RESUMEN
Interprofessional education within clinical teaching sites is a key part of training for pre-professional students. However, the necessary characteristics of these interprofessional clinical teaching sites is unclear. We developed a tool, the Interprofessional Education Site Readiness, or InSITE, tool, for individuals at a site to use as a self-assessment of the site's current readiness for providing interprofessional education. The tool progressed through six stages of development, collecting evidence for validity and reliability, resulting in a final tool with 23 questions distributed across five domains. Data from 94 respondents from a variety of national sites were used for the item analysis showing acceptable item-to-total correlations. Internal reliability testing gave a Cronbach's coefficient alpha of more than 0.70 for each group level comparison. Known groups validity testing provides strong evidence for its responsiveness in detecting differences in sites where IPE is implemented. The results of the testing lead us to conclude that the InSITE tool has acceptable psychometric properties. Additionally, we discovered that the process in which the InSITE tool was used demonstrated that it can facilitate learning in practice for the health professionals and can help make implicit, informal workplace learning and the hidden curriculum explicit.
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Relaciones Interprofesionales , Estudiantes del Área de la Salud , Humanos , Educación Interprofesional , Reproducibilidad de los Resultados , AprendizajeRESUMEN
INTRODUCTION: Cryptorchidism, or undescended testis (UDT), is identified in 1% of boys by one year of age and carries long term risks of infertility and testicular neoplasia. In 2014, the American Urological Association (AUA) released a guideline statement stating that patients with UDT should be referred to a urologist by 6 months of age in order to facilitate timely surgical correction. This study is the follow-up to a 2010 study assessing referral patterns to our university center from primary care providers. OBJECTIVE: In this new study, we aim to identify changes in referral patterns in response to the establishment of the 2014 AUA guidelines and to understand how our referring physicians stay abreast of current knowledge regarding UDT. STUDY DESIGN: A 9 question anonymous survey regarding UDT referral patterns was sent to providers who had previously referred a patient to our pediatric urology practice. The results were categorized by specialty and were compared to the similar survey from 2010. RESULTS: Surveys were sent to 500 physicians with 138 (27.6%) responses received. Less than half of respondents reported that they would refer a boy with unilateral or bilateral palpable UDT by 6 months of age (37.0% and 38.4% respectively). This was not significantly different than the 2010 survey (p = 0.68 and 0.27 respectively). Two-thirds of physicians would refer a patient with unilateral nonpalpable UDT within the recommended time frame (68.8%); this was also unchanged from 2010 (p = 0.87). There was an improvement in respondents who would refer immediately for bilateral nonpalpable testes from 49.8% in 2010 to 53.6% in 2017 (p = 0.01). Residency training was most commonly cited as the primary source of knowledge regarding UDT although 89.3% of respondents citing this were >5 years removed from residency training. DISCUSSION: Delayed referral patterns were reported by the majority of providers for palpable UDT and by greater than one-third of providers for nonpalpable UDT. There was minimal change in referral patterns between 2010 and 2017 despite the release of the AUA cryptorchidism guidelines in 2014. In both 2010 and 2017, residency training was identified as the primary source of knowledge regarding management of UDT. CONCLUSION: These findings suggest an unmet need for education regarding contemporary management of UDT for the primary care physicians in our community.
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Criptorquidismo , Niño , Criptorquidismo/cirugía , Personal de Salud , Humanos , Lactante , Masculino , Atención Primaria de Salud , Derivación y Consulta , TestículoRESUMEN
BACKGROUND: Liver transplants account for a high number of procedures with major investments from all stakeholders involved; however, limited studies address liver transplant population heterogeneity pretransplant predictive of posttransplant survival. OBJECTIVE: The aim of the study was to identify novel and meaningful patient clusters predictive of mortality that explains the heterogeneity of liver transplant population, taking a holistic approach. METHODS: A retrospective cohort study of 344 adult patients who underwent liver transplantation between 2008 through 2014. Predictors were summarized severity scores for comorbidities and other suboptimal health states grouped into 11 body systems, the primary reason for transplantation, demographics/environmental factors, and Model for End Liver Disease score. Logistic regression was used to compute the severity scores, hierarchical clustering with weighted Euclidean distance for clustering, Lasso-penalized regression for characterizing the clusters, and Kaplan-Meier analysis to compare survival across the clusters. RESULTS: Cluster 1 included patients with more severe circulatory problems. Cluster 2 represented older patients with more severe primary disease, whereas Cluster 3 contained healthiest patients. Clusters 4 and 5 represented patients with musculoskeletal (e.g., pain) and endocrine problems (e.g., malnutrition), respectively. There was a statistically significant difference for mortality between clusters (p < .001). CONCLUSIONS: This study developed a novel methodology to address heterogeneous and high-dimensional liver transplant population characteristics in a single study predictive of survival. A holistic approach for data modeling and additional psychosocial risk factors has the potential to address holistically nursing challenges on liver transplant care and research.
