Faculty Bibliography

OBJECTIVE: There is reluctance to use donation after cardiac death (DCD) organs for fear of worse outcomes due to increased warm ischemia time. Extensive evidence to confirm the quality of DCD pancreas transplants is not manifest. METHODS: A united network for organ sharing database review of pancreas transplants performed between 1996 and 2012 was conducted. We compared outcomes and all demographic variables between donors after cardiac death and donors after brain death in pancreas transplantation. RESULTS: There were 320 DCD pancreas transplants and 20,448 donation after brain death pancreas transplants performed in the United States between 1996 and 2012. There was no statistically significant difference in graft survival or patient survival in pancreas transplantation in DCD versus donation after brain death donors measured at 1-year, 3-year, 5-year, 10-year, and 15-year intervals. There was no significant difference between donor and recipient age, race, sex, and body mass index (BMI) between the groups. There was no significant difference between the recipient ethnicity or time on wait list between the groups. CONCLUSIONS: Pancreata procured by DCD have comparable outcomes to those procured after brain death. Donation after cardiac death pancreas transplant is a viable method of increasing the donor pool, decreasing wait list mortality, and improving the quality of life for type 1 diabetic patients.

BACKGROUND: To evaluate resident knowledge of colorectal cancer (CRC) screening guidelines and to define areas requiring attention. METHODS: A survey was created using three published guidelines for CRC screening. Program directors for internal medicine residency programs were contacted within the metro New York City area to have their residents participate. RESULTS: Five programs participated, and 115 responses were recorded. For the appropriate testing and interval to screen for CRC, 61/115 residents identified flexible sigmoidoscopy every 5 years, 108/115 identified colonoscopy every 10 years, 16/115 identified double contrast barium enema (DCBE) every 5 years and only 12/115 thought CT-colography every 5 years was appropriate. Only 40/115 respondents appropriately identified fecal occult blood testing (FOBT) administered in the patient's home annually, while fecal immunohistochemical testing (FIT) annually at home was identified by 8/115 residents. CONCLUSION: While most residents seem knowledgeable regarding CRC screening with colonoscopy, many deficiencies remain. FOBT for screening purposes remains undervalued, and confusion about administering the test persists. The distinction between screening and prevention needs further reinforcement.

This study sought to examine various factors that may prevent transplant candidates from completing their transplant workup prior to listing. We reviewed the records of 170 subjects (cases = 100, controls 70) who were either on dialysis or had less than 20 mL/min creatinine clearance and were therefore candidates for preemptive transplantation. Approximately, 56% of preemptive patients completed their workup, while only 36% of patients on dialysis completed their workup. Our data revealed that factors contributing toward completion of workup included intrinsic motivation (four times more likely), lack of specific medical comorbidities (three times more likely), and preemptive status (two times more likely). Among patients on dialysis, intrinsic motivation (five times more likely) and absence of cardiovascular complications (four times more likely) were associated with completion. When comparing patients on dialysis to patients not on dialysis, there were significant differences between the two groups in distance from home to the transplant center, level of education, and presence of medical comorbidities. We believe that targeted interventions such as timely referral, providing appropriate educational resources, and development of adequate support systems, have the potential to improve workup compliance of patients with advanced chronic kidney disease, including those on dialysis.

OBJECTIVE:To study medication discrepancies in clinical transitions across a large health care system. DESIGN/METHODS:Randomized chart review of electronic medical records and paper chart medication reconciliation lists across 3 transitions of care. SETTINGS AND PARTICIPANTS/METHODS:Subacute patient medication records were reviewed through 3 transition care points at a large health care system, including hospital admission to discharge (time I), hospital discharge to skilled nursing facility (SNF; time II) and SNF admission to discharge home or long term care (LTC; time III). MEASUREMENTS/METHODS:Medication discrepancies were identified and categorized by the principal investigator and a pharmacist. Discrepancies were defined as any unexplained documented change in the patients' medication lists between sites and unintentional discrepancies were defined as any omission, duplication, or failure to change back to original regimen when indicated. RESULTS:We reviewed 1696 medications in the 132 transition records of 44 patients, identifying 1002 discrepancies. Average age was 71.4 years and 68% were female. Median hospital stay was 5.5 days and 14.5 SNF days. Total medications at hospital admission, hospital discharge, SNF admission, and SNF discharge were 284, 472, 555, and 392, respectively. Total medication discrepancies were 357 (time I), 315 (time II), and 330 (time III). All patients experienced discrepancies and 86% had at least 1 unintentional discrepancy. The average number of medications per patient increased at time I from 6.5 to 10.7 (P < .001), increased at time II from 10.7 to 12.6 (P <.0174), and decreased at time III from 12.6 to 8.9 (P < .001). Patients, on average, had 8.1, 7.2, and 7.6 medication discrepancies at times I, II, and III, respectively. Surgical patients had more discrepancies than medical at times I and III (8.94 vs 5.3, P < .019; 8.0 vs 5.8, P < .028). In the unintentional group, cardiovascular drugs represented the highest number of discrepancies (26%). CONCLUSION/CONCLUSIONS:This study is the first to follow medication changes throughout 3 transition care points in a large health care system and to demonstrate the widespread prevalence of medication discrepancies at all points. Our findings are consistent with previously published results, which all focused on single site transitions. Outcomes of the current reconciliation process need to be revisited to insure safe delivery of care to the complex geriatric patient as they transition through health care systems.

