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Obese patients have a decreased risk of death on dialysis but an increased risk of death after transplantation, and may derive a lower survival benefit from transplantation. Using data from the United States between 1995 and 2007 and multivariate non-proportional hazards analyses we determined the relative risk of death in transplant recipients grouped by body mass index (BMI) compared to wait-listed candidates with the same BMI (n = 208 498). One year after transplantation the survival benefit of transplantation varied by BMI: Standard criteria donor transplantation was associated with a 48% reduction in the risk of death in patients with BMI ≥ 40 kg/m(2) but a ≥ 66% reduction in patients with BMI40 kg/m2. Living donor transplantation was associated with ≥ 66% reduction in the risk of death in all BMI groups. In sub-group analyses, transplantation from any donor source was associated with a survival benefit in obese patients ≥ 50 years, and diabetic patients, but a survival benefit was not demonstrated in Black patients with BMI ≥ 40 kg/m(2). Although most obese patients selected for transplantation derive a survival benefit, the benefit is lower when BMI is ≥ 40 kg/m(2), and uncertain in Black patients with BMI ≥ 40 kg/m(2).

Construct: We compared a single-item performance score with the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) for their ability in assessing surgical competency.Surgical programs are adopting competency-based frameworks. The adoption of these frameworks for assessment requires tools that produce accurate and valid assessments of knowledge and technical performance. An assessment tool that is quick to complete could improve feasibility, reduce delays, and result in a higher volume of assessments of learners. Previous work demonstrated that the 9-item O-SCORE can produce valid results; the goal of this study was to determine if a single-item performance rating (Is candidate competent to independently complete procedure: yes or no) completed at a separate viewing would correlate to the O-SCORE, thus increasing feasibility of procedural competence assessment.Nineteen residents and 2 staff orthopedic surgeons from the University of Ottawa volunteered for a 2-part OSCE-style station including a written questionnaire and videotaped simulated open reduction and internal fixation midshaft radius fracture. Each performance was rated independently by 3 orthopedic surgeons using a single-item performance score (Time 1). The performances were assessed again 6 weeks later by the 3 raters using the O-SCORE (Time 2). Correlation between the single-item performance score and the O-SCORE were evaluated.Three orthopedic surgeons completed 21 ratings each resulting in 63 orthopedic ratings. There was a high level of correlation and agreement between the single-item performance score at Time 1 and Time 2 (κ correlation =0.72-1.00; p .001; percentage agreement =90%-100%). The reliability of the O-SCORE at Time 2 with three raters was 0.83 and the internal consistency was 0.89. There was a tendency for each rater to assign more yes responses to the more senior trainees.A single-item performance score correlated highly with the O-SCORE in an orthopedic setting. A single-item score could be used to supplement a multi-item score with similar results in orthopedics. There is still benefit in completing multi-item scores such as the O-SCORE evaluations to guide specific areas of improvement and direct feedback.

Abstract Aim This review aimed to provide a comprehensive overview of the current state of evidence for the use of clinical and quality dashboards in health care environments. Methods A literature search was performed for the dates 1996–2012 on CINAHL, Medline, Embase, Cochrane Library, PsychInfo, Science Direct and ACM Digital Library. A citation search and a hand search of relevant papers were also conducted. Results One hundred and twenty two full text papers were retrieved of which 11 were included in the review. There was considerable heterogeneity in implementation setting, dashboard users and indicators used. There was evidence that in contexts where dashboards were easily accessible to clinicians (such as in the form of a screen saver) their use was associated with improved care processes and patient outcomes. Conclusion There is some evidence that implementing clinical and/or quality dashboards that provide immediate access to information for clinicians can improve adherence to quality guidelines and may help improve patient outcomes. However, further high quality detailed research studies need to be conducted to obtain evidence of their efficacy and establish guidelines for their design.

Abstract Background Increased incorporation of minimally invasive pancreatic resections (MIPR) has emerged into hepato-pancreato-biliary practice, however, no standardization exists for its safe adoption. Novel strategies are presented for dissemination of safe MIPR. Methods An international State-of-the-Art conference evaluating multiple aspects of MIPR was conducted by a panel of pancreas experts in Sao Paulo, Brazil on April 20, 2016. Training and education issues were discussed regarding the introduction of novel strategies for safe dissemination of MIPR. Results The low volume of pancreatic resections per institution poses a challenge for surgeons to overcome their MIPR learning curve without deliberate training. A mastery-based simulation and biotissue curriculum can improve technical proficiency and allow for training of surgeons before the operating room. Video-based platforms allow for performance reporting and feedback necessary for coaching and surgical quality improvement. Centers of excellence with training involving a standardized approach and proctorship are important concepts that can be utilized in various formats internationally. Discussion Surgical volume is not sufficient to ensure quality and patient safety in MIPR. Safe adoption of these complex procedures should consider innovative mastery-based training outside of the operating room, novel video based coaching techniques and prospective reporting of patient data and outcomes using standardized definitions.

