Background Patient satisfaction has been emphasized increasingly in all aspects of medicine, including the imposition of financial penalties for underperformance. Current measures of patient ...satisfaction, however, do not address aspects specific to the care of operative patients. Therefore, our aim was to examine the recently validated Consumer Assessment of Healthcare Providers and Systems (S-CAHPS) to determine which aspects of perioperative care are predictive of satisfaction with the surgeon. Methods All patients undergoing a general surgery operation at our institution during a 5-month period were sent a modified S-CAHPS within 3 days of discharge. Patients were then divided into 2 groups: those who rated their surgeon as the best possible and those giving a lower rating. Univariate and multivariate analyses were used to determine predictors of satisfaction with operative care. S-CAHPS results were then compared with other satisfaction measures in a subset of patients. Results The response rate was 45.3% (456/1,007). The average age was 59 ± 16 years, duration of stay was 4.1 ± 6.6 days, and 23% underwent unscheduled operations. A total of 72% of patients rated their surgeon as the best surgeon possible. On multivariate analysis, preoperative communication and attentiveness on the day of operation were the most important determinants of overall surgeon rating. S-CAHPS scores correlated with other standard measures of satisfaction (HCAHPS scores). Conclusion S-CAHPS is a novel operative satisfaction tool and is feasible to administer to patients undergoing general operative procedures. Surgeon characteristics most predictive of high patient satisfaction are effective preoperative communication and attentiveness on the day of operation.
Rhodopseudomonas palustris cytochrome c′, a four-helix bundle, and the second ubiquitin-associated domain, UBA(2), a three-helix bundle from the human homologue of yeast Rad23, HHR23A, deviate from ...random coil behavior under denaturing conditions in a fold-specific manner. The random coil deviations in each of these folds occur near interhelical turns and loops in their tertiary structures. Here, we examine an additional three-helix bundle with an identical fold to UBA(2), but a highly divergent sequence, the first ubiquitin-associated domain, UBA(1), of HHR23A. We use histidine–heme loop formation methods, employing eight single histidine variants, to probe for denatured state conformational bias of a UBA(1) domain fused to the N-terminus of iso-1-cytochrome c (iso-1-Cytc). Guanidine hydrochloride (GuHCl) denaturation shows that the iso-1-Cytc domain unfolds first, followed by the UBA(1) domain. Denatured state (4 and 6 M GuHCl) histidine–heme loop formation studies show that as the size of the histidine–heme loop increases, loop stability decreases, as expected for the Jacobson–Stockmayer relationship. However, loops formed with His35, His31, and His15, of UBA(1), are 0.6–1.1 kcal/mol more stable than expected from the Jacobson–Stockmayer relationship, confirming the importance of deviations of the denatured state from random coil behavior near interhelical turns of helical domains for facilitating folding to the correct topology. For UBA(1) and UBA(2), hydrophobic clusters on either side of the turns partially explain deviations from random coil behavior; however, helix capping also appears to be important.
Introduction
Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is utilized for peritoneal malignancies and is associated with significant resource use. To address ...potentially modifiable factors contributing to excessive cost, we sought to determine predictors of high cost of care for patients undergoing CRS/HIPEC.
Methods
An institutional CRS/HIPEC database was queried for adult patients from 2014 to 2018. Cost was defined as cost for the index hospitalization, and high-cost cases were defined as > 75th percentile for cost. Bivariate analyses for cost were performed, and all significant tumor, patient, and surgeon-specific variables were entered in a linear regression for cost. A separate linear regression was performed for length of stay (LOS).
Results
In total, 59 patients underwent 61 CRS/HIPEC procedures. The median direct variable cost was $20,509 (16,395–25,240). Median length of stay (LOS) was 8 (7–11.5) days and ICU stay was 1 (1–1.5) day. LOS, length of ICU stay and operative time were predictive of cost. Factors associated with increased LOS were Clavien-Dindo grade II complications and ostomy creation. Patient-related factors, including age and BMI, tumor-related factors, such as PCI and CCR, and surgeon were not predictive of cost nor LOS.
Discussion
Our results, the first to identify predictors of high cost of CRS/HIPEC-related care in the US, reveal cost was largely related to length and intensity of care. In turn, these drivers were influenced by complications and operative factors. Future work will focus on identifying an appropriate ERAS protocol following CRS/HIPEC and selection of those patients that may avoid routine ICU admission.
