 42% of patients underwent CEA after the recommended 14 days. The risk of stroke after CEA was low, but there may be a small increase in risk during the first 48 h after symptoms

The fate of proximally excluded iliac arteries following open repair of abdominal aortic aneurysms

Aneurysms occur throughout the length of the aorta, with a large proportion occurring in the infra-renal segment of the abdominal aorta (least 9 to 10 times more common than thoracic aortic aneurysms). Aneurysmal disease of the aorto-iliac segment which commonly occurs as a result of a degenerative process is invariably a progressive entity. Concomitant iliac artery aneurysms have been noted to occur in 15-40% of patients with abdominal aortic aneurysms (AAAs). As a result, following open AAA repair, there is a concern regarding the progressive enlargement of the iliac arteries. The aim of this study was to investigate the long term outcome of proximally excluded common iliac arteries (CIAs) following open bifurcated abdominal aortic aneurysm (AAA) repair. Baseline clinical and demographic data of 165 consecutive patients undergoing open AAA repair between April 2004 and April 2014 was collected. The aorta and iliac segments were measured in the 120 available preoperative Computed Tomographic (CT) angiograms. A single postoperative CT scan was performed and measurements recorded in 46 patients available for follow-up. The patients were grouped according to the type of surgical repair, open tube graft repair or bifurcated graft repair to the common iliac (CIA), external iliac artery (EIA) or common femoral artery (CFA). Entered into the study were 165 patients (133 men, 32 women) with a mean age of 66 years and a mean AAA diameter of 6.7cm (range 5.1 - 10.3cm). After a median follow-up of 49 months, 46 patients (88 CIAs) were available for a single postoperative CT scan

Modulation of Inflammation Driven Wound Healing after Glaucoma Surgery

Dysregulated wound healing contributes to most currently unanswered ophthalmological morbidity. Opacification and structure altering contractures compromise the delicate ocular anatomy upon which ocular function and healthy vision are reliant. Glaucoma filtration surgery, corneal stromal injury, proliferative vitreoretinopathy and age-related macular degeneration are major contributors to ocular morbidity – all with myofibroblast transdifferentiation and pathognomonic scarring activity at their core. This thesis aims to revaluate the means by which dysregulated ocular wound healing is combated with evidence describing a novel strategy to mitigate its effects. A translational approach was used. An initial retrospective analysis of over ten thousand glaucoma surgeries found that perioperative NSAID exposure was significantly associated with surgical success. The current standard of care, corticosteroids, showed no such association. This was surprising and provided impetus to evaluate these clinical findings within the basic science lab. The subsequent project examined the relative effects of NSAIDs to that of corticosteroids on the in vitro wound healing activity of ocular fibroblasts. Relative to steroids, NSAID exposure resulted in more ordered extracellular matrix remodelling, less cell-mediated collagen contraction and greater impairment of myofibroblast associated protein expression. We hypothesized that these differences were due to NSAIDs more specific targeting of COX enzyme activity. By sparing lipoxygenase activity, competitive NSAIDs leave intact the biosynthetic machinery responsible for signaling the endogenous resolution of inflammation. This system involves the collective effects of the pro-resolving superfamily of lipid mediators and promotes the active resolution of inflammatory processes. To assess the anti-fibrotic potential of inducing resolution within inflammation-induced ocular fibroblasts, two COX2 Ser516 acetylating molecules were utilized to modify the COX2 enzyme such that it: 1) ceases prostaglandin production, and 2) gains the capacity to produce pro-resolving lipid mediators. When applied to inflammation-induced ocular fibroblasts, a reduction in in vitro wound healing phenomena was observed with a corresponding shift in pro-/anti-fibrogenic transcription factor expression and downregulation of myofibroblast associated proteins. Together these findings suggest that the resolution of inflammation and the resolution of fibroproliferation may be controlled by a common signaling system, and that interventions promoting the production of resolving lipid mediators could have significant anti-cicatrizing properties

From Concept to Market: Surgical Robot Development

Surgical robotics and supporting technologies have really become a prime example of modern applied information technology infiltrating our everyday lives. The development of these systems spans across four decades, and only the last few years brought the market value and saw the rising customer base imagined already by the early developers. This chapter guides through the historical development of the most important systems, and provide references and lessons learnt for current engineers facing similar challenges. A special emphasis is put on system validation, assessment and clearance, as the most commonly cited barrier hindering the wider deployment of a system