THE UNIVERSITY OF VERMONT COLLEGE OF MEDICINE DEPARTMENT OF SURGERY

THE UNIVERSITY OF VERMONT
COLLEGE OF MEDICINE
DEPARTMENT OF SURGERY
FORTY-FOURTH ANNUAL
SURGERY SENIOR MAJOR SCIENTIFIC
PROGRAM
THURSDAY – MAY 1, 2014
AUSTIN AUDITORIUM, Shep 488, MCHV CAMPUS
7:30AM
FROM THE OBJECTIVES OF THE SENIOR MAJOR PROGRAM IN
SURGERY:
"To provide the student with the opportunity, through a library search or quality
improvement project, a patient chart review and/or laboratory investigation, to
complete a scholarly project, assemble and prepare the data in the form of a
scientific article acceptable for publication in a professional journal and to present
this research at a scientific seminar."
The abstracts included in this booklet have been prepared by the Surgery Senior Major students of
the Class of 2014. The papers will be presented at a seminar on Thursday, May 1, 2014 in Austin
Auditorium, MCHV Campus. This will be followed by an Awards Banquet in the Hoehl Gallery at
1:30pm in the Health Science Research Facility. We urge you to attend these presentations and
lend your support to their efforts. The presentations will be judged by a committee and awards for
outstanding scientific projects will be announced at a reception and luncheon that afternoon in
honor of the Surgery Senior Majors.
Dr. Ted James, Associate Professor of Surgery
Director, Surgical Senior Majors, Class of 2014
7:30AM
INTRODUCTION – JAMES HEBERT, M.D., FACS, Albert G. Mackay, MD’34 and
H. Gordon Page, MD’45, Professor of Surgery
Executive Vice Chair for Academic Affairs, Department of Surgery
Seminar Coordinator
7:35AM
Incidence of Post-Operative Deep Vein Thrombosis in Patients Managed
on an Enhanced Recovery Pathway Following Open or Laparoscopic
Colectomy Ashley Russo
7:50AM
The Effectiveness of Short-Term Surgical Volunteerism: A Review
Adam Ackerman
8:05AM
In-Depth Patient Characterization of a Hand Surgery Mission to
Honduras: Patient Education, Experience and Outcomes Jacob Azurdia
8: 20AM
HPV Vaccination Practices of Vaccinating Providers in Vermont:
Consideration of HPV-Related Head and Neck Disease
Elizabeth Blasberg
8:35AM
Identifying the Window of Therapeutic Opportunity for Salubrinal
Treatment Post Traumatic Brain Injury Larry Bodden
8:50am-9:05am INTERMISSION (Fifteen Minute Intermission)
9:05AM
Short-Term Outcomes of Low Anterior Resection for Rectal Cancer with
and without Diverting Ostomy: A NSQIP Study Kevin Kuruvilla
9:20AM
Role of Acute Kidney Injury in Perioperative Costs for Abdominal
Aortic Aneurysm Repair Gabriel Crowl
9:35AM
Impact of Gender on Outcomes of Peripheral Vascular Interventions for
the Treatment of Claudication and Critical limb ischemia Katelynn
Ferranti
9:50AM
Women Role Models: Are They Needed? Vanessa Franz
10:05AM
Fletcher Allen Health Care Gynecologic Surgeon Adherence to Venous
Thromboembolism Prophylaxis Guidelines: An Opportunity for Quality
Improvement and Cost Savings Margaret Gordon-Fogelson
10:20AM
Sign-Out Improvement Project: Needs Assessment of Handoff Procedure
and Resident Education at Fletcher Allen Healthcare Center
Chelsea Harris
10:35AM
The Impact of Health Literacy and Outcomes of Breast Cancer Patients
in Northern New England Francesca Boulos
10:50am
Patient Outcomes with the Fletcher Allen Health Care Trauma Service
Nathan Louras
11:05am
The Impact of Perioperative Glucose Control in Surgical Site Infections
following Orthopedic Spinal Surgeries Ashley Miller
11:20am
Literature Review of Interventions in Rural Antenatal Care: An Effort to
Reduce Maternal Morbidity in Rural Tanzania Jenna Pariseau
11:35pm
Optimizing the Prognostic Value of Sentinel Lymph Node Biopsy in
Breast Cancer Elizabeth Robison
11:50pm
Mini-Sternotomy Approach to Aortic Valve Replacement: A Single
Center Report Hany Abdallah
12:05pm
The Effect of Ophthalmic Examination on the Outcome of Intraocular
Lens Choice and Optical Biometric Parameters Dane Slentz
12:20pm
Emergency Department Prescriber Attitudes and Behaviors Regarding
Opioid Medications: A Vermont Statewide Survey Richard Tan
Incidence of Post-Operative Deep Vein Thrombosis in Patients Managed on an
Enhanced Recovery Pathway Following Open or Laparoscopic Colectomy
Authors: Ashley Russo MS-IV, Andrew Pellet MD, Jesse Moore, MD
Advisor: Dr. Jesse Moore
ABSTRACT
Introduction: The incidence of deep vein thrombosis (DVT) after colectomy is 2%.1 The average
hospital stay for patients undergoing major colorectal surgery is 9 days.2 During hospital admission, it has
been shown that the combination of mechanical thromboprophylaxis and pharmacologic
thromboprophylaxis is better than pharmacologic thromboprophylaxis alone in preventing DVT in this
subset of patients.3With the implementation of enhanced recovery pathways, length of hospital stay is
now as short as 2 days.4 With shortened hospital stays, patients receive less inpatient thromboprophylaxis.
Despite the fact that it has been shown that enhanced recovery pathways decrease postoperative
complications and length of hospital stay2, there is no specific data to show the impact of enhanced
recovery pathways on the incidence of DVT and whether or not DVT rates differ based on length of
hospital stay and length of inpatient thromboprophylaxis. The purpose of this study is to determine
whether patients managed on an enhanced recovery pathway after undergoing open or laparoscopic
colectomy are at an increased risk of developing DVT following discharge.