Low albumin and the albumin-globulin ratio (AGR) were associated with vascular adverse events. Our study explores the AGR as a predictor of mortality after non-ST-segment elevation myocardial infarction (NSTEMI). In an observational study of 570 NSTEMI patients admitted to a tertiary center between 2004 and 2006, patients were stratified into equal tertiles according to AGR. The primary outcome was 4-year all-cause mortality. The 4-year mortality rates in the first, second, and third AGR tertiles were 88 (47%) of 189, 48 (25%)of 190 , and 19 (10%) of 191, respectively (P < .0001). After adjusting for 20 confounding variables, AGR first tertile (AGR <1.12) had a higher mortality versus second tertile (hazard ratio [HR] 2.6, P < .001). Likewise, the AGR second tertile had higher mortality versus the third tertile (AGR ≥1.34; HR 2.3, P = .004). The albumin-globulin ratio is a significant independent predictor of long-term mortality after NSTEMI in patients with normal serum albumin levels. Further studies are needed to explain the underlying mechanisms.

Seroprevalence of antibodies to influenza A(H1N1)pdm09 virus among 193 emergency department health care personnel was similar among 147 non-health care personnel (odds ratio 1.4, 95% CI 0.8-2.4). Working in an acute care setting did not substantially increase risk for virus infection above risk conferred by community-based exposures.

OBJECTIVE: To assess intraoperative cognitive and motor skills using audio- and video-based analysis. MATERIALS AND METHODS: The study enrolled 11 surgeons who were categorized into novice (n = 4), intermediate (n = 4), and expert (n = 3) groups. Categorization of skill level was based on years of experience and as determined by the lead expert surgeon. A total of 32 cases were available for analysis, including 5 robotic and 27 laparoscopic renal cases. For each procedure, video and audio components were recorded and sent for grading to 4 blinded judges. The previously validated global rating scale (GRS) and operation-specific rating scale (ORS), as well as a novel cognitive rating scale (CRS), were used to assess performances. Statistical comparisons were performed by analysis of variance. RESULTS: Comparison of the 3 skill levels using analysis of variance showed that each scale was able to differentiate among the levels (P <.05). The mean scores for the before and after audio GRS, ORS, and CRS showed significant difference between the novice, intermediate, and expert groups, demonstrating construct validity. CONCLUSION: The use of intraoperative audio is an innovative way to assess the cognitive ability of the surgeon. The CRS demonstrated construct validity. The addition of the CRS to the already validated GRS and ORS may serve as a reliable system to objectively evaluate laparoscopic and robotic surgical skill.

Male NZW/BXSB.Yaa (W/B) mice express two copies of TLR7 and develop pathogenic autoantibodies, whereas females with only one copy of TLR7 have attenuated disease. Our goal was to analyze the regulation of the autoantibody response in male and female W/B mice bearing the autoreactive site-directed H chain transgene 3H9. Serum anti-dsDNA Abs appeared in males at 12 wk, and most had high-titer IgG anti-dsDNA and anti-cardiolipin Abs and developed >300 mg/dl proteinuria by 8 mo. Females had only low-titer IgG anti-cardiolipin Abs, and none developed proteinuria by 1 y. Males had a smaller marginal zone than females with a repertoire that was distinct from the follicular repertoire, indicating that the loss of marginal zone B cells was not due to diversion to the follicular compartment. Vk5-43 and Vk5-48, which were rare in the naive repertoire, were markedly overrepresented in the germinal center repertoire of both males and females, but the VJ junctions differed between males and females with higher-affinity autoreactive B cells being selected into the germinal centers of males. Administration of IFN-α to females induced anti-cardiolipin and anti-DNA autoantibodies and proteinuria and was associated with a male pattern of junctional diversity in Vk5-43 and Vk5-48. Our studies are consistent with the hypothesis that presence of the Yaa locus, which includes an extra copy of Tlr7, or administration of exogenous IFN-α relaxes the stringency for selection in the germinal centers resulting in increased autoreactivity of the Ag-driven B cell repertoire.

BACKGROUND: The benefit of adding a vena cava filter to anticoagulation in treating cancer patients with venous thromboembolism remains controversial. We initiated this study as the first prospectively randomized trial to evaluate the addition of a vena cava filter placement to anticoagulation with the factor Xa inhibitor fondaparinux sodium in patients with cancer. METHODS: Sixty-four patients with deep vein thrombosis (86 %) and/or pulmonary embolism (55 %) were randomly assigned to receive anticoagulation with fondaparinux sodium with or without a vena cava filter. Endpoints included rates of complications by treatment arm, recurrent thromboembolism, complete resolution of thromboembolism, and survival rates. RESULTS: No patient had a recurrent deep vein thrombosis; two (3 %) patients had new pulmonary emboli, one in each randomized cohort. Major bleeding occurred in three patients (5 %). Two patients on the vena cava filter arm (7 %) had complications from the filter. Median survivals were 493 days in the anticoagulation only arm and 266 days for anticoagulation + vena cava filter (p < 0.57). Complete resolution of venous thromboembolism occurred in 51 % of patients within 8 weeks of initiating anticoagulation. CONCLUSIONS: No advantage was found for placement of a vena cava filter in addition to anticoagulation with fondaparinux sodium in terms of safety, recurrent thrombosis, recurrent pulmonary embolism, or survival in this prospective randomized trial evaluating anticoagulation plus a vena cava filter in cancer patients. Favorable complete resolution rates of thrombosis were observed on both study arms.