Incidence and risk factors for cytomegalovirus (CMV) disease in a Colombian cohort of kidney transplant recipients. CMV infection and disease are important causes of morbidity and mortality in kidney transplant recipients, and its prevalence varies with economic, geographic, and ethnic factors. Among 1620 records from a Colombian reference center, CMV immunoglobulin (Ig)G seroprevalence was found to be 90.9% among recipients and 90.2% among donors. In 86% (n = 264) of the cases, CMV disease occurred during the first 6 months after the transplantation, and the most frequent clinical presentation was CMV syndrome, followed by gastrointestinal disease. The following parameters were independent predictors of CMV disease: serological status of D+/R+ (hazard ratio [HR], 1.64; 95% confidence interval [CI], 1.03-2.63) and D+/R- (HR, 2.72; 95% CI, 1.49-4.93), age of the recipient (HR, 1.02; 95% CI, 1.01-1.03), and receiving more than 30 mg of prednisolone by the end of the first month after transplantation (HR, 1.59; 95% CI, 1.22-2.07). Acyclovir prophylaxis or other antiviral agents significantly decreased the risk of disease (HR, 0.41; 95% CI, 0.29-0.58 and HR, 0.34; 95% CI, 0.20-0.58, respectively). In conclusion, we found a high prevalence of CMV infection in a cohort of Latin American transplant recipients. In accord with findings from other regions, serological status is the main risk factor, prophylaxis with acyclovir is effective, and induction with alemtuzumab does not increase the risk of CMV disease.

Abstract: Current data indicate that pharmacokinetic (PK) monitoring of cyclosporin microemulsion (CsA) should be performed using the 2‐h concentration (C2), that tacrolimus (Tac) is commonly monitored using the trough level, and mycophenolate mofetil (MMF) should be monitored using the 1‐h (C1), 2‐h (C2) and 6‐h (C6) concentrations. The three differing time‐point requirements are cumbersome, and we aimed to develop universal guidelines for all three drugs using a large number of full PK profiles in children. One‐hundred and twenty two stable pediatric patients, receiving either CsA (165 PK profiles, 69 patients, 24 with concomitant MMF) or Tac (122 PK profiles, 53 patients, 18 with MMF) were analyzed retrospectively. Pearson r for the CsA C2 was 0.90 [95% confidence interval(CI): 0.86–0.92], for Tac C2 r was 0.86 (95% CI: 0.80–0.90), and for MPA C2 r was 0.77 (95% CI: 0.68–0.83), respectively. For MPA, at least three time‐points are required to accurately estimate the area under the concentration–time curve (AUC), and C1, C2 and C6 serve as best markers. Excellent AUC estimations could be obtained from a limited sampling strategy from C1, C2 and C6 or C0, C1, C2 and C4 with clinically acceptable errors for all three drugs. The AUC can be estimated with great precision by using an identical approach for all three drugs. Target AUCs for a given time‐point after transplantation remain to be established.

Bilateral synchronous renal cell carcinoma (RCC) is uncommonly encountered. Debate exists among urologists in managing these cases in a single surgery versus staged surgeries. We aim to report our experience in managing encountered cases using single-stage surgeries. Retrospective collection of cases with pathologically confirmed RCC that had single-stage bilateral renal surgery over the past 2 years. Three cases were identified. Patients were managed using bilateral transverse lateral lumbotomy. All patients did not have intraoperative or postoperative complications. Kidney function stayed stable after surgery. Single-stage bilateral renal surgery is a safe procedure. Bilateral transverse lateral lumbotomy allows for a fast and safe surgery with minimal complications. There is a possible histological dis-concordance in bilateral synchronous RCC.

Well-designed randomized, placebo-controlled clinical tri-als are critical for assessing the safety and effectivenessof immunosuppressive therapy (1). However pivotal im-munosuppressive trials have generally had relatively shortfollow-up: from 6 months in the case of MMF to 2 years inthe case of belatacept. Despite the estimated half-life ofmore than a decade for a kidney transplant, the long-termimpact of immunosuppressive therapy is largely unknown.Furthermore, surrogate markers and composite endpointsare often used but their association with long-term out-comes is uncertain. As the main focus of organ transplanthasshiftedtolong-termgraftandpatientsurvival,weneedlonger term follow-up studies.In this issue of AJT, Cortazar et al. compared the long-term outcomes in kidney recipients who received and didnot receive mTOR inhibitor containing regimens at Sem-melweis University in Hungary (2). Despite the limitationsnoted by the authors, this study raises concern about long-term sequelae of immunosuppression and also illustratesthe fact that we currently do not have long-term studies onmTOR inhibitors.This observational cohort study included 993 primarilyEasternEuropeanCaucasianswhosemediantimeatstudyentry was 72 months posttransplant with a median follow-up of 37 months. One hundred and one received mTORinhibitor containing regimens. We do not have details onwhat proportion of the mTOR inhibitor use was