Methods: All patients undergoing elective open or laparoscopic colectomy between April 2012 and July
2013 were included in this study. All 116 patient charts that met inclusion criteria were reviewed for
variables including demographics, procedure type, indication, and length, adherence to ERP protocol in
the pre-operative, intra-operative, and post-operative settings, post-operative complications, VTE
prophylaxis, and relevant medical history.
Results: 50% of the patients underwent open colectomy and 50% underwent laparoscopic colectomy.
80% of the patients were 50 years old or older. 33.6% of patients had a BMI of 30 or greater. 98.2% of
patients underwent a procedure with a duration of longer than 60 minutes. 47.4% of patients were former
smokers, 37.1% patients had never smoked, and 15.5% of patients were current smokers at the time of
procedure. 97.4% of patients received VTE chemoprophylaxis and 97.4% received mechanical
prophylaxis. For co-morbid risk factors for VTE, 4.3% of patients carried a diagnosis of CHF and 5.2%
patients had a history of renal failure. 40.5% of patients underwent elective colectomy for a primary
diagnosis of malignancy, whereas 59.5% of patients had non-malignant preoperative diagnoses. 61.2% of
patients were discharged on postoperative day three or sooner. The median length of stay was 3 days. No
patients received VTE chemoprophylaxis or mechanical prophylaxis after discharge. There were no
documented postoperative venous thromboembolic events within 30 days of original operation. Chart
review did reveal that two of the patients had a documented diagnosis of DVT within 3 months of original
operation. Subsequent thorough chart reviews of both patients with diagnosed DVT were conducted and
revealed that the incidence of DVT was unrelated to the ERP protocol that was adhered to following their
original elective operations.
Conclusions: This study provides evidence that despite a shorter length of stay and a truncated duration
of VTE prophylaxis there is no increased risk of DVT in patients who are managed on an enhanced
recovery pathway after undergoing elective open or laparoscopic colectomy.
ABSTRACT
"The Effectiveness of Short-Term Surgical Volunteerism"
Adam Ackerman, Surgical Senior Major, Class of 2014
Mentor: Neil Hyman, MD, Professor of Surgery
Background: Nearly 550 organizations currently support at least 10 medical missions per year with an
average expenditure of $50,000 per mission. The total annual cost surpasses 250 million dollars per year.
There is a surge in the overall number of surgical volunteer missions, and surgical residents show an
increasing interest in working abroad during and after their training. Despite excellent intentions, shortterm surgical volunteerism (STSV) is often questionably effective in changing outcomes and fostering
sustainable improvement to healthcare delivery. The objective of this project is to complete a literature
review of the current research pertaining to short term surgical volunteerism with a focus on sub-Saharan
Africa.
Methods: A literature search was performed using PubMed and Google Scholar. Combinations of
keywords were tried with appropriate filters. The results were checked individually to determine whether
or not the result was relevant to this review.
Results: A total of 62 results were returned. Upon evaluation, only 8 of these results were found to be
relevant. The published material tends to be weighted towards editorials and personal perspectives, which
encourage surgical volunteerism. Only one paper attempted to assess the impact of short-term medical
volunteerism, but this was not specific to surgical volunteerism.
Conclusion: There continues to be a demand for participation in short-term surgical volunteerism.
However, the lack of oversight by a governing body and absence of literature indicating the effectiveness
of STSV demonstrates an urgent need for further investigation. This is unlikely to be forthcoming due to
multiple obstacles including the lack of clear endpoints to measure. In the meantime, organizations that
support surgical volunteerism and volunteers themselves must be extra vigilant in their activities overseas
to ensure the safety of patients, sovereignty of local healthcare workers, and maintain an open culture of
exchange.
In-Depth Patient Characterization of a Hand Surgery Mission to Honduras: Patient
Education, Experience and Outcomes
Authors: C. Chuang, BS, J. Azurdia, BA, K. Ragins, BA,
J Grant Thomson, MD, MSci
Advisor: Donald Laub Jr, MD, FACS
Introduction: The goal of this study is to examine patient education, experience and outcomes
from a hand surgery mission to San Pedro Sula, Honduras.
Methods: A team of hand surgeons and medical support staff traveled to Honduras in March of
2013 and operated on 63 patients. Patient knowledge was evaluated with a quiz on hand function and
anatomy given before and after patients viewed an educational video. Patient experience and perspectives
were evaluated using a self-developed survey. Patient outcomes were evaluated using the QuickDASH
both pre-operatively and at 3 months post-operatively.
Results: Participants scoring 60% or less (n=34 [71%], mean 31%, SD 23%) on an anatomy and
function quiz showed a statistically significant improvement in scores after watching an educational video
(mean 54%, SD 32%, p < 0.05). Mean annual income for patients was 3,330USD (SD $2,030) and each
spent, on average, 100USD (SD $106) to have surgery with the mission. As motivation for attending the
mission, “better quality” was rated most important by the majority of participants (59%). Pre-operatively,
anxiety was rated by participants as a mean of 6.8 (SD 3) on a scale of 1-10 with pain (42%) and
anesthesia (39%) being the most significant factors. When compared with pre-operative scores (mean 38,
SD 24), post-operative adult QuickDASH scores showed a statistically significant improvement (mean
26, SD 20, p<0.05).
Conclusions: This study suggests that an educational video may be an effective way to educate
this population in hand anatomy and function. Although annual income is strikingly low, the majority of
patients sought surgical care from the medical mission due to a perceived higher quality in care. These
results also suggest that the QuickDASH may be a useful tool to evaluate surgical outcomes in the setting
of a medical mission trip.
HPV Vaccination Practices of Vaccinating Providers in Vermont: Consideration of
HPV-Related Head and Neck Disease
Author: Elizabeth A. Blasberg
Advisor & Co-Author: Damon Silverman MD & Christie Barnes MD
Introduction: Although knowledge of HPV’s role in cervical cancer and anogenital warts is widespread
among practitioners who vaccinate against it, the virus’s role in diseases of the head and neck outside of
the otolaryngology specialty is not yet common knowledge. Consequently, these potentially lethal
diseases, Oropharyngeal Squamous Cell Cancer (OPSCC) and Recurrent Respiratory Papillomatosis
(RRP), may not be included in discussions with patients surrounding vaccination for HPV. This study
aims to survey current HPV vaccination practices of Family Practice and Pediatrician physicians in
Vermont and how they may be impacted after education on OPSCC and RRP.
