Mentoring: the VA experience.
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Career Choice↗
Biomedical subjects
Leigh Neumayer
Publications and source records attributed to Leigh Neumayer.
Imaging in appendicitis: a review with special emphasis on the treatment of women.
OBJECTIVE: Acute abdominal pain in women often presents the clinician with a diagnostic dilemma, especially if it is lower abdominal pain. Appendicitis is frequently entertained as a diagnosis, but until recently, the gold standard diagnostic procedure was operation, carrying a high false-negative rate. In recent years, computed tomographic (CT) scan has been advocated as a diagnostic aid. The purpose of this systematic review was to evaluate the accuracy of CT scan in diagnosing appendicitis. DATA SOURCES: Investigators searched PubMed between January and July 2003 using the terms "CT scan" and "appendicitis" with the limits "All adults 19+ years" and "English [language]." In addition, reference lists of all obtained articles were reviewed for other potential citations. METHODS OF STUDY SELECTION: All prospective studies of adults published in English were considered. TABULATION, INTEGRATION, AND RESULTS: Initial searches and reviews yielded 248 citations. Twenty-three of the citations reported prospective studies; only two of these were randomized studies. Prospective studies report sensitivities ranging from 77% to 100%, specificities ranging from 83% to 100%, and accuracies ranging from 88% to 98% for the diagnosis of acute appendicitis. Information gained from CT scans in patients with suspected appendicitis results in alternative diagnosis in 6% to 36%. These values are similar for both men and women. CONCLUSION: The data support routine use of CT scan in both men and women for the diagnosis of appendicitis.
Appendicitis↗
Honor, respect, and passion.
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Attitude of Health Personnel↗
Prognostic models of abdominal wound dehiscence after laparotomy.
BACKGROUND: Portions of the prospective, multi-institutional National Veterans Affairs Surgical Quality Improvement Program were used to develop and validate a perioperative risk index to predict abdominal wound dehiscence after laparotomy. METHODS: Perioperative data from 17,044 laparotomies resulting in 587 (3.4%) wound dehiscences performed at 132 Veterans Affairs Medical Centers between October 1, 1996, and September 30, 1998, were used to develop the model. Data from 17,763 laparotomies performed between October 1, 1998, and September 30, 2000, resulting in 562 (3.2%) dehiscences were used to validate the model. Models were developed using multivariable stepwise logistic regression with preoperative, intraoperative, and postoperative variables entered sequentially as independent predictors of wound dehiscence. The model was used to create a scoring system, designated the abdominal wound dehiscence risk index. RESULTS: Factors contributing significantly to the model and their point values (in parentheses) for the risk index include CVA with no residual deficit (4), history of COPD (4), current pneumonia (4), emergency procedure (6), operative time greater than 2.5 h (2), PGY 4 level resident as surgeon (3), clean wound classification (-3), superficial (5), or deep (17) wound infection, failure to wean from the ventilator (6), one or more complications other than dehiscence (7), and return to OR during admission (-11). Scores of 11-14 are predictive of 5% risk of dehiscence while scores of >14 predict 10% risk. CONCLUSIONS: This abdominal wound dehiscence risk index identifies patients at risk for dehiscence and may be useful in guiding perioperative management.
Abdomen↗
Tension-free inguinal hernia repair: the design of a trial to compare open and laparoscopic surgical techniques.
BACKGROUND: Inguinal hernia is a common condition in men and represents a large component of health-care expenditures. Approximately 700,000 herniorrhaphies are performed each year in the United States. The most effective method of repair of an inguinal hernia is not known. STUDY DESIGN: A multicenter, randomized, clinical trial was designed to compare open tension-free inguinal hernia repair with laparoscopic tension-free repair on recurrence rates, complications, patient-centered outcomes, and cost. The study design called for randomization of 2,200 men over a period of 3 years. These men will be followed for a minimum of 2 years. This will allow determination of as little as a 3% absolute difference in recurrence rates with 80% power. Randomization is stratified by hospital, whether the hernia is unilateral or bilateral and whether the hernia is primary or recurrent. RESULTS: This is a report of the study design and current status. The study involves 14 Veterans Affairs medical centers with previous experience in laparoscopic hernia repair. After 35 months of enrollment, 2,165 men were randomized and recruitment was then closed. The majority of the patients (82.3%) had unilateral hernias and 90.6% of the hernias were primary. Sixty-seven percent of the patients had an outpatient operation. CONCLUSIONS: We report successful recruitment into a large multicenter trial comparing open and laparoscopic hernia repair. When followup is complete, this study will provide data regarding both clinical (recurrence rates) and patient-centered outcomes.
Costs and Cost Analysis↗
Transthoracic versus transhiatal esophagectomy: a prospective study of 945 patients.
