Recipient of the 2010 Alumni Distinguished Leadership Award

Lillian S. Kao, M.D., M.S., is an associate professor in the Department of Surgery and faculty for the Center for Clinical Research and Evidence-Based Medicine at the University of Texas Health Science Center in Houston (UTHSC). She also serves as the Vice-Chief of Surgery at the Lyndon B. Johnson General Hospital in Houston. Dr. Kao’s main research interest is the prevention and treatment of surgical infections. She has several grants for her clinical research, including an NIH career development award. In 2006, Dr. Kao was the recipient of a Robert Wood Johnson Physician Faculty Scholar to study interventions to improve the prevention of surgical site infections, which are a significant problem resulting in worsened patient outcome and increased health care expenditures. In particular, she is interested in maximizing compliance with evidence-based guidelines for the prevention of these infections within a county hospital system with limited resources. Her other interest is in educating surgeons about clinical research. She has co-founded a Center for Surgical Trials and Evidence-based Practice (C-STEP) at UTHSC, co-directed the Fundamentals of Surgical Research Course (a yearly national course which is put on by the Association for Academic Surgery or AAS, a society for academic surgeons of which she is the Secretary on the Executive Council), participated as guest faculty at international research courses (i.e. Developing a Career in Academic Surgery in Australia), and recently was the AAS Visiting Professor to the Taiwan Surgical Association where she lectured on evidence-based surgery. Dr. Kao received her medical degree from the University of Michigan in Ann Arbor, completed surgical residency and a fellowship in gastrointestinal surgery at the University of Washington in Seattle, and completed a surgical critical care fellowship and obtained a Masters Degree in Clinical Research at UTHSC

2011 Convocation

Pledge of Allegiance and Welcome: Aadi Tolappa, Student Council President; Dr. Glenn W. Max McGee, IMSA President; Dr. Eric McLaren, IMSA Principal & Vice President for Academic Programs Featured Piece: Dr. Jeong Hwang-Choe, IMSA Science Faculty Member Keynote Speaker: Dr. Lillian Kao, Associate Professor of Surgery at University of Texas Health Science Center Closing Remarks: Dr. Eric McLare

Breaking Down Academic Silos: Mentoring Across Medical Specialties Through Facilitated Peer Mentorship

Background: Facilitated peer mentorship is an effective forum for professional development of faculty in academic medicine but has only been studied within single specialties. An interdisciplinary faculty development program was created to benefit faculty participants across different specialties and improve faculty connectedness at the medical school. The objective was to evaluate the early outcomes of an interdisciplinary faculty development program using the facilitated peer mentorship model. Methods: Junior faculty participants were placed into small groups with equal distribution of specialties across groups. Peer groups were facilitated by a senior faculty. The study duration involved two cohorts enrolled in 2018-2019 and 2020-2021. Monthly small group meetings were held during each year. A baseline needs assessment was performed to ensure the curriculum was relevant to all specialties. Participants were surveyed on their understanding of promotion, barriers to attending meetings, and intra- and interdepartmental connectivity. In the second year of the program, meetings were held virtually in accordance with institutional COVID-19 pandemic guidelines. Results: A total of 92 faculty participated in the program over the two periods. In the baseline assessment, promotion was considered to be the most important component of a mentorship program, yet only one-quarter of participants considered themselves to have at least a moderate understanding of promotion prior to the start of the program. The ability to identify a primary mentor was significantly associated with a shorter anticipated time to promotion (p=0.001). While nearly all surveyed participants identified a barrier to involvement in the peer mentorship program, there were significant gender differences in the types of barriers with women faculty more likely to be concerned about family responsibilities and timing of day (p=0.007). At the conclusion of the program, participants had an enhanced perception of connectivity within and between departments (p=0.012) and improved readiness for promotion. Conclusion: Interdisciplinary facilitated peer mentoring increases the scope of influence by senior faculty mentors across different specialties measured by enhanced readiness for promotion. Additional benefits included improving professional relationships across the institution. The program demonstrated its reproducibility in a virtual format, effectively addressing challenges related to networking and career advancement caused by pandemic restrictions

Impact of COVID Status and Blood Group on Complications in Patients in Hemorrhagic Shock