Methods :Data was collected via electronic survey with pre-education questions, an educational module,
and post education questions sent via a SurveyMonkey Link in an email to Family Practitioners and
Pediatricians belonging to the Vermont Medical Society. Descriptive statistics were calculated to describe
the population of respondents and survey answers. Pearson’s Chi Square test and the Fischer Exact test
were used to detect relationships within the data.
Results: There was a total of 102 responses. The respondents were equally divided between Family
Practice (53%) and Pediatrics (46%). All respondents vaccinate both boys and girls against HPV. Most
providers stated they were familiar with RRP (65.6%) and OPSCC (73.7%) but fewer cited RRP or
OPSCC as factor in recommending the HPV Vaccine (28.1% and 53.8%, respectively) and even fewer
discussed RRP or OPSCC in patient counseling on HPV vaccination (8.8% and 41.8%, respectively).
Also, only 41.1% correctly identified which subtypes the quadrivalent vaccine (the only vaccine available
in the state of Vermont) covered for, and only 1.9% could do so for the bivalent vaccine. After reviewing
the educational material about OPSCC and RRP, 55.1% of respondents reported they were more likely to
recommend HPV vaccination for their patients.
Conclusions: Familiarity with HPV-related diseases was significantly related to provider consideration
and discussion of these diseases when counseling patients about HPV vaccination. There was a low
response rate for the survey, however, education regarding the role of HPV in head and neck disease may
be valuable to increase physician comfort with discussing these diseases with patients and potentially
their efficacy in counseling parents and patients to undergo HPV vaccination. Consideration should be
given to implementation of a method for delivering information to vaccinating practitioners in Vermont
about Recurrent Respiratory Papillomatosis and Oropharyngeal Squamous Cell Cancer and the
relationship between these diseases and the HPV virus.
IDENTIFYING THE WINDOW OF THERAPEUTIC OPPORTUNITY FOR
SALUBRINAL TREATMENT POST TRAUMATIC BRAIN INJURY
Author: Larry O. Bodden
Advisor: Dr. Raghu Vemuganti
Introduction: Disruption of neuronal endoplasmic reticulum post traumatic brain injury (TBI)
activates a complex set of signaling pathways known as the unfolded protein response which unchecked
can lead to cell death. One component of this stress signaling pathway initiated by pancreatic ER kinase
(PKR)-like ER kinase (PERK) has been shown to be mediated by the drug salubrinal through reduction of
apoptosis and oxidative stress. This study’s purpose was to define when salubrinal treatment post-TBI
was most effective in curtailing cerebral tissue death and loss of motor function.
Methods: A moderate grade TBI was induced in adult male C57BL/6 mice through a
craniectomy. Mice received salubrinal i.p. (1.5mg/kg) at 5min, 2h, or 4h post-TBI with one control group
receiving vehicle solution at 2 hours. At 24 hours post-TBI groups received an additional dose of
salubrinal or vehicle. All mice underwent beam walk footfall (number of right hindpaw footfalls over
80cm), beam walk latency (time to traverse 80cm), and rotarod (time on rod) tests. Mice were euthanized
on day 7 post-TBI for cortical lesion volume histopathology.
Results: A total of 36 mice were tested with n=9 per experimental group. Treatment mean times
on rotarod were not significantly different than control except for one time point (2h injection on day 5
post TBI, (p= 0.038)). Mean beam walk latency showed no difference between treatment and control at
any time point. The beam walk footfall means for the entire 2h post TBI treatment group and the latter
half of the 4h post TBI treatment groups showed significant difference to control on all testing dates (both
p=0.013). Lesion volume mean was significantly different in both 5min and 2h groups than control
(p=0.03 and p=0.05 respectively).
Conclusion: This study suggested that early administration of salubrinal provides both prevention
of loss of motor function and increases neuronal survival post-TBI.
Short-term Outcomes of Low Anterior Resection for Rectal Cancer with and without
Diverting Ostomy: A NSQIP Study
Kevin Kuruvilla, B.S.1, Stefan D. Holubar M.D., M.S. 2, Turner Osler M.D., MSc3,
Neil H. Hyman, M.D3*
1
2
University of Vermont College of Medicine, Burlington, VT, USA
Division of Colon and Rectal Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
3
Department of Surgery, University of Vermont College of Medicine, Burlington, VT, USA
Background: Proximal fecal diversion may minimize the impact of anastomotic leak after low anterior
resection for rectal cancer. However creation of a diverting stoma and its subsequent reversal is associated
with considerable morbidity.
Objective: In order to assess the impact of stoma on short-term outcomes, we compared the morbidity
associated with LAR-alone to LAR+diverting stoma. We also described the morbidity associated with
reversal of diverting stomas.
Design: Retrospective data review using the American College of Surgeons – National Surgical Quality
Improvement Project (ACS-NSQIP) from 2009-2011.
Setting: NSQIP Database
Patients: We identified all patients with a postoperative diagnosis of rectal cancer who underwent LAR
with or without concurrent stoma procedures.
Main outcome measures: Demographics, comorbidities, operative outcomes and 30-day postoperative
complications were collected.