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Análisis por Conglomerados , Trasplante de Hígado/mortalidad , Adulto , Anciano , Estudios de Cohortes , Comorbilidad/tendencias , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Persona de Mediana Edad , Medio Oeste de Estados Unidos , Análisis Multivariante , Modelos de Riesgos Proporcionales , Sistema de Registros/estadística & datos numéricos , Estudios Retrospectivos , Factores de Riesgo , Análisis de SupervivenciaRESUMEN
This study replicates a validation of the Interprofessional Collaboration Competency Attainment Survey (ICCAS), a 20-item self-report instrument designed to assess behaviours associated with patient-centred, team-based, collaborative care. We appraised the content validity of the ICCAS for a foundation course in interprofessional collaboration, investigated its internal (factor) structure and concurrent validity, and compared results with those obtained previously by ICCAS authors. Self-assessed competency ratings were obtained from a broad spectrum of pre-licensure, health professions students (n = 785) using a retrospective, pre-/post-design. Moderate to large effect sizes emerged for 16 of 20 items. Largest effects (1.01, 0.94) were for competencies emphasized in the course; the smallest effect (0.35) was for an area not directly taught. Positive correlations were seen between all individual item change scores and a separate item assessing overall change, and item-total correlations were moderate to strong. Exploratory factor analysis was used to understand the interrelationship of ICCAS items. Principal component analysis identified a single factor (Cronbach's alpha = 0.96) accounting for 85% of the total variance-slightly higher than the 73% reported previously. Findings suggest strong overlaps in the proposed constructs being assessed; use of a total average score is justifiable for assessment and evaluation.
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Relaciones Interprofesionales , Competencia Profesional , Estudiantes del Área de la Salud/psicología , Encuestas y Cuestionarios/normas , Adulto , Comunicación , Conducta Cooperativa , Análisis Factorial , Femenino , Humanos , Masculino , Negociación , Grupo de Atención al Paciente/organización & administración , Atención Dirigida al Paciente/organización & administración , Grupos Raciales , Reproducibilidad de los Resultados , Estudios Retrospectivos , Adulto JovenRESUMEN
OBJECTIVE: Liver transplantation is a costly and risky procedure, representing 25 050 procedures worldwide in 2013, with 6729 procedures performed in the United States in 2014. Considering the scarcity of organs and uncertainty regarding prognosis, limited studies address the variety of risk factors before transplantation that might contribute to predicting patient's survival and therefore developing better models that address a holistic view of transplant patients. This critical review aimed to identify predictors of liver transplant patient survival included in large-scale studies and assess the gap in risk factors from a holistic approach using the Wellbeing Model and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. DATA SOURCE: Search of the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, and PubMed from the 1980s to July 2014. STUDY SELECTION: Original longitudinal large-scale studies, of 500 or more subjects, published in English, Spanish, or Portuguese, which described predictors of patient survival after deceased donor liver transplantation. DATA EXTRACTION: Predictors were extracted from 26 studies that met the inclusion criteria. DATA SYNTHESIS: Each article was reviewed and predictors were categorized using a holistic framework, the Wellbeing Model (health, community, environment, relationship, purpose, and security dimensions). CONCLUSIONS: The majority (69.7%) of the predictors represented the Wellbeing Model Health dimension. There were no predictors representing the Wellbeing Dimensions for purpose and relationship nor emotional, mental, and spiritual health. This review showed that there is rigorously conducted research of predictors of liver transplant survival; however, the reported significant results were inconsistent across studies, and further research is needed to examine liver transplantation from a whole-person perspective.
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Trasplante de Hígado/mortalidad , Tasa de Supervivencia , Supervivencia de Injerto , Humanos , Factores de Riesgo , Estados UnidosRESUMEN
BACKGROUND: A simplified and consensus-based donor scoring process could improve donor lung use. METHODS: To develop the University of Minnesota Donor Lung Quality Index (UMN-DLQI), we used expert opinion to create an online survey that ranked 17 lung donor and recipient factors and graded their importance on a scale of 0 to 10. To arrive at consensus-based weights for each of the 17 factors, we used magnitude estimation (ME) methods. We performed receiver operating characteristic (ROC) analyses to evaluate predictive value. An application (app) was developed to simplify the scoring process. A second review process was instituted for every donor offer with an UMN-DLQI score greater than 40 as of September 2014 (post-donor score era). RESULTS: Worldwide, 11 transplantation centers (including ours) completed our survey. Results showed strong consensus among transplantation physicians across disparate practices. UMN-DLQI scores greater than 40 provided a sensitivity of 89%, a specificity of 55%, and a positive predictive value of 52% for donor offer acceptance. Number of transplants (63 versus 48) and donor lung use (15.1% versus 8.9%; p = 0.02) were significantly better in the post-donor score era without a penalty in transplantation outcomes. There was a trend toward a lower incidence of any primary graft dysfunction within 72 hours (40% versus 75%; p = 0.06) with a UMN-DLQI greater than 40 but no difference in 30-day or 1-year survival. CONCLUSIONS: The UMN-DLQI scoring app is a simple tool for describing the attributes of a donor lung offer. More attention to scores greater than 40 safely improved donor lung use at a single institution.