OBJECTIVE: Among critically injured patients of various blood groups, we sought to compare survival and complication rates between COVID-19-positive and COVID-19-negative cohorts. BACKGROUND: SARS-CoV-2 infections have been shown to cause endothelial injury and dysfunctional coagulation. We hypothesized that, among patients with trauma in hemorrhagic shock, COVID-19-positive status would be associated with increased mortality and inpatient complications. As a secondary hypothesis, we suspected group O patients with COVID-19 would experience fewer complications than non-group O patients with COVID-19. METHODS: We evaluated all trauma patients admitted 4/2020-7/2020. Patients 16 years or older were included if they presented in hemorrhagic shock and received emergency release blood products. Patients were dichotomized by COVID-19 testing and then divided by blood groups. RESULTS: 3281 patients with trauma were evaluated, and 417 met criteria for analysis. Seven percent (29) of patients were COVID-19 positive; 388 were COVID-19 negative. COVID-19-positive patients experienced higher complication rates than the COVID-19-negative cohort, including acute kidney injury, pneumonia, sepsis, venous thromboembolism, and systemic inflammatory response syndrome. Univariate analysis by blood groups demonstrated that survival for COVID-19-positive group O patients was similar to that of COVID-19-negative patients (79 vs 78%). However, COVID-19-positive non-group O patients had a significantly lower survival (38%). Controlling for age, sex and Injury Severity Score, COVID-19-positive patients had a greater than 70% decreased odds of survival (OR 0.28, 95% CI 0.09 to 0.81; p=0.019). CONCLUSIONS: COVID-19 status is associated with increased major complications and 70% decreased odds of survival in this group of patients with trauma. However, among patients with COVID-19, blood group O was associated with twofold increased survival over other blood groups. This survival rate was similar to that of patients without COVID-19

Quality Care Is Equitable Care: A Call to Action To Link Quality to Achieving Health Equity Within Acute Care Surgery

Health equity is defined as the sixth domain of healthcare quality. Understanding health disparities in acute care surgery (defined as trauma surgery, emergency general surgery and surgical critical care) is key to identifying targets that will improve outcomes and ensure delivery of high-quality care within healthcare organizations. Implementing a health equity framework within institutions such that local acute care surgeons can ensure equity is a component of quality is imperative. Recognizing this need, the AAST (American Association for the Surgery of Trauma) Diversity, Equity and Inclusion Committee convened an expert panel entitled \u27Quality Care is Equitable Care\u27 at the 81st annual meeting in September 2022 (Chicago, Illinois). Recommendations for introducing health equity metrics within health systems include: (1) capturing patient outcome data including patient experience data by race, ethnicity, language, sexual orientation, and gender identity; (2) ensuring cultural competency (eg, availability of language services; identifying sources of bias or inequities); (3) prioritizing health literacy; and (4) measuring disease-specific disparities such that targeted interventions are developed and implemented. A stepwise approach is outlined to include health equity as an organizational quality indicator

Differentiating Urgent from Elective Cases Matters in Minority Populations: Developing an Ordinal Desirability of Outcome Ranking to Increase Granularity and Sensitivity of Surgical Outcomes Assessment

BACKGROUND: Surgical analyses often focus on single or binary outcomes; we developed an ordinal Desirability of Outcome Ranking (DOOR) for surgery to increase granularity and sensitivity of surgical outcome assessments. Many studies also combine elective and urgent procedures for risk adjustment. We used DOOR to examine complex associations of race/ethnicity and presentation acuity. STUDY DESIGN: NSQIP (2013 to 2019) cohort study assessing DOOR outcomes across race/ethnicity groups risk-adjusted for frailty, operative stress, preoperative acute serious conditions, and elective, urgent, and emergent cases. RESULTS: The cohort included 1,597,199 elective, 340,350 urgent, and 185,073 emergent cases with patient mean age of 60.0 ± 15.8, and 56.4% of the surgeries were performed on female patients. Minority race/ethnicity groups had increased odds of presenting with preoperative acute serious conditions (adjusted odds ratio [aORs] range 1.22 to 1.74), urgent (aOR range 1.04 to 2.21), and emergent (aOR range 1.15 to 2.18) surgeries vs the White group. Black (aOR range 1.23 to 1.34) and Native (aOR range 1.07 to 1.17) groups had increased odds of higher/worse DOOR outcomes; however, the Hispanic group had increased odds of higher/worse DOOR (aOR 1.11, CI 1.10 to 1.13), but decreased odds (aORs range 0.94 to 0.96) after adjusting for case status; the Asian group had better outcomes vs the White group. DOOR outcomes improved in minority groups when using elective vs elective/urgent cases as the reference group. CONCLUSIONS: NSQIP surgical DOOR is a new method to assess outcomes and reveals a complex interplay between race/ethnicity and presentation acuity. Combining elective and urgent cases in risk adjustment may penalize hospitals serving a higher proportion of minority populations. DOOR can be used to improve detection of health disparities and serves as a roadmap for the development of other ordinal surgical outcomes measures. Improving surgical outcomes should focus on decreasing preoperative acute serious conditions and urgent and emergent surgeries, possibly by improving access to care, especially for minority populations

Robotic Versus Laparoscopic Ventral Hernia Repair: Two-Year Results From a Prospective, Multicenter, Blinded Randomized Clinical Trial