Results: We identified 1171 patients with LAR-alone and 1304 patients with LAR+stoma. The mean age
in the LAR-alone group was 62.3±12.7 vs. 60.7±12.5 in the LAR+stoma group (p = 0.00). Radiation
therapy was more frequent in the LAR+stoma group (48.6% vs. 21.5%, p<0.01). The 30-day postoperative outcomes are presented in Table 1. Univariate analysis found no difference in the incidence of
serious complications, sepsis, superficial/organ space infection or other system complications between
groups. Patients in the LAR-alone group were more likely to return to the OR (7.3 vs. 5.2%, p=0.03), but
had shorter OR times and LOS (236 vs. 207 min, p<0.01, 8.0 vs. 7.2 days, p=0.01 respectively). However
multivariate analysis after propensity score matching found that the only difference between groups was
that the LAR+stoma had longer operative times. A separate analysis showed the outcomes of diverting
stoma reversal are as follows: any septic events: 11%, any SSI: 10.3%, return to OR: 3.3%, LOS in days:
5.6±6.3.
Limitations: The inherent weakness of a retrospective study and lack of long term follow-up are the
major weaknesses of this study.
Conclusions: We found that 30-day post-operative complications in patients undergoing LAR for rectal
cancer are similar with or without proximal diversion. However, patients with a diverting stoma require a
second operation to reverse the stoma and are subjected to further complications and hospitalization.
Defining the subgroup of patients who benefit from proximal diversion could increase patient safety and
satisfaction while reducing costs
Key words: Low anterior resection, rectal cancer, diverting stoma, complications, ileostomy reversal
POSTOPERATIVE EVENTS ASSOCIATED WITH INCREASED
PERIOPERATIVE COST IN ABDOMINAL AORTIC ANEURYSM REPAIR
Author: Gabriel Crowl, AB
Advisor: Andrew Stanley, MD
Introduction: Acute kidney injury (AKI) has adverse consequences on both clinical outcomes
and cost in the inpatient population. We sought to understand the impact of AKI as a post-operative
complication by evaluating the additional cost it imposed during the hospital course of patients
undergoing elective abdominal aortic aneurysm (AAA) repair.
Methods: Using data from two academic medical centers submitted to a regional quality
improvement registry, cost data for patients undergoing elective endovascular (EVAR) and open (OSR)
abdominal aortic aneurysm repair were extracted. Patients were stratified by degree of kidney
dysfunction incurred during the primary hospitalization. Contributors to total inpatient cost for the
hospitalization were then identified using multivariate analysis.
Results: 999 patients were included, of whom 52% received OSR and 48% EVAR. 9.5% were
diagnosed with some form of kidney injury, of whom 1.5% required dialysis. Stepwise linear regression
revealed that for OSR; length of stay (p < 0.001), estimated blood loss (p < 0.001), length of primary
procedure (p < 0.001), length of ICU stay (p < 0.001), return to operating room (p < 0.001), and need for
temporary dialysis (p = 0.003) as independent events associated with higher cost. For EVAR; length of
ICU stay (p < 0.001), length of primary procedure (p = 0.008), and estimated blood loss (p = 0.043) were
identified as associated with higher cost.
Conclusions: AKI could not be established as an independent predictor of higher costs in this
patient population when adjusted for confounders.
IMPACT OF GENDER ON OUTCOMES OF PERIPHERAL VASCULAR
INTERVENTIONS FOR THE TREATMENT OF CLAUDICATION AND
CRITICAL LIMB ISCHEMIA
Author: Katelynn Ferranti
Advisor: Daniel Bertges, MD
Introduction: Gender has previously been studied as an independent risk factor for poor outcomes in
patients who have undergone treatment for peripheral arterial occlusive disease. Some groups have
suggested that women experience poorer outcomes following peripheral vascular interventions (PVI) for
the treatment of peripheral arterial disease; however, this has not been studied within the Vascular Study
Group of New England (VSGNE) cohort. The purpose of this study is to evaluate the impact of gender on
early and late outcomes of PVI for intermittent claudication and critical limb ischemia (CLI) within the
VSGNE cohort.
Methods: We reviewed 3,338 patients (1,316; 39% women) undergoing PVI for claudication (1,892;
57%) or CLI (1,446; 43%) in the Vascular Study Group of New England from January 2010 to June 2012.
Kaplan-Meier analysis evaluated relationships between gender and the main outcome measures of
major amputation and overall survival at one year.
Results: Indications for PVI included claudication in 719 (22%) vs. 1173 (35%) and CLI in 597 (18%) vs.
849 (25%), women and men respectively. Women were older (69 vs. 66 mean yrs., P<.00001) with less
diabetes (43% vs. 49%, P=.01), renal insufficiency (4.6% vs. 7.3%, P=.0029), CAD (28% vs. 35%,
P<.00001), smoking (76% vs. 86%, P=.01) and statin use (60% vs. 64%, P=.0058). Women were more
likely to present with CLI (45% vs. 42%, P=.0028) and ambulate with assistance (16% vs. 12%,
P=.0016).
Technical success (95% vs. 94%, P=.11), vascular injury (1.3% vs. 1.0%, P=.82) and
embolization (1.6% vs. 1.3%, P=.46) were similar with higher rates of hematoma (7.1% vs. 3.4%,
P=<.0001) and access-site occlusion (0.91% vs. 0.24%, P=.0085) in women. There were no differences
in one-year major amputation rates between genders for patients with claudication or CLI. One-year
survival was similar between women and men with claudication (95% vs. 96%, P=.19) or CLI (77% vs.
79%, P=.35). The model demonstrated moderate discriminative ability (ROC 0.81).
Conclusions: Procedural morbidity was modestly greater in women with higher rates of hematoma and
access-site occlusion. We found no gender disparity in amputation rates or overall survival in patients
undergoing PVI for claudication or CLI. Further study is necessary to determine if gender should play a
role in selection of therapy for patients harboring lower extremity occlusive disease.
WOMEN ROLE MODELS: ARE THEY NEEDED?
Vanessa Franz
Advisor: Dr. Neil Hyman
Introduction: Whether women in surgery need female role models is an area of research that
has been touched on in other studies, but has not been explored in depth. Role models differ from
mentors in many ways. Role models are people that we can identify with, who have qualities we would
like to have and are in positions we would like to reach. It is not an active relationship, while mentorship
is a partnership in which a mentee is guided and aided in personal and professional development. This
study will look at the need for and exposure to same gender role models.
