Journal of the American College of Surgeons
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Glycosylated hemoglobin (HbA1c) is diagnostic of and a measure of the quality of control of diabetes mellitus. Both HbA1c and perioperative hyperglycemia have been targeted as modifiable risk factors for postoperative complications. The HbA1c percent cutoff that best predicts major complications has not been defined. ⋯ Elevated HbA1c ≥ 6.5% and perioperative hyperglycemia were associated with an increased rate of major complications after abdominal surgery. Elevated peak postoperative glucose levels were correlated with elevated HbA1c and were independently associated with major complications. More liberal HbA1c testing should be considered in high-risk patients before elective surgery. Safe, feasible, and effective strategies to reduce both HbA1c and perioperative hyperglycemia need to be developed to optimize patient outcomes.
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The 2011 ACGME regulations required substantial changes to the structure of general surgery residency programs, due primarily to the 16-hour in-house rule for PGY1 residents. However, the scope of changes that programs have undertaken to meet these requirements, and the educational impact of those changes, are poorly understood. ⋯ Most programs used a month-long night float (NF) rotation (14 of 20 [75%]). A minority of programs (5 of 20 [25%]) used a weekly rotating schedule, in which interns worked 5 to 6 nights in a month. Multiple programs (65%) had an NF in place before 2011; these programs made changes to and expanded their existing schedule to accommodate the new regulations. Commonly cited challenges to instituting NF included weekend coverage (60%) and providing adequate days off during day-to-night transition. Interns spent as much as 3 months of the year on NF. Only 5 programs made explicit changes to teaching schedules or developed a curriculum for residents on NF. Seventy-five percent of programs excused interns, explicitly or implicitly, from didactic teaching when on NF. Common themes noted by program directors included delayed maturation of trainees, interns being isolated from the team culture, and a conflict between the professional behaviors of "following the rules" and "doing what is right."
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Intestinal ischemia and reperfusion injury results in damage to elements critical to maintaining intestinal barrier function, including neurons and glia cells, which are part of the enteric nervous system (ENS). To limit inflammation, the ENS must be restored or replaced, yet the process by which this occurs is poorly understood. Multipotent progenitor cells called enteric nervous stem cells (ENSC) can differentiate into neurons or glia when stimulated. The ability of this cell population to respond to intestinal injury is unknown. In this study, we hypothesized that resolution of intestinal barrier injury would be associated with vagus nerve-mediated expansion of ENSCs. ⋯ Vagal-mediated expansion of ENSCs occurs after ischemia and reperfusion injury and results in improved kinetics of injury resolution.