OBJECTIVE: Report the 2-year outcomes of a multicenter randomized controlled trial comparing robotic versus laparoscopic intraperitoneal onlay mesh ventral hernia repair. BACKGROUND: Ventral hernia repair is one of the most common operations performed by general surgeons. To our knowledge, no studies have been published to date comparing long-term outcomes of laparoscopic versus robotic ventral hernia repair. METHODS: The trial was registered at clinicaltrials.gov (NCT03490266). Clinical outcomes included surgical site infection, surgical site occurrence, hernia occurrence, readmission, reoperation, and mortality. RESULTS: A total of 175 consecutive patients were approached that were deemed eligible for elective minimally invasive ventral hernia repair. In all, 124 were randomized and 101 completed follow-up at 2 years. Two-year follow-up was completed in 54 patients (83%) in the robotic arm and 47 patients (80%) in the laparoscopic arm. No differences were seen in surgical site infection or surgical site occurrence. Hernia recurrence occurred in 2 patients (4%) receiving robotic repair versus in 6 patients (13%) receiving laparoscopic repair (relative risk: 0.3, 95% CI: 0.06-1.39; P =0.12). No patients (0%) required reoperation in the robotic arm whereas 5 patients (11%) underwent reoperation in the laparoscopic arm ( P =0.019, relative risk not calculatable due to null outcome). CONCLUSIONS: Robotic ventral hernia repair demonstrated at least similar if not improved outcomes at 2 years compared with laparoscopy. There is potential benefit with robotic repair; however, additional multi-center trials and longer follow-up are needed to validate the hypothesis-generating findings of this study

Ketamine for Acute Pain After Trauma: the Kapt Randomized Controlled Trial

BACKGROUND: Evidence for effective pain management and opioid minimization of intravenous ketamine in elective surgery has been extrapolated to acutely injured patients, despite limited supporting evidence in this population. This trial seeks to determine the effectiveness of the addition of sub-dissociative ketamine to a pill-based, opioid-minimizing multi-modal pain regimen (MMPR) for post traumatic pain. METHODS: This is a single-center, parallel-group, randomized, controlled comparative effectiveness trial comparing a MMPR to a MMPR plus a sub-dissociative ketamine infusion. All trauma patients 16 years and older admitted following a trauma which require intermediate (IMU) or intensive care unit (ICU) level of care are eligible. Prisoners, patients who are pregnant, patients not expected to survive, and those with contraindications to ketamine are excluded from this study. The primary outcome is opioid use, measured by morphine milligram equivalents (MME) per patient per day (MME/patient/day). The secondary outcomes include total MME, pain scores, morbidity, lengths of stay, opioid prescriptions at discharge, and patient centered outcomes at discharge and 6 months. DISCUSSION: This trial will determine the effectiveness of sub-dissociative ketamine infusion as part of a MMPR in reducing in-hospital opioid exposure in adult trauma patients. Furthermore, it will inform decisions regarding acute pain strategies on patient centered outcomes. TRIAL REGISTRATION: The Ketamine for Acute Pain Management After Trauma (KAPT) with registration # NCT04129086 was registered on October 16, 2019

The Geriatric Nutritional Risk Index as a Predictor of Complications in Geriatric Trauma Patients

BACKGROUND: Malnutrition is associated with increased morbidity and mortality after trauma. The Geriatric Nutritional Risk Index (GNRI) is a validated scoring system used to predict the risk of complications related to malnutrition in nontrauma patients. We hypothesized that GNRI is predictive of worse outcomes in geriatric trauma patients. METHODS: This was a single-center retrospective study of trauma patients 65 years or older admitted in 2019. Geriatric Nutritional Risk Index was calculated based on admission albumin level and ratio of actual body weight to ideal body weight. Groups were defined as major risk (GNRI98). The primary outcome was mortality. Secondary outcomes included ventilator days, intensive care unit length of stay (LOS), hospital LOS, discharge home, sepsis, pneumonia, and acute respiratory distress syndrome. Bivariate and multivariable logistic regression analyses were performed to determine the association between GNRI risk category and outcomes. RESULTS: A total of 513 patients were identified for analysis. Median age was 78 years (71-86 years); 24 patients (4.7%) were identified as major risk, 66 (12.9%) as moderate risk, 72 (14%) as low risk, and 351 (68.4%) as no risk. Injury Severity Scores and Charlson Comorbidity Indexes were similar between all groups. Patients in the no risk group had decreased rates of death, and after adjusting for Injury Severity Score, age, and Charlson Comorbidity Index, the no risk group had decreased odds of death (odds ratio, 0.13; 95% confidence interval, 0.04-0.41) compared with the major risk group. The no risk group also had fewer infectious complications including sepsis and pneumonia, and shorter hospital LOS and were more likely to be discharged home. CONCLUSIONS: Major GNRI risk is associated with increased mortality and infectious complications in geriatric trauma patients. Further studies should target interventional strategies for those at highest risk based on GNRI. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level III