Methods: A survey was used to assess views of attendings, surgical residents and medical students
on the need for same gender role models when pursuing a surgical career as well as their views on the need
for same gender.
Data: A total of 205 surveys were sent out with a total response rate of 40%. More women reported
having a role model than men (94% of women v. 70% of men, P=.03). Of the respondents, both men and
women did not find it necessary to have a same gender role model (96% men v. 82% women, P=0.38).
While 60% of men though that it would not be beneficial for their role model to be the same gender compared
to 24% of women (P=0.001). With regards to mentors, 75% of men and 83% of women reported a mentor
and 83% of men and 76% of women agreed that it is not necessary for a person’s mentor to be the same
gender. While only 7% of men thought it would be beneficial if this was true, 48% of women though there
would be a benefit (P=.003).
Conclusions: Our results show that while women do not feel it is necessary for a role model or
mentor to be the same gender, they do feel that it would be beneficial. Men were more inclined to think that
there is no added benefit, as well as not necessary. Both men and women were split on whether a role
model should be in the same field that they wished to pursue while they both agreed that a mentor should be
in the same field that they wished to pursue. Majority of both men and women reported having a mentor while
more women reported having a role model than men.
Fletcher Allen Health Care Gynecologic Surgeon Adherence to Venous
Thromboembolism Prophylaxis Guidelines: An Opportunity for Quality
Improvement and Cost Savings
Abstract
Authors: M.R. Gordon-Fogelson1, E.N. Everett2, and B.W. Nielsen3
Affiliations:
University of Vermont College of Medicine, 89 Beaumont Ave, Burlington, VT 05405
2
Department of Gynecologic Oncology, Fletcher Allen Health Care, 111 Colchester Avenue, Burlington, VT 05401
3
Department of Obstetrics and Gynecology, Fletcher Allen Health Care, 111 Colchester Avenue, Burlington, VT 05401
1
Introduction: Evidence-based guidelines provide recommendations for perioperative venous
thromboembolism (VTE) prophylaxis based on risk stratification. Studies have shown inconsistent
physician adherence to guidelines and use of VTE prophylaxis. In this study, we evaluated the adequacy
of VTE prophylaxis for gynecologic surgical patients.
Methods: We retrospectively assessed individual risk factors for VTE in patients who underwent a
gynecologic surgery at Fletcher Allen Healthcare from November 1, 2011 to March 31, 2012. We used
two risk assessment models to assign patients a risk level and compared the recommended prophylaxis
with the actual treatment received. Patients were divided into three treatment level groups; under-treated,
appropriately treated, or over-treated. We examined the association between risk level and treatment level.
Results: We identified 139 gynecologic surgical patients. Using the Caprini risk assessment model,
66.7% of patients in the High risk group were over-treated and 82.4% of patients in the High risk group
were over-treated using ACOG guidelines. Patients in the High risk group were more likely to be overtreated (p<0.001). Over-treatment occurred most often due to use of both heparin and intermittent
pneumatic compression devices. 54.7% of patients fell into the Very high risk group using the Caprini
model and 94.7% of these patients were appropriately treated. There were no reported post-operative VTE
events.
Discussion: Based on two risk assessment models, physicians were better at choosing appropriate
prophylaxis for patients in the Very high risk group. Physicians tended to over-treat patients in the High
risk group by using dual prophylaxis with both mechanical and pharmacologic treatment.
Sign-Out Improvement Project: Needs Assessment of Handoff Procedure and
Resident Education at Fletcher Allen Healthcare Center
Authors: Harris, C. Hum, J.
Research Mentors: Dr. Julie Adams, Dr. Elise Everett and
Dr. Mark Pasanen
Introduction: The Joint Commission and the AGME have called for handoff standardization and resident
education; however consensus regarding how this should occur is still developing. Our study conducted a
Needs Assessment to define resident and attending attitudes regarding sign-out (SO) utility, and the
education or evaluation of residents in achieving handoff competency.
Methods: Residents and attendings from core clerkship departments were asked to take an anonymous
online survey. Participants were recruited at didactic sessions and via e-mail. The surveys contained 21
queries, with multiple choice, Likert scale, and free text questions. The data was analyzed using STATA.
Results: 66 residents and 68 attendings returned completed surveys. 80% of residents reported that
written SO was useful during regular shifts.44% reported written SO was their primary source of
information during coverage shifts. 81% of residents overall reported agreement that “written sign-out is
reliable, up to date, and trustworthy”; whereas 71% of surgical residents disagreed. Surgical residents also
cited the highest rates of crucial information omission: 43% reported daily omission in written SO, and
57% reporting omissions 1-4x per week in verbal. On education, 50% of residents overall express a desire
for education in handoff. Among attendings, 71% had limited familiarity with their department’s written
hand-off, 60% had no formal training in verbal sign-off, and 52% reported no strong evaluative criteria
for evaluating residents’ competency in hand-off.
Conclusions: Our data suggest SO as a global process is critical to residents during coverage shifts. Our
results demonstrate variable interdepartmental reliability of written and verbal sign-out, with surgical
residents finding it the least accurate and consistent. These data indicate that instituting meaningful SO
education will be difficult as most attendings have received no formal training themselves, many are very
unfamiliar with resident SO, and have limited evaluative criteria.
THE IMPACT OF HEALTH LITERACY ON DECISION-MAKING AND
SURGICAL OUTCOMES OF BREAST CANCER PATIENTS IN
NORTHERN NEW ENGLAND
Francesca Marisa Boulos MSc / Advisor- Ted A. James MD
Introduction: Studies demonstrate that the choice of breast cancer surgery is dependent on the degree of
informed, shared decision-making. Patients’ choices for breast cancer surgery are strongly influenced by
perceptions of risk, available options and personal priorities. Health literacy plays an important role in the
patient’s decision-making process, and lower educational status has been shown to have a high predictive
index of “vulnerability” in true informed consent (Tropman, 1999 / Haggstrom, 2005 / Krieger, 2010).
The purpose of this study was to evaluate the association between patient educational status and the type
of breast cancer surgery received in Northern New England. We hypothesize that lower educational status
in this population will be associated with lower rates of breast conservation.
