Research Spotlight

Parekh, J., C. Ko, J. Lappin, S. Greenstein and R. Hirose (2017). “A transplant-specific quality initiative-introducing transqip: A joint effort of the asts and acs.” Am J Transplant 17(7): 1719-1722.

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In an attempt to improve surgical quality in the field of transplantation, the American College of Surgeons (ACS) and American Society of Transplant Surgeons have initiated a national quality improvement program in transplantation. This transplant-specific quality improvement program, called TransQIP, has been built from the ground up by transplant surgeons and captures detailed information on donor and recipient factors as well as transplant-specific outcomes. It is built upon the existing ACS/National Surgical Quality Improvement Program infrastructure and is designed to capture 100% of liver and kidney transplants performed at participating sites. TransQIP has completed its alpha pilot and will embark upon its beta phase at approximately 30 centers in the spring of 2017. Going forward, we anticipate TransQIP will help satisfy Centers for Medicare and Medicaid Services requirements for a quality improvement program, surgeon requirements for maintenance of certification, and qualify as a clinical practice improvement activity under the Merit-Based Incentive Payment System. Most importantly, we believe TransQIP will provide insight into surgical outcomes in transplantation that will allow the field to provide better care to our patients.

Zogg, C. K., O. A. Olufajo, W. Jiang, A. Bystricky, J. W. Scott, S. Shafi, J. M. Havens, A. Salim, A. J. Schoenfeld and A. H. Haider (2017). “The need to consider longer-term outcomes of care: Racial/ethnic disparities among adult and older adult emergency general surgery patients at 30, 90, and 180 days.” Ann Surg 266(1): 66-75.

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OBJECTIVES: Following calls from the National Institutes of Health and American College of Surgeons for “urgently needed” research, the objectives of the present study were to (1) ascertain whether differences in 30/90/180-day mortality, major morbidity, and unplanned readmissions exist among adult (18-64 yr) and older adult (>/=65 yr) emergency general surgery (EGS) patients; (2) vary by diagnostic category; and (3) are explained by variations in insurance, income, teaching status, hospital EGS volume, and a hospital’s proportion of minority patients. BACKGROUND: Racial/ethnic disparities have been described in in-hospital and 30-day settings. How longer-term outcomes compare-a critical consideration for the lived experience of patients-has, however, only been limitedly considered. METHODS: Survival analysis of 2007 to 2011 California State Inpatient Database using Cox proportional hazards models. RESULTS: A total of 737,092 adults and 552,845 older adults were included. In both cohorts, significant differences in 30/90/180-day mortality, major morbidity, and unplanned readmissions were found, pointing to persistently worse outcomes between non-Hispanic Black and White patients [180-d readmission hazard ratio (95% confidence interval):1.04 (1.03-1.06)] and paradoxically better outcomes among Hispanic adults [0.85 (0.84-0.86)] that were not encountered among Hispanic older adults [1.06 (1.04-1.07)]. Stratified results demonstrated robust morbidity and readmission trends between non-Hispanic Black and White patients for the majority of diagnostic categories, whereas variations in insurance/income/teaching status/EGS volume/proportion of minority patients all significantly altered the effect-combined accounting for up to 80% of risk-adjusted differences between racial/ethnic groups. CONCLUSIONS: Racial/ethnic disparities exist in longer-term outcomes of EGS patients and are, in part, determined by differences in factors associated with emergency care. Efforts such as these are needed to understand the interplay of influences-both in-hospital and during the equally critical, postacute phase-that underlie disparities’ occurrence among surgical patients.

Souza, R. F. (2017). “Reflux esophagitis and its role in the pathogenesis of barrett’s metaplasia.” J Gastroenterol 52(7): 767-776.