Background Patient-reported outcomes (PRO) have been increasingly emphasized, however, determining clinically valuable PRO has been problematic and investigation limited. This study examines the ...association of readiness for discharge, which has been described previously, with patient satisfaction and readmission. Study Design Data from adult patients admitted to our institution from 2009 to 2012 who completed both the Hospital Consumer Assessment of Healthcare Providers and Systems and the Press Ganey surveys post discharge were extracted from an existing database of patients (composed of 220 patients admitted for small bowel obstruction and 98 patients with hospital stays ≥21 days). Using the survey question, “Did you feel ready for discharge?” (RFD), 2 groups were constructed, those RFD and those with lesser degrees of readiness (ie, less ready for discharge LRFD) using topbox methodology. Outcomes, readmission rates, and satisfaction were compared between RFD and LRFD groups. Results Three hundred and eighteen patients met the inclusion criteria; 45% were female and 94% were Caucasian. Median age was 62.3 years (interquartile range 52.5 to 70.8 year). Median length of stay was 10 days (interquartile range 6.0 to 24.0 days) and 69.2% were admitted with small bowel obstruction. The 30-day readmission rate was 14.3% and 55% indicated they were RFD. Those RFD and LRFD had similar demographics, comorbidity scores, and rates of surgery. Those RFD had higher overall hospital satisfaction (87.3% RFD vs 62.4% LRFD; p < 0.001), higher physician communication scores (median 3.0 RFD vs 2.0 LRFD; p < 0.001), and higher nursing communication scores (median 3.0 RFD vs 2.0 LRFD, p < 0.001). Readmission rates were similar between the groups (11.4% RFD vs 18.2% LRFD; p = 0.09). Conclusions Readiness for discharge appears to be a clinically useful patient-reported metric, as those RFD have higher satisfaction with the hospital and physicians. Prospective investigation into variables affecting patient satisfaction in those LRFD is needed.
Poorly coordinated transitions of care in complex abdominal surgery patients contribute to frequent hospital readmissions and inflated healthcare spending. Mobile health (mHealth) transitional care ...technologies may reduce surgical readmissions yet remain understudied in high-risk surgical populations.
We conducted a single-group, prepost study of a mHealth transitional care app in 50 complex surgical patients. Eligible patients were adults undergoing complex abdominal surgery in the divisions of Surgical Oncology and Colorectal Surgery. The main outcome was app engagement, calculated by notification response rate (number of participant-entered datapoints divided by the total number of app-requested datapoints) over the 30-day postoperative period. Secondary outcomes included changes in engagement over time and by individual app feature.
A total of 85% (50/59) of eligible patients enrolled. Most participants were male (58%, n = 29), and mean age was 50 years (range 24–80 years). Overall notification response rate was 28%. Among the 58% of participants (29/50) who engaged with the app at least once after discharge (app users), the average notification response rate was 45%. The mean notification response rate among app users decreased over time from 50% to 32% between weeks 1 and 4 after hospital discharge. Engagement with individual app features ranged from 48–81%, with highest engagement for symptom reports and lowest engagement for wound care instructions.
mHealth transitional care is feasible in complex surgical patients using only patients’ existing smart devices. Randomized controlled trials are required to determine the impact on hospital readmissions, surgical outcomes, patient satisfaction, and overall resource utilization.
Patient satisfaction is a patient-centered outcome of particular interest. Previous work has suggested that global measures of satisfaction may not adequately evaluate surgical care, therefore the ...surgery-specific Consumer Assessment of Healthcare Providers and Systems survey was developed. It remains unclear how traditional outcome measures, such as morbidity, impact patient satisfaction. Our aim was to determine whether National Surgical Quality Improvement Program–defined complications impacted satisfaction with the surgeon as measured by a surgery-specific survey, the surgery-specific Consumer Assessment of Healthcare Providers and Systems survey.
All patients undergoing a general surgical operation from June 2013–November 2013 were sent the surgery-specific Consumer Assessment of Healthcare Providers and Systems survey after discharge. Retrospective chart review was conducted using the National Surgical Quality Improvement Program variable definitions, and major complications were defined. Data were analyzed as a function of response to the overall surgeon-rating item, and those surgeons rated as the “best possible” or “topbox” were compared with those rated lower. Univariate and logistic regression were used to determine variable importance.
A total of 529 patients responded, and 71.5% (378/529) rated the surgeon as topbox. The overall National Surgical Quality Improvement Program complication rate was 14.2% (75/529), with 26.7% of those (20/75) being major complications. On univariate analysis, patients who rated their surgeon more highly were somewhat older (59 vs 54 years: P < .001), more often underwent elective surgery (81% vs 57%: P < .001), and had an increased rate of operation for malignancy (31% vs 17%). Neither the complication rate (total or major) nor the number of complications were associated with satisfaction scores.
When examined on a patient level with surgery-specific measures and outcomes, the presence of complications after an operation does not appear to be associated with overall patient satisfaction with surgeon care. This finding suggests that satisfaction may be an outcome distinct from traditional measures.
Several serotypes of Escherichia coli produce protein toxins closely related to Shiga toxin (Stx) from Shigella dysenteriae serotype 1. These Stx-producing E. coli cause outbreaks of hemorrhagic ...colitis and hemolytic uremic syndrome in humans, with the latter being more likely if the E. coli produce Stx2 than if they only produce Stx1. To investigate the differences among the Stxs, which are all AB5 toxins, the crystal structure of Stx2 from E. coli O157:H7 was determined at 1.8-Å resolution and compared with the known structure of Stx. Our major finding was that, in contrast to Stx, the active site of the A-subunit of Stx2 is accessible in the holotoxin, and a molecule of formic acid and a water molecule mimic the binding of the adenine base of the substrate. Further, the A-subunit adopts a different orientation with respect to the B-subunits in Stx2 than in Stx, due to interactions between the carboxyl termini of the B-subunits and neighboring regions of the A-subunit. Of the three types of receptor-binding sites in the B-pentamer, one has a different conformation in Stx2 than in Stx, and the carboxyl terminus of the A-subunit binds at another. Any of these structural differences might result in different mechanisms of action of the two toxins and the development of hemolytic uremic syndrome upon exposure to Stx2.