Methods: Partial mastectomy (PM) rates in the Northern New England states of Vermont, Maine and
New Hampshire were derived using the National Cancer Database. Measures of educational attainment
were obtained by matching patients’ zip code with files derived from year 2000 US Census data. We used
groups at the extreme ends of educational status for comparison; lowest educational group (>30% without
a high school degree) vs. highest educational group (<12% without a high school degree).
Results: From 2000-2011 the rate of PM in Northern New England was 63.9% (VT: 67.4%, ME: 58.3%,
NH: 66.1%). Women in the lower education group had PM rates of 58.2% compared to 65.4% in the
higher education group. Vermont demonstrated the greatest degree of change between the two extremes in
education (57.9% PM rate in the lower education group vs. 70.9% PM rate in the higher education group),
followed by New Hampshire (56.7% PM rate in the lower education group vs. 66.1% in the higher
education group) and then Maine (60% rate in the lower education group vs. 59.3% in the higher
education group). Statistical analyses of these differences are pending.
Conclusions: Our analysis demonstrates a pattern of lower breast conservation rates in a patient cohort
with lower educational status. This degree of this pattern appears to vary among the three states evaluated.
These findings allude to need to improve patient education and enhance the shared decision-making
process of patients living in areas with lower educational status, and for further investigation into different
statewide practice patterns that influence decision-making.
Patient Outcomes within the Fletcher Allen Health Care Trauma Service
Author: Nathan Louras
Advisor: Dr. Neil Hyman
Introduction: There have been many studies, in recent years that look at the efficacy of “full
time” trauma surgeons at Level 1 trauma centers as compared to on-call surgeons on patient mortality.
Fletcher Allen is such that, it is a level I trauma center, but does not have a 24 hour trauma attending
coverage. However, specific protocols have been established by the trauma surgeons, such as the solid
organ protocol, to aid in the acute management of these patients and are well known by housestaff and
readily accessible. It is uncertain whether these protocols and systems enable care of the trauma patient to
be safe and effective, even when a full time trauma surgeon is not on-call.
Methods: This is a six year retrospective chart review of all multi-trauma patients admitted to the
FAHC trauma service. Variables include age, overall mortality, length of stay, injury severity score,
Glasgow Coma Scale, missed injuries, for each surgeon on call. The data collected over the past six
years, through the trauma registry, was used to evaluate the different outcomes of each physician on call.
Results: Of the 2571 trauma patients were seen at Fletcher Allen Health Care (FAHC) between
2007 and 2012, 1,621 were admitted directly to the Trauma service. 1415 were initially seen by a trauma
attending on-call and 206 were initially seen by a non-trauma attending on-call. The mean injury severity
score for trauma and non-trauma attendings on-call were 17.0 and 16.0 (p=0.13). The mean Glasgow
Coma Scale for patients seen by trauma and non-trauma attendings on-call were 12.7 and 12.3
respectively (p=0.7). The mean length of stay (LOS) was 7.9 and 6.3 (p=0.016) and patient age 44.7 and
39.4 (p=0.002) for trauma and non-trauma attendings on-call. A total of 128 patients died following
admission, of which, 112 (88%) were initially seen by a trauma attending and 16 (12%) were initially
seen by a non-trauma attending on-call (p=0.25).
Conclusions: In conclusion, there was no difference in mortality, between trauma and nontrauma attendings taking call at FAHC. Patients cared for by the trauma attendings on-call, had an
increased length of stay, but saw older patients compared to non-trauma attendings taking call. Trauma
systems of care and algorithms can be developed that allow non-trauma surgeons to provide equally safe
and effective care.
The Impact of Perioperative Glucose Control on Surgical Site Infections following
Orthopedic Spinal Surgeries
Ashley Miller1; James Michelson, MD1; S. Elizabeth Ames, MD1
1Department
of Orthopaedics and Rehabilitation, University of Vermont College of Medicine
Background
Spinal surgeries have one of the highest rates of infections of any orthopedic surgery, due in large part to
the extended length of spinal procedures as well as the use of hardware. Patients undergoing spinal
operations often have multiple medical comorbidities and risk factors for infection. Although diabetes is
a well-documented major risk factor for infection, to date almost no literature has investigated the effect
of perioperative glucose control on surgical site infections (SSI) in the orthopedic spinal surgical
population.
Methods
In a retrospective analysis of patient electronic medical records, the effect of perioperative glucose control
was evaluated in orthopedic spinal surgeries. Patients 18 years of age and older having had a spinal
operation performed by an orthopedic surgeon between January 2010 and December 2012 at our
institution, as well as a fingerstick glucose value drawn during the hospitalization, were included in this
study (n=469). Perioperative glucose control was defined as the highest fingerstick glucose value during
the operative hospitalization. Good control was defined as less than 200 mg/dL, poor control 200 mg/dL
and greater. Hemoglobin A1c (HbA1c) values were also analyzed. The primary end point was a primary
surgical site infection as determined clinically by the attending physician.
Results
The incidence of SSI following orthopedic spinal surgery between January 2010 and December 2012 was
4.3% (54 infections out of 1247 total patients). Patients with good perioperative glucose control were
significantly less likely to have a surgical site infection than those with poor perioperative glucose control
(Odds Ratio (OR): 2.49 (1.29-4.83), p=0.005). Similarly, patients not developing a primary SSI had
tighter perioperative glucose control than those developing a primary SSI (163.5 v. 194.2 mg/dL,
p=0.007). There was no significant difference in HbA1c in patients without a primary SSI versus those
with a primary SSI (6.28 v. 6.14 mmol/mol, p = 0.616) nor did patients with low HbA1c (less than 6.5
mmol/mol) have a higher rate of SSI compared to those with a high HbA1c (6.5 mmol/mol or greater)
(OR: 0.81 (0.302.18), p=0.671). There was an observed weakly positive correlation between
perioperative glucose control and HbA1c in this subset of patients (y = 27.37x + 27.78; R² = 0.219,
n=148).