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Encuestas de Atención de la Salud/métodos , Trasplante de Pulmón/métodos , Aplicaciones Móviles/estadística & datos numéricos , Mejoramiento de la Calidad , Obtención de Tejidos y Órganos/métodos , Centros Médicos Académicos , Consenso , Femenino , Rechazo de Injerto , Supervivencia de Injerto , Humanos , Trasplante de Pulmón/efectos adversos , Masculino , Minnesota , Valor Predictivo de las Pruebas , Indicadores de Calidad de la Atención de Salud , Curva ROC , Donantes de TejidosRESUMEN
BACKGROUND: Teaching residents to lead end of life (EOL) and error disclosure (ED) conferences is important. METHODS: We developed and tested an intervention using videotapes of EOL and error disclosure encounters from previous Objective Structured Clinical Exams. Residents (n = 72) from general and orthopedic surgery programs at 2 sites were enrolled. Using a prospective, pre-post, block group design with stratified randomization, we hypothesized the treatment group would outperform the control on EOL and ED cases. We also hypothesized that online course usage would correlate positively with post-test scores. RESULTS: All residents improved (pre-post). At the group level, treatment effects were insignificant, and post-test performance was unrelated to course usage. At the subgroup level for EOL, low performers assigned to treatment scored higher than controls at post-test; and within the treatment group, post graduate year 3 residents outperformed post graduate year â1 residents. CONCLUSIONS: To be effective, online curricula illustrating communication behaviors need face-to-face interaction, individual role play with feedback and discussion.
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Educación de Postgrado en Medicina/métodos , Errores Médicos , Relaciones Médico-Paciente , Cuidado Terminal/métodos , Grabación en Video , Adulto , Comunicación , Evaluación Educacional , Femenino , Cirugía General/educación , Humanos , Internado y Residencia , Masculino , Ortopedia/educación , Valores de ReferenciaRESUMEN
BACKGROUND & AIMS: Therapeutic options are limited for patients with recurrent acute pancreatitis who have intractable symptoms despite maximal endoscopic and medical treatment, but equivocal or no morphologic or functional evidence of chronic pancreatitis. We performed a prospective observational cohort study to determine the efficacy of total pancreatectomy with islet autotransplantation (TPIAT) for these patients. METHODS: We collected data from all patients undergoing TPIAT at the University of Minnesota from 2007 through 2013; 49 patients (42 female; mean age, 32.8 ± 7.8 years) had a diagnosis of recurrent acute pancreatitis not provoked by intervention, with negative or equivocal findings from nondiagnostic imaging or pancreatic function tests for chronic pancreatitis, and intractable pain between episodes. Data on insulin use, narcotic requirements, pain scores, and health-related quality of life were collected before TPIAT; 3 months, 6 months, and 1 year afterward; and then yearly. RESULTS: All 49 patients studied required narcotics before TPIAT (45 daily users and 4 intermittent users); 2 had insulin-treated diabetes. At 1 year after TPIAT, 22 out of 48 patients (46%) reported no use of narcotic pain medications (P < .001 vs baseline). Health-related quality of life score, measured by the physical and mental component summary score, increased by approximately 1 standard deviation from the population mean (P < .001 for the physical component summary; P = .019 for the mental component summary). At 1 year after TPIAT, 21 out of 48 patients (45%) were insulin independent; their mean percent glycosylated hemoglobin A1c at 1 year after TPIAT was 6.0% ± 0.9% (5.2% ± 0.6% pre-TPIAT). CONCLUSIONS: Patients with recurrent acute pancreatitis but lacking clear chronic pancreatitis benefit from TPIAT, with outcomes similar to those previously described for patients with chronic pancreatitis (improved quality of life and reduced narcotic use). For these patients who have otherwise limited surgical treatment options, TPIAT can be considered when medical and endoscopic therapies have failed.