The main peptidase (M
pro) from the coronavirus (CoV) causing severe acute respiratory syndrome (SARS) is one of the most attractive molecular targets for the development of anti-SARS agents. We ...report the irreversible inhibition of SARS-CoV M
pro by an aza-peptide epoxide (APE;
k
inact/
K
i=1900(±400)
M
−1
s
−1). The crystal structures of the M
pro:APE complex in the space groups
C2 and
P2
12
12
1 revealed the formation of a covalent bond between the catalytic Cys145 S
γ atom of the peptidase and the epoxide C3 atom of the inhibitor, substantiating the mode of action of this class of cysteine-peptidase inhibitors. The aza-peptide component of APE binds in the substrate-binding regions of M
pro in a substrate-like manner, with excellent structural and chemical complementarity. In addition, the crystal structure of unbound M
pro in the space group
C2 revealed that the “N-fingers” (N-terminal residues 1 to 7) of both protomers of M
pro are well defined and the substrate-binding regions of both protomers are in the catalytically competent conformation at the crystallization pH of 6.5, contrary to the previously determined crystal structures of unbound M
pro in the space group
P2
1.
Cathepsin K is the major collagenolytic enzyme produced by bone-resorbing osteoclasts. We showed earlier that the unique triple-helical collagen-degrading activity of cathepsin K depends on the ...formation of complexes with bone-or cartilage-resident glycosaminoglycans, such as chondroitin 4-sulfate (C4-S). Here, we describe the crystal structure of a 1:
n complex of cathepsin K:C4-S inhibited by E64 at a resolution of 1.8 Å. The overall structure reveals an unusual “beads-on-a-string”-like organization. Multiple cathepsin K molecules bind specifically to a single cosine curve-shaped strand of C4-S with each cathepsin K molecule interacting with three disaccharide residues of C4-S. One of the more important sets of interactions comes from a single turn of helix close to the N terminus of the proteinase containing a basic amino acid triplet (Arg8-Lys9-Lys10) that forms multiple hydrogen bonds either to the caboxylate or to the 4-sulfate groups of C4-S. Altogether, the binding sites with C4-S are located in the R-domain of cathepsin K and are distant from its active site. This explains why the general proteolytic activity of cathepsin K is not affected by the binding of chondroitin sulfate. Biochemical analyses of cathepsin K and C4-S mixtures support the presence of a 1:
n complex in solution; a dissociation constant,
K
d, of about 10 nM was determined for the interaction between cathepsin K and C4-S.
Increasing emphasis is being placed on appropriateness of care and avoidance of over- and under-treatment. Indeterminate thyroid nodules (ITNs) present a particular risk for this problem because ...cancer found via diagnostic lobectomy (DL) often requires a completion thyroidectomy (CT). However, initial total thyroidectomy (TT) for benign ITN results in lifelong thyroid hormone replacement. We sought to measure the accuracy and factors associated with the extent of initial thyroidectomy for ITN.
We queried a single institution thyroid surgery database for all adult patients undergoing an initial operation for ITN. Multivariate logistic regression identified factors associated with either oncologic under- or overtreatment at initial operation.
There were 639 patients with ITN. The median age was 52 (range, 18 to 93) years, 78.4% were female, and final pathology revealed a cancer >1 cm in 24.7%. The most common cytology was follicular neoplasm (45.1%) followed by Hürthle cell neoplasm (20.2%). CT or initial oncologic undertreatment was required in 58 patients (9.3%). Excluding those with goiters, 19.0% were treated with TT for benign final pathology. Multivariate analysis failed to identify any factor that independently predicted the need for CT. Female gender was associated with TT in benign disease (odds ratio OR, 2.1; 95% confidence interval CI, 1.0 to 4.5; P = .05). Age >45 years predicted correct initial use of DL (OR, 2.6; 95% CI, 1.2 to 5.7; P = .02). Suspicious for papillary thyroid carcinoma (OR, 5.7; 95% CI, 2.1 to 15.3; P<.01) and frozen section (OR, 9.7; 95% CI, 2.5 to 38.6; P<.01) were associated with oncologically appropriate initial TT. The highest frequency of CT occurred in patients with follicular lesion of undetermined significance (11.6%). TT for benign final pathology occurred most frequently in patients with a Hürthle cell neoplasm (24.8%).
In patients with ITN, nearly 30% received an inappropriate extent of initial thyroidectomy from an oncologic standpoint. Tools to pre-operatively identify both benign and malignant disease can assist in the complex decision making to gauge the proper extent of initial surgery for ITN.
ATA = American Thyroid Association AUS = atypia of undetermined significance CI = confidence interval CT = completion thyroidectomy FLUS = follicular lesion of undetermined significance ITN = indeterminate thyroid nodule OR = odds ratio PTC = papillary thyroid carcinoma TT = total thyroidectomy.
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