Conclusions
In adult orthopedic spinal surgical patients, improved perioperative glucose control is associated with a
lower risk of primary SSI. We saw no association between HbA1c and SSI. Potential complications
associated with tight perioperative glucose control (namely perioperative hypoglycemia) were out of the
realm of the current study but merit further investigation.
LITERATURE REVIEW OF INTERVENTIONS IN RURAL ANTENATAL CARE:
AN EFFORT TO REDUCE MATERNAL MORBIDITY IN RURAL TANZANIA
ABSTRACT
Author: Jenna Pariseau1
Advisor: Anne Dougherty, MD2
1
University of Vermont College of Medicine
Fletcher Allen Women’s Healthcare Services
2
Introduction: Every year thousands of women in sub-Saharan Africa suffer from obstructed labor
and debilitating complications such as obstetrical fistula. Maternal morbidity and mortality has been
shown to decrease with hospital births, which is more likely to happen if antenatal care is accessible. The
aims of this study are to review literature specific to barriers to antenatal care in Tanzania and explore
current literature to identify successful interventions employed in other rural communities. Using this
information, a focused needs assessment will be completed and the findings used to propose an
intervention model specific to Tanzania.
Methods: Abstracts that discussed barriers to perinatal care in Tanzania were reviewed as well as
literature describing interventions employed to improve outcomes in other rural countries. A data
gathering tool and needs assessment will be developed and utilized during a Tanzanian field study in
April.
Results: Literature on antenatal care in Tanzania describes socioeconomic, access, quality and
availability challenges. Interventions described in successful models for addressing barriers in rural
obstetrical care included improving access to care by increasing local resource training, education, and
transportation while other models focused on improving quality of care by access to ultrasound,
emergency supplies, and efficiently delivered care. Challenges identified included healthcare staff level
of support and training, supply chain difficulties, funding, and effectively tracking outcomes data.
Conclusions: Tanzania and sub-Saharan Africa continue to have birth practices and resource
limitations that reduce hospital births and increase maternal complications such as fistula. In other rural
communities, successful interventions have been employed to improve antenatal care access, quality,
education and delivery; however the impact on outcomes remains difficult to analyze. A needs
assessment and further research will be completed to obtain a better understanding of which interventions
will best serve rural Tanzania.
ABSTRACT
Optimizing the Prognostic Value of Sentinel Lymph Node Biopsy in
Breast Cancer
Robison EH1 and James TA2
1
2
MS-IV, University of Vermont College of Medicine
MD, FACS; Associate Professor of Surgery at University of Vermont College of Medicine; Fletcher Allen Healthcare
Division of Surgical Oncology, Director, Skin and Soft Tissue Surgical Oncology
Background
The literature now shows that completion axillary lymph node dissection (cALND) is not always necessary in
sentinel lymph node-positive (pSLN+) breast cancer patients [1-4], thus the sentinel lymph node (SLN) pathology
may be the only axillary information available to clinicians as they determine stage, prognosis and clinical
management. While the literature has clearly shown that the hottest SLN may be negative when other SLNs are
positive, there is still debate regarding the optimum number of nodes needed for pathologic examination to
appropriately stage the axilla [5-8]. In this study we describe the prevalence of patients who have remaining SLN
metastases after disease has been identified in the first and/or second hottest SLNs removed. This information may
inform patient management decisions.
Methods
Since 2003, we have maintained a University of Vermont IRB approved database on all breast cancer surgery
performed at Fletcher Allen Health Care. SLNs were evaluated with a single full-face routinely stained section
from each paraffin block; immunohistochemistry was not routinely used. The database was queried for pSLN+
patients and a subsequent chart review was performed to obtain additional information including: 10-second
radioactivity counts and individual nodal status (macrometastasis, micrometastasis, ITC only, or negative).
Radioactivity counts were ranked (1=highest count, 2= second highest, etc) and then evaluated in relation to their
pathological status.
Results
There are 1317 breast cancer patients in the database, 827 underwent SLNB, and 136 were pSLN+ patients
(macrometastases, micrometastasis, and ITC included) with procedure dates ranging from January 2003 to July
2009. 114 were included in the study; 22 were excluded due to previous ipsilateral breast surgery, neoadjuvant
therapy, missing records, or “other” reasons. The median number of SLNs per patient is 3 (range, 1-8). 81.6%
(93/114) had 2 or more SLNs and 51.7% (59/114) had 3 or more SLNs. The median number of positive SLNs is 1
(1-6) but 7.9% (9/114) had 3 or more positive SLNs. When considering patients with 2 or more SLNs (n=93), 82%
of the pSLN+ patients were correctly identified by two hottest SLNs removed, 98% by the 3rd hottest, and 100%
when the 3 hottest SLNs and palpable nodes were included. 8 patients had a palpable node, 5 of those harbored
macrometastases. 20.4% (19/93) had metastases in the 3rd and/or 4th hottest node in addition to the 1st and/or 2nd
hottest nodes.
Conclusion
Among pSLN+ breast cancer patients in our study, the excision and pathologic examination of the 4 hottest SLNs
plus any palpable nodes (when present) correctly identifies all patients with SLN metastasis as well as any patients
with ≥3 metastatic SLNs. Our data show that palpable nodes have a high rate of metastasis; clinicians should
continue to manually sweep the axilla and examine any suspicious nodes. Correct identification of pSLN patients
as well as those with tumor burden >2 SLNs is important information which may inform treatment decisions. This
is especially true for decision making considering cALND and adjuvant care strategies.
MINI-STERNOTOMY APPROACH TO AORTIC VALVE REPLACEMENT:
A SINGLE CENTER REPORT
Author: Hany Hamdy Abdallah
Advisor: Joseph Schmoker, MD
Introduction: The rapidly changing landscape of medicine and burgeoning technological feats
have allowed surgeons to perform surgeries in ways that were unimaginable in the past. While cardiac
surgery is perhaps the most invasive of all surgeries it still has not been elucidated whether less invasive
approaches improve morbidity or mortality.