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Reflux esophagitis damages the squamous epithelium that normally lines the esophagus, and promotes replacement of the damaged squamous lining by the intestinal metaplasia of Barrett’s esophagus, the precursor of esophageal adenocarcinoma. Therefore, to prevent the development of Barrett’s metaplasia and esophageal adenocarcinoma, the pathogenesis of reflux esophagitis must be understood. We have reported that reflux esophagitis, both in a rat model and in humans, develops as a cytokine-mediated inflammatory injury (i.e., cytokine sizzle), not as a caustic chemical injury (i.e., acid burn), as traditionally has been assumed. Moreover, reflux induces activation of hypoxia inducible factor (HIF)-2alpha, which enhances the transcriptional activity of nuclear factor kappa-light-chain-enhancer of activated B cells (NF-kappaB) causing increases in pro-inflammatory cytokines and in migration of T lymphocytes, an underlying molecular mechanism for this cytokine-mediated injury. In some individuals, reflux esophagitis heals with Barrett’s metaplasia. A number of possibilities exist for the origin of the progenitor cells that give rise to this intestinal metaplasia including those of the esophagus, the proximal stomach, or the bone marrow. However, intestinal cells are not normally found in the esophagus, the stomach, or the bone marrow. Thus, the development of Barrett’s intestinal metaplasia must involve some molecular reprogramming of key developmental transcription factors within the progenitor cell, a process termed transcommitment, which may be initiated by the noxious components of the gastric refluxate. This review will highlight recent studies on the pathogenesis of reflux esophagitis and on reflux-related molecular reprogramming of esophageal squamous epithelial cells in the pathogenesis of Barrett’s metaplasia.

Wolk, C. B., S. Jager-Hyman, S. C. Marcus, B. K. Ahmedani, J. E. Zeber, J. A. Fein, G. K. Brown, A. Lieberman and R. S. Beidas (2017). “Developing implementation strategies for firearm safety promotion in paediatric primary care for suicide prevention in two large us health systems: A study protocol for a mixed-methods implementation study.” BMJ Open 7(6): 1-10.

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INTRODUCTION: The promotion of safe firearm practices, or firearms means restriction, is a promising but infrequently used suicide prevention strategy in the USA. Safety Check is an evidence-based practice for improving parental firearm safety behaviour in paediatric primary care. However, providers rarely discuss firearm safety during visits, suggesting the need to better understand barriers and facilitators to promoting this approach. This study, Adolescent Suicide Prevention In Routine clinical Encounters, aims to engender a better understanding of how to implement the three firearm components of Safety Check as a suicide prevention strategy in paediatric primary care. METHODS AND ANALYSIS: The National Institute of Mental Health-funded Mental Health Research Network (MHRN), a consortium of 13 healthcare systems across the USA, affords a unique opportunity to better understand how to implement a firearm safety intervention in paediatric primary care from a system-level perspective. We will collaboratively develop implementation strategies in partnership with MHRN stakeholders. First, we will survey leadership of 82 primary care practices (ie, practices serving children, adolescents and young adults) within two MHRN systems to understand acceptability and use of the three firearm components of Safety Check (ie, screening, brief counselling around firearm safety and provision of firearm locks). Then, in collaboration with MHRN stakeholders, we will use intervention mapping and the Consolidated Framework for Implementation Research to systematically develop and evaluate a multilevel menu of implementation strategies for promoting firearm safety as a suicide prevention strategy in paediatric primary care. ETHICS AND DISSEMINATION: Study procedures have been approved by the University of Pennsylvania. Henry Ford Health System and Baylor Scott & White institutional review boards (IRBs) have ceded IRB review to the University of Pennsylvania IRB. Results will be submitted for publication in peer-reviewed journals.

Spechler, S. J., J. L. Merchant, T. C. Wang, P. Chandrasoma, J. G. Fox, R. M. Genta, J. R. Goldenring, Y. Hayakawa, E. J. Kuipers, P. K. Lund, F. McKeon, J. C. Mills, R. D. Odze, R. M. Peek, Jr., T. Pham, J. Que, A. K. Rustgi, N. J. Shaheen, R. A. Shivdasani, R. F. Souza, P. Storz, A. Todisco, D. H. Wang and N. A. Wright (2017). “A summary of the 2016 james w. Freston conference of the american gastroenterological association: Intestinal metaplasia in the esophagus and stomach: Origins, differences, similarities and significance.” Gastroenterology 153(1): e6-e13.

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Robert Genta reviewed the histologic features of intestinal metaplasia, and Jason Mills provided a historical overview, noting that Rudolph Virchow coined the term “metaplasia” at the VIIIth International Medical Congress in Copenhagen in 1884. In 1900, the pathologist George Adami presciently contended that there are “mother” (stem) cells that regenerate normal tissue and, “under abnormal conditions, the fully differentiated functioning cells of certain tissues are capable of proliferation and giving rise to cells of like nature, but this is only after a preliminary reversion to a simpler, more embryonic type.” Adami proposed that this process of dedifferentiation leading to increased proliferation might result in “glandular cancer.”2 During the 1930s, developmental biologists largely abandoned Adami’s concepts, instead embracing Conrad Waddington’s notion that stem cell differentiation was unidirectional. However, recent evidence vindicates Adami, showing that differentiated cells can indeed contribute to metaplasia.