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Islas Genómicas , Pancreatectomía/métodos , Pancreatitis Aguda Necrotizante/cirugía , Trasplante Autólogo , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Hospitales Universitarios , Humanos , Masculino , Persona de Mediana Edad , Minnesota , Estudios Prospectivos , Calidad de Vida , Encuestas y Cuestionarios , Resultado del Tratamiento , Adulto JovenRESUMEN
There are little data on longterm outcomes, health-related quality of life (HRQoL), and issues related to living donor right hepatectomy specifically. We studied longterm HRQoL in 127 living liver donors. A donor-specific survey (DSS) was used to evaluate the living liver donor morbidity, and the 36-item short-form health survey (short-form 36 health survey, version 1 [SF-36]) was used to assess generic outcomes. The DSS was completed by 107 (84.3%) donors and the SF-36 by 62 (49%) donors. Median follow-up was 6.9 years. Of the 107 donors, 12 (11.2%) donors reported their health as better, whereas 84 (78.5%) reported their health the same as before donation. Ninety-seven (90.7%) are currently employed. The most common postdonation symptom was incisional discomfort (34%). Twenty-four donors (22.4%) self-reported depression symptoms after donation. Ninety-eight (91.6%) rated their satisfaction with the donation process ≥ 8 (scale of 1-10). Three factors-increased vitality (correlation, 0.44), decreased pain (correlation, 0.34), and a recipient who was living (correlation, 0.44)-were independently related to satisfaction with the donor experience. Vitality showed the strongest association with satisfaction with the donor experience. Mental and physical component summary scale scores for donors were statistically higher compared to the US population norm (P < 0.001). Donors reported a high satisfaction rate with the donation process, and almost all donors (n = 104, 97.2%) would donate again independent of experiencing complications. Our study suggests that over a longterm period, liver donors continue to have above average HRQoL compared to the general population.
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Hepatectomía/efectos adversos , Complicaciones Posoperatorias/epidemiología , Donantes de Tejidos/estadística & datos numéricos , Adulto , Femenino , Estudios de Seguimiento , Humanos , Trasplante de Hígado , Masculino , Persona de Mediana Edad , Minnesota/epidemiología , Satisfacción del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/etiología , Calidad de Vida , Reproducibilidad de los Resultados , Donantes de Tejidos/psicología , Adulto JovenRESUMEN
BACKGROUND: An adult-to-adult living donor liver transplant (LDLT) has emerged as a possible option to help alleviate the organ shortage. The aim of this study was to analyze our experience with biliary complications in LDLT recipients and to identify their risk factors for biliary complications. This paper aimed to describe therapeutic interventions and to evaluate the impact of biliary complications on long-term patient and graft survival rates. METHODS: We evaluated biliary complications in a cohort of 120 LDLT recipients at a single institution and studied the impact on long-term graft and patient survival. RESULTS: Of the 120 recipients, 26 (21.7%) developed biliary complications. Endoscopy was the initial choice of treatment for recipients with biliary complications. The median time for resolution of bile leaks was 37 days; for resolution of strictures, 82 days. A decreased risk of biliary complications was associated with an interrupted duct-to-duct (versus continuous choledocho-choledochostomy) (hazard ratio [HR]=0.22, P=0.002) and a Roux-en-Y hepaticojejunostomy (HR=0.13, P<0.001). In multivariate analysis of factors associated with graft failure and patient mortality, biliary complications were unrelated to long term (3 and 5 years) graft failure or patient mortality. CONCLUSIONS: In our study LDLT recipients had a 21.7% incidence of biliary complications, however, with successful endoscopic techniques, long-term patient and graft survival rates were not negatively affected.
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Fístula Biliar/diagnóstico , Fístula Biliar/etiología , Trasplante de Hígado/efectos adversos , Donadores Vivos , Adulto , Anciano , Anastomosis Quirúrgica/efectos adversos , Fístula Biliar/cirugía , Procedimientos Quirúrgicos del Sistema Biliar/efectos adversos , Diagnóstico Precoz , Femenino , Estudios de Seguimiento , Supervivencia de Injerto , Humanos , Trasplante de Hígado/mortalidad , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
OBJECTIVE: Our objective was to analyze factors predicting outcomes after a total pancreatectomy and islet autotransplantation (TP-IAT). BACKGROUND: Chronic pancreatitis (CP) is increasingly treated by a TP-IAT. Postoperative outcomes are generally favorable, but a minority of patients fare poorly. METHODS: In our single-centered study, we analyzed the records of 581 patients with CP who underwent a TP-IAT. Endpoints included persistent postoperative "pancreatic pain" similar to preoperative levels, narcotic use for any reason, and islet graft failure at 1 year. RESULTS: In our patients, the duration (meanâ±âSD) of CP before their TP-IAT was 7.1â±â0.3 years and narcotic usage of 3.3â±â0.2 years. Pediatric patients had better postoperative outcomes. Among adult patients, the odds of narcotic use at 1 year were increased by previous endoscopic retrograde cholangiopancreatography (ERCP) and stent placement, and a high number of previous stents (>3). Independent risk factors for pancreatic pain at 1 year were pancreas divisum, previous body mass index >30, and a high number of previous stents (>3). The strongest independent risk factor for islet graft failure was a low islet yield-in islet equivalents (IEQ)-per kilogram of body weight. We noted a strong dose-response relationship between the lowest-yield category (<2000 IEQ) and the highest (≥5000 IEQ or more). Islet graft failure was 25-fold more likely in the lowest-yield category. CONCLUSIONS: This article represents the largest study of factors predicting outcomes after a TP-IAT. Preoperatively, the patient subgroups we identified warrant further attention.