Methods: Single-center retrospective cohort analysis of patients who have undergone ministernotomy or conventional sternotomy for aortic valve replacement at Fletcher Allen Health Care by one
physician (Joseph Schmoker, MD) from the year of 1998 to the current date.
Results: The immense amount of data to be collected has hampered the expediency of this project.
As of yet, not all of the data has been collected.
Conclusions: Not many conclusions can be made without all data so as to exclude confounders
and biases. The data, does however, support that there is less chest tube output and shorter lengths of stay.
It still remains to be seen whether these are results of the change in procedure itself or changes in
protocols or institutional demands.
The Effect of Ophthalmic Examination on the Outcome of Intraocular Lens Choice
and Optical Biometric Parameters
Dane H. Slentz1, Peter Callas2 and Jonathan D. Paul3
University of Vermont College of Medicine1
University of Vermont, Dept. of Medical Biostatistics, College of Medicine2
Division of Ophthalmology at Fletcher Allen Health Care, Burlington Vermont3
Abstract
Importance: To improve the quality of care given to surgical cataract patients.
Objective: To evaluate the influence that a standard ophthalmic examination has on intraocular lens
(IOL) choice and optical biometric parameters.
Design, Setting, and Participants: A single surgeon, prospective cohort study conducted during 20132014 at a university-affiliated, tertiary referral hospital in Vermont. All patients with visually
symptomatic age-related cataracts undergoing a standard ophthalmic examination (visual acuity, manifest
refraction, brightness acuity testing, applanation tonometry with topical anesthetic, slit lamp
biomicrosocpy, and indirect dilated fundoscopy) without significant corneal pathology or prior lens or
refractive surgery were included in this study. Participants were subject to IOLMaster optical biometric
measurements both in the absence of, and thirty minutes following, a standard ophthalmic examination.
Patients previously known to have visually significant age-related cataracts could obtain control
measurements prior to ophthalmic examination. Patients evaluated with contact techniques other than
applanation tonometry such as gonioscopy, sceleral depression or contact lens evaluation were excluded.
Main Outcome Measures: Equivalence testing was used to evaluate the mean difference in calculated
IOL strength from the SRK/T formula at the 90% confidence interval and an equivalence margin of
±0.25D. Difference testing was used to analyze the effect of ophthalmic examination on the optical
parameters (axial length, keratometry and anterior chamber depth) at the 95% confidence interval. All
analyses included a subgroup analysis of age, gender, and the timing of control measurement.
Results: 70 eyes were analyzed from 36 patients (61.1%M, 38.9%F) with a mean age of 70.0yrs. The
difference in IOL power was completely contained within the equivalence margin [-0.04D, 0.13D]
(p<0.01). AL, K1, and K2 showed no significant difference between measurements. The ACD was
significantly deeper in the interventional group [0.11, 0.18] (p<0.001). All subgroup analyses showed
similar trends to the population analyses.
Conclusions and relevance: A standard ophthalmic examination performed during the same clinical visit
as optical biometric measurements has no influence on the outcome of calculated IOL choice from the
SRK/T formula. The ability to eliminate a clinical encounter for the sole purpose of obtaining these
measurements has the potential to improve the quality of healthcare delivered to this cohort.
.
Emergency Department Prescriber Attitudes and Behaviors Regarding Opioid
Medications: A Vermont Statewide Survey
Richard Tan, MS-IV
Surgical Senior Major Scholarly Project Abstract
Advisors: Mario Trabulsy, MD, Emergency Medicine, Fletcher Allen Health Care
Charles MacLean, MD, Medicine, Fletcher Allen Health Care
Introduction: As prescription opioid misuse and overdose deaths continue to be growing societal issues
within the context of evolving tools to counter this, it has not been quantified how these issues have
affected VT ED (emergency department) opioid prescribers. The purpose of the study is to determine how
attitudes and behaviors of VT ED prescribers have been adapting to these changes, especially in regards
to workplace policies and new resources such as VPMS (Vermont Prescription Monitoring System).
Methods: An anonymous, confidential, IRB-approved 35-item survey was completed by VT ED opioid
prescribers on issues regarding their attitudes and behaviors on opioid abuse and diversion from June
2013 through January 2014. Results were summarized using descriptive statistics. A two-tailed Fisher’s
exact test was used in instances of perceived associations between data sets.
Results: 29 surveys were completed, revealing that although 59% believed that we are making progress
on addressing prescription drug abuse and diversion in our state, nearly all believed the medical
community should do a better job addressing the issue of abuse and diversion of prescription opioids. All
prescribe opioid pain medications at least once per shift on average, but only 14% provide >5-day
prescriptions 1 time per shift or more. Access to various types of information were deemed to be useful,
such as if current patients had recently received take-home pills or a 'starter pack' of opioid medication
from another ED (97%), a roster of patients who frequently present to their ED with pain complaints
(90%), and opioid prescribing patterns of other ED prescribers (72%). Nearly 80% believe that VPMS is an
effective tool for identifying patients who require closer attention when prescribing opioid pain
medication, although 31% had difficulty using it, which was associated with decreased use among other
prescribers of less than 1 time per shift (p=0.03). 38% wanted to learn more about VPMS and comments
indicated suggestions to improve VPMS.
Conclusions: Vermont ED prescribers’ attitudes and behaviors continue to demonstrate their cognizance
of and opposition against prescription opioid misuse. However, their responses convey concern that the
medical community needs to better address these issues. As a result, there are several areas for
improvement and policy changes, which include improved access to information such as knowledge of
patients receiving opioid medications from other ED’s, rosters of patients with pain complaints, and
prescribing patterns of other ED prescribers. Regarding VPMS, difficulty of use in particular is associated
with decreased frequency of utility, which indicates that ease of use and/or training of this system are
areas for improvement, among other areas such as electronic medical record compatibility and interfacing
with other state prescription monitoring systems. Nevertheless, VPMS is perceived to serve as a useful
tool to identify patients that require extra attention when prescribing opioid medications.