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St. Louis, MO, United States

Jimenez R.E.,The Surgical Center | Jimenez R.E.,University of Connecticut | Hawkins W.G.,University of Washington | Hawkins W.G.,Alvin teman Cancer Center
Surgery (United States) | Year: 2012

Background: Pancreatic fistula occurs in approximately 30% of patients after distal pancreatectomy. Fistula formation is multifactorial in nature, influenced by patient-specific anatomic features of the pancreas and operative techniques at the time of resection. Methods: In this article, we review past, present, and future strategies postulated to address this problem. Results: The results of the stapler versus hand-sewn closure after distal pancreatectomy trial are presented in detail. This trial established equivalency between these 2 techniques, putting to rest a 25-year-old controversy. The implications of the stapler versus hand-sewn closure after distal pancreatectomy trial are discussed in the context of the current revolution in minimally invasive surgery, which will likely bring stapler closure to the forefront. Technologic improvements in surgical staplers are also discussed, with a focus in their applicability to pancreatic transection. Specifically, the results of a newly -published trial from Washington University in St. Louis are presented, showing improved fistula rates when stapler closure of the pancreas is reinforced with an external prosthesis. Conclusion: Based on these results, we postulate that stapler transection with mesh reinforcement is the best currently available method of pancreatic remnant closure. Results of ongoing trials using energy sealing devices are eagerly awaited, and further research into this area is necessary to make further progress in this field. © 2012 Mosby, Inc. All rights reserved. Source

Griffey R.T.,University of Washington | Jeffe D.B.,University of Washington | Jeffe D.B.,Alvin teman Cancer Center | Bailey T.,University of Washington
Academic Emergency Medicine | Year: 2014

Objectives Although computerized decision support for imaging is often recommended for optimizing computed tomography (CT) use, no studies have evaluated emergency physicians' (EPs') preferences regarding computerized decision support in the emergency department (ED). In this needs assessment, the authors sought to determine if EPs view overutilization as a problem, if they want decision support, and if so, the kinds of support they prefer. Methods A 42-item, Web-based survey of EPs was developed and used to measure EPs' attitudes, preferences, and knowledge. Key contacts at local EDs sent letters describing the study to their physicians. Exploratory principal components analysis (PCA) was used to determine the underlying factor structure of multi-item scales, Cronbach's alpha was used to measure internal consistency of items on a scale, Spearman correlations were used to describe bivariate associations, and multivariable linear regression analysis was used to identify variables independently associated with physician interest in decision support. Results Of 235 surveys sent, 155 (66%) EPs responded. Five factors emerged from the PCA. EPs felt that: 1) CT overutilization is a problem in the ED (α = 0.75); 2) a patient's cumulative CT study count affects decisions of whether and what type of imaging study to order only some of the time (α = 0.75); 3) knowledge that a patient has had prior CT imaging for the same indication makes EPs less likely to order a CT (α = 0.42); 4) concerns about malpractice, patient satisfaction, or insistence on CTs affect CT ordering decisions (α = 0.62); and 5) EPs want decision support before ordering CTs (α = 0.85). Performance on knowledge questions was poor, with only 18% to 39% correctly responding to each of the three multiple-choice items about effective radiation doses of chest radiograph and single-pass abdominopelvic CT, as well as estimated increased risk of cancer from a 10-mSv exposure. Although EPs wanted information on patients' cumulative exposures, they feel inadequately familiar with this information to make use of it clinically. If provided with patients' cumulative radiation exposures from CT, 87% of EPs said that they would use this information to discuss imaging options with their patients. In the multiple regression model, which included all variables associated with interest in decision support at p < 0.10 in bivariate tests, items independently associated with EPs' greater interest in all types of decision support proposed included lower total knowledge scores, greater frequency that cumulative CT study count affects EP's decision to order CTs, and greater agreement that overutilization of CT is a problem and that awareness of multiple prior CTs for a given indication affects CT ordering decisions. Conclusions Emergency physicians view overutilization of CT scans as a problem with potential for improvement in the ED and would like to have more information to discuss risks with their patients. EPs are interested in all types of imaging decision support proposed to help optimize imaging ordering in the ED and to reduce radiation to their patients. Findings reveal several opportunities that could potentially affect CT utilization. © 2014 by the Society for Academic Emergency Medicine. Source

Schootman M.,Alvin teman Cancer Center
American Journal of Preventive Medicine | Year: 2010

Background: A human papillomavirus (HPV) vaccine was approved by the Food and Drug Administration for use among women/girls in 2006. Since that time, limited research has examined HPV vaccine uptake among adolescent girls and no studies have examined the role of geographic disparities in HPV vaccination. Purpose: The purpose of this study is to examine geographic disparity in the prevalence of human papillomavirus (HPV) vaccination and to examine individual-, county-, and state-level correlates of vaccination. Methods: Three-level random intercept multilevel logistic regression models were fitted to data from girls aged 13-17 years living in six U.S. states using data from the 2008 Behavioral Risk Factor Surveillance System (BRFSS) and the 2000 U.S. census. Results: Data from 1709 girls nested within 274 counties and six states were included. Girls were predominantly white (70.6%) and insured (74.5%). Overall, 34.4% of girls were vaccinated. Significant geographic disparity across states (variance=0.134, SE=0.065) and counties (variance=0.146, SE=0.063) was present, which was partially explained by state and county poverty levels. Independent of individual-level factors, poverty had differing effects at the state and county level: girls in states with higher levels of poverty were less likely whereas girls in counties with higher poverty levels were more likely to be vaccinated. Household income demonstrated a similar pattern to that of county-level poverty: Compared to girls in the highest-income families, girls in the lowest-income families were more likely to be vaccinated. Conclusions: The results of this study suggest geographic disparity in HPV vaccination. Although higher state-level poverty is associated with a lower likelihood of vaccination, higher county-level poverty and lower income at the family level is associated with a higher likelihood of vaccination. Research is needed to better understand these disparities and to inform interventions to increase vaccination among all eligible girls. © 2010 American Journal of Preventive Medicine. Source