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Trasplante de Islotes Pancreáticos , Pancreatectomía , Pancreatitis Crónica/cirugía , Adolescente , Adulto , Anciano , Niño , Preescolar , Femenino , Supervivencia de Injerto , Humanos , Masculino , Persona de Mediana Edad , Narcóticos/uso terapéutico , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/etiología , Estudios Retrospectivos , Factores de Riesgo , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Obstructive sleep apnea (OSA) is associated with increased systemic oxidative stress, endothelial dysfunction, and activation of pro-inflammatory cascades, which increase host susceptibility to infection. OSA has not been evaluated as a risk factor for surgical site infection (SSI) following colectomy. We hypothesized that OSA increases the risk for SSI after colectomy. METHODS: We performed a retrospective review of 507 colectomies that took place between August 2011 and September 2013. Forty-two patients carried the diagnosis of OSA prior to surgery. These 42 patients were matched to 68 patients with no OSA for age, body mass index (BMI), diabetes mellitus (DM), reason for surgery and surgical approach. RESULTS: The rate of SSI was 28.6% (12 of 42) in the patients with and 10.3% (7 of 68) in the patients without OSA (p=0.03). Using logistic regression, the predictors of SSI following colectomy were found to be OSA (odds ratio [OR] of 3.98, 95% confidence interval [CI]=1.29-12.27), and DM (OR of 7.16, 95% CI=2.36-21.96). The average hospital stay after colectomy for patients with OSA complicated with SSI was 16.7 d whereas patients with OSA without SSI stayed 7.4 d (p<0.001). The rate of organ space infections was 9.5% (4 of 42) in the patients with OSA compared with 0 (p=0.02) in patients without OSA. CONCLUSIONS: OSA is an independent risk factor for SSI following colectomy. Patients with OSA have substantially greater rates of organ space SSI and longer hospital stay.
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Colectomía/efectos adversos , Apnea Obstructiva del Sueño/complicaciones , Infección de la Herida Quirúrgica/epidemiología , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de RiesgoRESUMEN
OBJECTIVE(S): A public health nurse (PHN) in the Midwestern United States (U.S.) led a collaborative system-level intervention to translate the Institute of Clinical Systems Improvement (ICSI) Adult Obesity Guideline into interprofessional practice. This study (1) evaluated the extent of guideline translation across organizations and (2) assessed the Omaha System as a method for translating system-level interventions and measuring outcomes. DESIGN AND SAMPLE: This retrospective, mixed methods study was conducted with a purposeful sample of one administrator (n = 10) and two to three clinicians (n = 29) from each organization (n = 10). MEASURES: Omaha System Problem Rating Scale for Outcomes Knowledge, Behavior, and Status (KBS). KBS ratings gathered from semi-structured interviews and Omaha System documentation were analyzed using standard descriptive and inferential statistics and triangulated findings with participant quotes. RESULTS: KBS ratings and participant quotes revealed intervention effectiveness in creating sustained system-level changes. Self-reported and observed KBS ratings demonstrated improvement across organizations. There was moderate to substantial agreement regarding benchmark attainment within organizations. On average, self-reported improvement exceeded observer improvement. CONCLUSIONS: System-level PHN practice facilitator interventions successfully translated clinical obesity guidelines into interprofessional use in health care organizations. The Omaha System Problem Rating Scale for Outcomes reliably measured system-level outcomes.
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Obesidad/terapia , Evaluación de Resultado en la Atención de Salud/métodos , Guías de Práctica Clínica como Asunto/normas , Adulto , Benchmarking , Conducta Cooperativa , Humanos , Medio Oeste de Estados Unidos , Enfermería en Salud Pública , Estudios Retrospectivos , Vocabulario ControladoRESUMEN
PURPOSE: To explore the relationship between clinical faculty members' time/effort in four mission areas, their assessment of the distribution of that time/effort, and their intent to leave the institution and academic medicine. METHOD: Faculty from 14 U.S. medical schools participated in the 2011-2012 Faculty Forward Engagement Survey. The authors conducted multivariate logistic regression analyses to evaluate relationships between clinical faculty members' self-reported time/effort in each mission area, assessment of time/effort, and intent to leave the institution and academic medicine. RESULTS: Of the 13,722 clinical faculty surveyed, 8,349 (60.8%) responded. Respondents reported an average of 54.5% time/effort in patient care. The authors found no relationship between time/effort in patient care and intent to leave one's institution. Respondents who described spending "far too much/too much" time in patient care were more likely to report intent to leave their institution (odds ratio 2.12, P<.001). Those who assessed their time/effort in all mission areas as "about right" were less likely to report intent to leave their institution (64/1,135; 5.6%) than those who reported "far too little/too little" or "far too much/too much" time/effort in one or more mission areas (535/3,671; 14.6%; P<.001). CONCLUSIONS: Although the authors found no relationship between reported time/effort in patient care and intent to leave, the perception of "far too much/too much" time/effort spent in that mission area was correlated with intent to leave the institution. Efforts to align time/effort spent in each mission area with faculty expectations may improve retention.