OBJECTIVE: Debate continues as to whether transhiatal esophagectomy results in lower morbidity and mortality than transthoracic esophagectomy. Most data addressing this issue are derived from single-institution studies. To investigate this question from a nationwide multicenter perspective, we used the Veterans Administration National Surgical Quality Improvement Program to prospectively analyze risk factors for morbidity and mortality in patients undergoing transthoracic esophagectomy or transhiatal esophagectomy from 1991 to 2000. METHODS: Univariate and multivariate analyses were performed on 945 patients (mean age, 63 +/- 10 years). There were 562 transthoracic esophagectomies and 383 transhiatal esophagectomies in 105 hospitals, with complete 30-day outcomes recorded. RESULTS: There were no differences in recorded preoperative variables between the groups that might bias any comparisons. Overall mortality was 10.0% (56/562) for transthoracic esophagectomy and 9.9% (38/383) for transhiatal esophagectomy (P =.983). Morbidity occurred in 47% (266/562) of patients after transthoracic esophagectomy and in 49% (188/383) of patients after transhiatal esophagectomy (P =.596). Risk factors for mortality common to both groups included a serum albumin value of less than 3.5 g/dL, age greater than 65 years, and blood transfusion of greater than 4 units (P <.05). When comparing transthoracic esophagectomy with transhiatal esophagectomy, there was no difference in the incidence of respiratory failure, renal failure, bleeding, infection, sepsis, anastomotic complications, or mediastinitis. Wound dehiscence occurred in 5% (18/383) of patients undergoing transhiatal esophagectomy and only 2% (12/562) of patients undergoing transthoracic esophagectomy (P =.036). CONCLUSIONS: These data demonstrate no significant differences in preoperative variables and postoperative mortality or morbidity between transthoracic esophagectomy and transhiatal esophagectomy on the basis of a 10-year, prospective, multi-institutional, nationwide study.
Coma↗
Perceptions of women medical students and their influence on career choice.
BACKGROUND: Although women make up nearly half of medical school classes in the United States, just over 20% of residents in surgery are women (excluding obstetrics/gynecology). The objective of this study was to identify whether the proportion of women surgeons on the faculty who have frequent encounters with medical students during their surgery rotation influences the student's perceptions about women surgeons or their career choice. METHODS: Seven US medical schools with proportions of women surgeons on the fulltime faculty varying from 10% to 40% were selected to participate in this survey. Women medical students graduating in the spring of 2000 were asked to complete an anonymous 29 question survey designed to assess their perceptions of women surgeons' career satisfaction. Demographic information about the students such as career choice, age, and marital status was also collected. The differences in responses between those schools with 40% women faculty and those with less than 15% were analyzed. RESULTS: The overall response rate was 74% (305 of 413). Forty-five percent of students had daily or weekly contact with a woman surgery attending. There were no differences in perceptions of women surgeons' career satisfaction for those students at schools with 40% women surgeons versus those with less than 15%. However, 21 of 24 (88%) students choosing surgery as a career were from the three schools with a greater number of women surgical role models (P <0.0001). Students who chose a career in surgery perceived the women faculty's career satisfaction to be higher than did those students not choosing a surgical career (P <0.01). CONCLUSIONS: Women medical students perception of women surgeons' career satisfaction did not appear to be affected by the proportion of women surgeons on the faculty at their medical school. However, their choice of surgery as a career was strongly associated with a higher proportion of women on the surgical faculty.
Career Choice↗
Impact of journal articles and grand rounds on practice: CT scanning in appendicitis.
The purpose of this study was to determine whether a report in a high-impact journal published in January 1998 changed practice patterns and to further explore the impact of a review of the subject in a department of surgery grand rounds (January 2000). Charts from all patients undergoing appendectomy at our institution during three time periods (January to December 1997, January to December 1999, and January to June 2000) were reviewed. Rates of CT scanning, negative appendectomy, and perforated/gangrenous appendicitis were compared for the three periods to determine the impact of the journal article and the subject review during grand rounds on practice patterns and outcomes. Charts from 230 (88%) of 262 patients who underwent appendectomy during the time periods were available for review. Age, percentage of male patients, temperature on admission, and white blood cell count did not differ among the groups. The rate of CT scanning increased significantly from 1997 to 1999 and again in 2000 (6.7%, 43%, and 70%, respectively; P < 0.001), whereas the proportion of perforated/gangrenous appendicitis decreased significantly from 33% in 1997 and 31% in 1999 to 13% in 2000 (P = 0.012). The use of CT scanning in appendicitis increased both after publication of a report in a high-impact journal and after review during grand rounds. A rate of CT scanning above 45% appeared to affect outcomes as well.
Adult↗