Andriole D.A.,University of Washington | Jeffe D.B.,University of Washington | Jeffe D.B.,Alvin teman Cancer Center
JAMA - Journal of the American Medical Association | Year: 2010

Context: The relationship between increasing numbers and diversity of medical school enrollees and the US physician workforce size and composition has not been described. Objective: To identify demographic and prematriculation factors associated with medical school matriculants' outcomes. Design, Setting, and Participants: Retrospective study using deidentified data for the 1994-1999 national cohort of 97 445 matriculants who were followed up through March 2, 2009, and had graduated, had withdrawn, or were dismissed. Data were analyzed using multivariable logistic regression to identify factors associated with suboptimal outcomes. Main Outcome Measures: Academic withdrawal or dismissal, nonacademic withdrawal or dismissal, and graduation without first-attempt passing scores on the US Medical Licensing Examination Step 1 and/or Step 2 Clinical Knowledge (CK) compared with graduation with first-attempt passing scores on both of the examinations. Results: Of 84 018 matriculants (86.2%), 74 494 graduated and had first-attempt passing scores on both the Step 1 and Step 2 CK (88.7%), 6743 graduated and did not have first-attempt passing scores on the Step 1 and/or Step 2 CK (8.0%), 1049 withdrew or were dismissed for academic reasons (1.2%), and 1732 withdrew or were dismissed for nonacademic reasons (2.1%). Variables associated with greater likelihood of graduation without first-attempt passing scores on the Step 1 and/or Step 2 CK and of academic withdrawal or dismissal, respectively, were (1) Medical College Admission Test scores (scores of 18-20 [2.9% of sample] vs >29: adjusted odds ratio [AOR], 13.06 [95% confidence interval {CI}, 11.56-14.76] and AOR, 11.08 [95% CI, 8.50-14.45]; scores of 21-23 [5.6% of sample] vs >29: AOR, 7.52 [95% CI, 6.79-8.33] and AOR, 5.97 [95% CI, 4.68-7.62]; and scores of 24-26 [13.9% of sample] vs >29: AOR, 4.27 [95% CI, 3.92-4.65] and AOR, 3.56 [95% CI, 2.88-4.40]), (2) race/ethnicity (Asian or Pacific Islander [18.2% of sample] vs white: AOR, 2.15 [95% CI, 2.00-2.32] and AOR, 1.69 [95% CI, 1.37-2.09]; under-represented minority [14.9% of sample] vs white: AOR, 2.30 [95% CI, 2.13-2.48] and AOR, 2.96 [95% CI, 2.48-3.54]), and (3) premedical debt (≥$50 000 [1.0% of sample] vs no debt: AOR, 1.68 [95% CI, 1.35-2.08] and AOR, 2.33 [95% CI, 1.57-3.46]). Conclusions: Lower scores on the Medical College Admission Test, nonwhite race/ethnicity, and premedical debt of at least $50 000 were independently associated with a greater likelihood of academic withdrawal or dismissal and graduation without first-attempt passing scores on the US Medical Licensing Examination Step l and/or Step 2 CK. ©2010 American Medical Association. All rights reserved. Source

Andriole D.A.,University of Washington | Jeffe D.B.,University of Washington | Jeffe D.B.,Alvin teman Cancer Center
Journal of the American College of Surgeons | Year: 2012

Background: We sought to identify variables associated with American Board of Medical Specialties (ABMS)-member board certification and lack thereof among US medical graduates who planned at medical school graduation to become certified in surgery and entered graduate medical education in general surgery. Study Design: Deidentified, individualized records updated through March 2009 for all 1993-2000 US medical school matriculants who graduated by 2002, intended to become certified in surgery, and entered general surgery training were analyzed using multivariable logistic regression to identify variables associated with graduates' board certification status, including American Board of Surgery (ABS)-board certified (BC), other ABMS-member-BC (other-BC) and non-BC. Results: Of 3,373 graduates included in the study sample, 2,036 (60.4 %) were ABS-BC, 342 (10.1 %) were other-BC, and 995 (29.5 %) were non-BC. Graduates who were women, older than 26 years old at graduation, and initially failed US Medical Licensing Examination Step 2 Clinical Knowledge were more likely, and graduates who rated the quality of their surgery clerkship in medical school more highly were less likely, to be other-BC vs ABS-BC. Graduates who were women, under-represented minority race/ethnicity, Asian/Pacific Islander race/ethnicity, older than 28 years old at graduation, initially failed US Medical Licensing Examination Step l, initially failed or received low passing scores on US Medical Licensing Examination Step 2 Clinical Knowledge, and graduated in more recent years were more likely to be non-BC vs ABS-BC. Conclusions: Demographic and professional development variables were associated with ABMS-member BC status among US medical graduates who had intended at medical school graduation to become certified in surgery. © 2012 American College of Surgeons. Source

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