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Selección de Profesión , Docentes Médicos/organización & administración , Intención , Satisfacción en el Trabajo , Facultades de Medicina , Administración del Tiempo/organización & administración , Femenino , Humanos , Masculino , Administración del Tiempo/psicología , Carga de Trabajo/psicologíaRESUMEN
OBJECTIVES: In a large cohort of subjects undergoing total pancreatectomy with islet autotransplantation (TPIAT), we assessed the prevalence and duration of gastrointestinal (GI) symptoms before and after the procedure to determine the impact of enzyme adherence on GI symptoms. METHODS: Three hundred fifty-six preoperative and postoperative questionnaires were collected from 184 subjects between ages of 5 and 66 years who underwent TPIAT between 2008 and 2011 at the University of Minnesota. Questionnaires were analyzed for self-reported frequency and severity of GI symptoms, pancreatic enzyme usage, and glycemic variability index (GVI). RESULTS: After surgery, patient-reported steatorrhea increased whereas constipation decreased. Gastrointestinal symptoms interfered with daily activity in 44% to 69% of subjects, before and after surgery, despite high reported enzyme adherence. Postoperatively, more than 79% of subjects reported consistent use of enzymes at all meals. Presence of GI symptoms did not vary with adherence. The GVI of 2 had a 2.8-fold increased odds of steatorrhea (95% confidence interval, 1.1-7.0) compared with GVI of 0. CONCLUSIONS: Gastrointestinal symptoms were common after TPIAT; ongoing management is needed. Enzyme nonadherence was not a major contributor to diarrhea/steatorrhea in this cohort. Glycemic variability was closely associated with steatorrhea; poor response to enzyme replacement may complicate diabetes management.
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Terapia de Reemplazo Enzimático , Insuficiencia Pancreática Exocrina/tratamiento farmacológico , Enfermedades Gastrointestinales/prevención & control , Trasplante de Islotes Pancreáticos , Lipasa/administración & dosificación , Cumplimiento de la Medicación , Pancreatectomía , Pancreatitis Crónica/cirugía , Adolescente , Adulto , Anciano , Glucemia/metabolismo , Niño , Preescolar , Terapia de Reemplazo Enzimático/efectos adversos , Insuficiencia Pancreática Exocrina/diagnóstico , Insuficiencia Pancreática Exocrina/epidemiología , Femenino , Enfermedades Gastrointestinales/diagnóstico , Enfermedades Gastrointestinales/epidemiología , Encuestas de Atención de la Salud , Humanos , Trasplante de Islotes Pancreáticos/efectos adversos , Lipasa/efectos adversos , Masculino , Persona de Mediana Edad , Minnesota/epidemiología , Pancreatectomía/efectos adversos , Pancreatitis Crónica/diagnóstico , Prevalencia , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Encuestas y Cuestionarios , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND AND STUDY AIMS: Urgent placement or replacement of pancreatic stents shortly after endoscopic retrograde cholangiopancreatography (ERCP) might attenuate the course of evolving post-ERCP pancreatitis (PEP). PATIENTS AND METHODS: Salvage ERCP with de novo pancreatic stent placement or replacement of outwardly migrated stents was performed within 2â-â48 hours in patients with evolving PEP accompanied by severe pain, systemic inflammatory response syndrome (SIRS), and major elevations in serum amylase and lipase. Serial pain scores, amylase and lipase levels, and hospital course were studied. RESULTS: PEP according to Cotton consensus criteria developed after 64 (2â%) of 3216 ERCPs over 3 years. Of the 64 patients with PEP, 14 underwent salvage ERCP (5 without and 9 with prior pancreatic stents, 7 of which had migrated outwards prematurely). All patients had SIRS and a high score (≥â3) for the bedside index for severity in acute pancreatitis. Median clinical onset of PEP was at 5 hours (range 0â-â68 hours) in patients with prophylactic pancreatic stents vs. 2 hours (range 0.5â-â2.5 hours) in patients without prophylactic pancreatic stents (Pâ<â0.05). Salvage ERCP was performed at a median of 10 hours (interquartile range [IQR] 2.4â-â22.7 hours). Improvement in pain, amylase, lipase, and resolution of SIRS were statistically significant at 24 hours after salvage ERCP (Pâ=â0.003). Median length of hospital stay was 2 days (IQR 1â-â4.75). No necrotizing pancreatitis or late complications occurred. CONCLUSION: Urgent salvage ERCP with de novo pancreatic stent placement or replacement of a migrated stent is a novel approach in the setting of early PEP, and was associated with rapid resolution of clinical pancreatitis and reduction in levels of amylase and lipase.
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Colangiopancreatografia Retrógrada Endoscópica/efectos adversos , Colangiopancreatografia Retrógrada Endoscópica/métodos , Remoción de Dispositivos/métodos , Conductos Pancreáticos/cirugía , Pancreatitis/cirugía , Terapia Recuperativa/métodos , Stents , Adulto , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Pancreatitis/diagnóstico , Pancreatitis/etiología , Estudios Prospectivos , Falla de Prótesis , Resultado del TratamientoRESUMEN
BACKGROUND: Children with severe chronic pancreatitis may undergo total pancreatectomy with islet autotransplantation (TPIAT) to relieve pain while minimizing the risk of postsurgical diabetes. Because overstimulation of transplanted islets by hyperglycemia can result in ß-cell loss, we developed a specialized intravenous insulin infusion protocol (IIP) for pediatric TPIAT recipients to maintain euglycemia or near-euglycemia posttransplant. SUBJECTS AND METHODS: Our objective was to review glucose control using an IIP specific for TPIAT recipients at a single institution. We reviewed postoperative blood glucose (BG) levels for 32 children 4-18 years old with chronic pancreatitis who underwent TPIAT between July 2011 and June 2013. We analyzed the proportion of BG values in the range of 70-140 mg/dL, mean glucose, glucose variability, and occurrence of hypoglycemia during the IIP; we also evaluated the transition to subcutaneous therapy (first 72 h with multiple daily injections [MDI]). RESULTS: During IIP, the mean patient BG level was 116±27 mg/dL, with 83.1% of all values in the range of 70-140 mg/dL. Hypoglycemia was rare, with only 2.5% of values <70 mg/dL. The more recent era (n=16) had a lower mean BG and less variability than the early era (first 16 patients) (P≤0.004). Mean glucose level (116 vs. 128 mg/dL) and glucose variability were significantly lower during the IIP compared with MDI therapy (P<0.0001). CONCLUSIONS: Tight glycemic control without excessive severe hypoglycemia was achieved in children undergoing TPIAT using an IIP specifically designed for this population; the ability to maintain BG in target range improved with experience with the protocol.
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Glucemia/metabolismo , Diabetes Mellitus Tipo 1/cirugía , Hipoglucemia/prevención & control , Sistemas de Infusión de Insulina , Trasplante de Islotes Pancreáticos , Pancreatectomía , Pancreatitis Crónica/cirugía , Adolescente , Autoinjertos , Niño , Preescolar , Protocolos Clínicos , Diabetes Mellitus Tipo 1/metabolismo , Diabetes Mellitus Tipo 1/fisiopatología , Femenino , Técnica de Clampeo de la Glucosa , Humanos , Hipoglucemiantes/administración & dosificación , Infusiones Intravenosas , Masculino , Pancreatitis Crónica/metabolismo , Pancreatitis Crónica/fisiopatología , Periodo Posoperatorio , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Academic medical centers strive for clinical excellence with operational efficiency and financial solvency, which requires institutions to retain productive and skillful surgical specialists. Faculty workplace perceptions, overall satisfaction, and intent to leave are relationships that have not been examined previously among US surgeons in academic medicine. We hypothesize that critical factors related to workplace satisfaction and engagement could be identified as important for enhancing institutional retention of academic surgeons. STUDY DESIGN: The 2011-2012 Association of American Medical Colleges Faculty Forward Engagement Survey evaluated demographic variables, physician workplace satisfaction, and overall engagement among faculty subgroups, including comparison of surgical and nonsurgical clinicians. Multiple regression analysis (ß = standard regression coefficient) was performed to identify critical factors most closely related to surgeon satisfaction and intent to leave their institutions. RESULTS: A total of 1,356 of 1,949 (70%) surgeons from 14 medical schools responded across different faculty subgroups, and comparisons were made with 1,105 nonsurgical clinicians. Multiple regression indicated that the strongest predictors of surgeons' overall satisfaction with their department included department governance (ß = 0.36; p < 0.001), collegiality and collaboration (ß = 0.23; p < 0.001), and relationship with supervisor (ß = 0.17; p < 0.001). Although compensation and benefits were important (ß = 0.08; p < 0.001), these did not rank as the most important factors. Promotion equality (odds ratio = 0.62; p < 0.05), collegiality and collaboration (odds ratio = 0 .51; p < 0.05), and nature of their work (odds ratio = 0.52; p < 0.05) were most closely related to intent to leave the medical school within 1 to 2 years. CONCLUSIONS: In the largest survey focusing on workplace factors affecting surgical faculty satisfaction and intent to leave, we conclude that institutional understanding of, and improvement in, specific work environment factors can enhance recruitment and retention of academic surgeons.
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Centros Médicos Académicos/organización & administración , Actitud del Personal de Salud , Docentes Médicos/organización & administración , Satisfacción en el Trabajo , Especialidades Quirúrgicas/organización & administración , Adulto , Anciano , Movilidad Laboral , Recolección de Datos , Femenino , Humanos , Relaciones Interprofesionales , Modelos Logísticos , Masculino , Persona de Mediana Edad , Cultura Organizacional , Estados Unidos , Lugar de TrabajoRESUMEN
BACKGROUND: Chronic pancreatitis is a debilitating disease resulting from many causes. The subset with hereditary/genetic pancreatitis (HGP) not only has chronic pain, but also an increased risk for pancreatic cancer. Long-term outcomes of total pancreatectomy (TP) and islet autogeneic transplantation (IAT) for chronic pancreatitis due to HGP are not clear. STUDY DESIGN: We reviewed a prospectively maintained database of 484 TP-IATs from 1977 to 2012 at a single center. The outcomes (eg, pain relief, narcotic use, ß-cell function, health-related quality of life measures) of patients who received TP-IAT for HGP (protease trypsin 1, n = 38; serine protease inhibitor Kazal type 1, n = 9; cystic fibrosis transmembrane conductance regulator, n = 14; and familial, n = 19) were evaluated and compared with those with non-hereditary/nongenetic causes. RESULTS: All 80 patients with HGP were narcotic dependent and failed endoscopic management or direct pancreatic surgery. Post TP-IAT, 90% of the patients were pancreatitis pain free with sustained pain relief; >65% had partial or full ß-cell function. Compared with nonhereditary causes, HGP patients were younger (22 years old vs 38 years old; p ≤ 0.001), had pancreatitis pain of longer duration (11.6 ± 1.1 years vs 9.0 ± 0.4 years; p = 0.016), had a higher pancreas fibrosis score (7 ± 0.2 vs 4.8 ± 0.1; p ≤ 0.001), and trended toward lower islet yield (3,435 ± 361 islet cell equivalent vs 3,850 ± 128 islet cell equivalent; p = 0.28). Using multivariate logistic regression, patients with non-HGP causes (p = 0.019); lower severity of pancreas fibrosis (p < 0.001); shorter duration of years with pancreatitis (p = 0.008); and higher transplant islet cell equivalent per kilogram body weight (p ≤ 0.001) were more likely to achieve insulin independence (p < 0.001). There was a significant improvement in health-related quality of life from baseline by RAND 36-Item Short Form Health Survey and in physical and mental component health-related quality of life scores (p < 0.001). None of the patients in the entire cohort had cancer of pancreatic origin in the liver or elsewhere develop during 2,936 person-years of follow-up. CONCLUSIONS: Total pancreatectomy and IAT in patients with chronic pancreatitis due to HGP cause provide long-term pain relief (90%) and preservation of ß-cell function. Patients with chronic painful pancreatitis due to HGP with a high lifetime risk of pancreatic cancer should be considered earlier for TP-IAT before pancreatic inflammation results in a higher degree of pancreatic fibrosis and islet cell function loss.
Asunto(s)
Trasplante de Islotes Pancreáticos , Pancreatectomía , Pancreatitis Crónica/cirugía , Adulto , Dolor Crónico/etiología , Bases de Datos Factuales , Femenino , Estudios de Seguimiento , Humanos , Trasplante de Islotes Pancreáticos/métodos , Estimación de Kaplan-Meier , Modelos Lineales , Modelos Logísticos , Masculino , Análisis Multivariante , Pancreatectomía/métodos , Pancreatitis Crónica/complicaciones , Pancreatitis Crónica/genética , Calidad de Vida , Trasplante Autólogo , Resultado del TratamientoRESUMEN
BACKGROUND: The islet size distribution in a preparation may contribute to islet transplant outcomes. At the same islet equivalent (IE) dose, larger islets may exhibit poorer therapeutic value and this may be because of oxygen diffusion limitations that worsen in proportion to islet size. METHODS: To test this hypothesis, we studied the impact of islet size index (ISI) and other islet product characteristics on outcomes after islet autotransplant (IAT) in recipients receiving a marginal islet dose (2000-4999 IEs per kg body weight) from January 1, 2009 to June 11, 2012, at the University of Minnesota (n=58). ISI was defined as the number of IE divided by the number of islet particles (IPs) in a preparation; an ISI less than 1 indicates a mean islet diameter that is less than 150 µm. The primary post-IAT outcome was 6-month insulin use status. RESULTS: Logistic regression analysis indicate that IPs/kg (P=0.001), IEs/kg (P=0.019), total IPs transplanted (P=0.040), and ISI (P=0.074) were most strongly correlated with the primary outcome. The ISI (mean±standard error) was lower for recipients achieving insulin independence at 6 months (0.71±0.05) versus those partially (0.83±0.05) or completely (1.00±0.07) insulin dependent. The combination of islet dose (expressed as units IPs/kg) and ISI exhibited a sensitivity of 75% and specificity of 74% in predicting insulin independence in this population of patients. CONCLUSION: Islet autotransplant recipients of a marginal islet doses were more likely to achieve insulin independence when transplanted with a greater number of smaller islets.