Medical student preparation for the operating room.

BACKGROUND: This study examines student perceptions of preparedness for the operating room (OR), resources used, and time spent in preparation. METHODS: Third-year medical and second-year physician assistant students across two campuses at a single academic institution were surveyed to assess perceptions of preparedness, time spent in preparation, resources used, and perceived benefits of preparation. RESULTS: 95 responses (response rate 49%) were received. Students reported being most prepared to discuss operative indications and contraindications (73%), anatomy (86%), and complications (70%), but few felt prepared to discuss operative steps (31%). Students spent a mean of 28 min preparing per case, citing UpToDate and online videos as the most used resources (74%; 73%). On secondary analysis, only the use of an anatomic atlas was weakly correlated with improved preparedness to discuss relevant anatomy (p = 0.005); time spent, number of resources or other specific resources were not associated with increased preparedness. CONCLUSION: Students felt prepared for the OR, though there is room for improvement and a need for student-oriented preparatory materials. Understanding the deficits in preparation, preference for technology-based resources, and time constraints of current students can be used to inform optimisation for medical student education and resources to prepare for operating room cases.

Ten-Year Trends in Traumatic Cardiac Injury and Outcomes: A Trauma Registry Analysis.

BACKGROUND: Cardiac injury is a significant cause of death in patients with traumatic injuries. The Oklahoma Trauma Registry collects data from acute care hospitals in Oklahoma. This study investigated the trends and outcomes of traumatic cardiac injury in Oklahoma over a 10-year period. METHODS: The Oklahoma Trauma Registry tracks patients with major severity and one of the following criteria: hospital stay 48 hours or longer, death on arrival or in the hospital, hospital transfer, intensive care unit admission, or surgery. Cardiac injuries were identified from data acquired 2005 to 2014. Characteristics, mechanisms of injury, associated injuries, and outcomes were analyzed. Results were further divided into blunt vs penetrating injuries and operative vs nonoperative management. RESULTS: Of 107,549 patients, 426 patients suffered cardiac injury, and 160 patients suffered penetrating trauma. Commonly associated injuries were rib fractures, pneumothorax, hemothorax, and intraabdominal injuries. Of blunt cardiac injuries, 26.7% had spinal fractures. Operative management occurred in 16.9%. Overall mortality rate was 35.7% (51.9% in penetrating and 26.3% in blunt injuries). Mortality was higher for patients who had operative management but was similar in penetrating and blunt cardiac injury. Over 10 years, the percentage of cardiac injury decreased. However, mortality in patients who suffered a cardiac injury increased, correlating with an increase in proportion of penetrating cardiac injury. CONCLUSIONS: Traumatic cardiac injury, particularly penetrating injury, continues to be a significant source of mortality. Analysis of state-base trauma registries can identify trends in causes of injury and death, serving as a reference point for quality improvement, therapeutic triage, and preventative action plans.

Mortality in open abdominal aortic surgery in patients with morbid obesity.

BACKGROUND: Open abdominal aortic surgery is among procedures with high morbidity and mortality. Adverse postoperative complications may be more common in morbidly obese patients. OBJECTIVES: This study compared the outcomes of open abdominal aortic surgeries in patients with and without morbid obesity. SETTING: A retrospective analysis of 2007-2014 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample. METHODS: We included patients who underwent open abdominal aortic aneurysm (AAA) repair or open aorta-iliac-femoral (AIF) bypass. Demographic factors, morbid obesity, co-morbidities, and emergent versus elective surgery were considered for univariate and multivariate analyses. RESULTS: A total of 29,340 patients (13,443 AAA repair and 15,897 AIF bypass) were included (age 66.3 ± 10.8 years, 65.7% male). The mortality was 9.1% in 536 patients with morbid obesity compared with 7.1% in patients without morbid obesity. Based on multivariate analysis, age, existing co-morbidities, emergent versus elective setting, and morbid obesity were found to be independent predictors of mortality. Patients with morbid obesity had an odds ratio of 3.61 (95% CI, 1.50-8.68; P = .004) for mortality, longer mean length of stay (11.2 versus 9.3 days, P < .001), and higher total hospital charges ($99,500 versus $73,700, P < .001). CONCLUSIONS: Morbid obesity is an independent risk factor of mortality in patients undergoing open AAA repair and AIF bypass. Weight loss strategies should be considered for morbidly obese patients with an anticipation of open abdominal aortic procedures.

Outcomes of Bariatric Surgery Versus Medical Management for Type 2 Diabetes Mellitus: a Meta-Analysis of Randomized Controlled Trials.

INTRODUCTION: Bariatric surgery improves type 2 diabetes (T2D) in obese patients. The sustainability of these effects and the long-term results have been under question. OBJECTIVE: To compare bariatric surgery versus medical management (MM) for T2D based on a meta-analysis of randomized controlled trials (RCTs) with 2 years of follow-up. MATERIAL AND METHODS: Seven RCTs with at least 2-year follow-up were identified. The primary endpoint was remission of T2D (full or partial). Four hundred sixty-three patients with T2D and body mass index > 25 kg/m2 were evaluated. RESULTS: After 2 years, T2D remission was observed in 138 of 263 patients (52.5%) with bariatric surgery compared to seven of 200 patients (3.5%) with MM (risk ratio (RR) = 10, 95% CI 5.5-17.9, p < 0.001). Subgroup analysis of the Roux-en-Y gastric bypass (RYGB) showed a significant effect size at 2 years in favor of RYGB over MM for a higher decrease of HbA1C (0.9 percentage points, 95% CI 0.6-1.1, p < 0.001), decrease of fasting blood glucose (35.3 mg/dl, 95% CI 13.3-57.3, p = 0.002), increase of high-density lipoprotein (HDL) (12.2 mg/dl, 95% CI 7.6-16.8, p < 0.001), and decrease of triglycerides (32.4 mg/dl, 95% CI 4.5-60.3, p = 0.02). Four studies followed patients up to 5 years and showed 62 of 225 patients (27.5%) with remission after surgery, compared to six of 156 patients (3.8%) with MM (RR = 6, 95% CI 2.7-13, p < 0.001). CONCLUSION: This meta-analysis shows a superior and persistent effect of bariatric surgery versus MM for inducement of remission of T2D. This benefit of bariatric surgery was significant at 2 years and superior to MM even after 5 years. Compared with MM, patients with RYGB had better glycemic control and improved levels of HDL and triglycerides.

The cost of robotics: an analysis of the added costs of robotic-assisted versus laparoscopic surgery using the National Inpatient Sample.

BACKGROUND: Robotic-assisted surgery (RAS) with its advantages continues to gain popularity among surgeons. This study analyzed the increased costs of RAS in common surgical procedures using the National Inpatient Sample. METHODS: Retrospective analysis of the 2012-2014 Healthcare Cost and Utilization Project-NIS was performed for the following laparoscopic/robotic procedures: cholecystectomy, ventral hernia repair, right and left hemicolectomy, sigmoidectomy, abdominoperineal resection, and total abdominal hysterectomy (TAH). Patients with additional concurrent procedures were excluded. Costs were compared between the laparoscopic procedures and their RAS counterparts. Total costs and charges for cholecystectomy (the most common procedure in the dataset) were compared based on the payer and characteristics of hospital (region, rural/urban, bed size, and ownership). RESULTS: A total of 91,630 surgeries (87,965 laparoscopic, 3665 robotic) were analyzed. The average cost for the laparoscopic group was $10,227 ± $4986 versus $12,340 ± $5880 for the robotic cases (p < 0.001). The overall and percentage increases for laparoscopic versus robotic for each procedure were as follows: cholecystectomy $9618 versus $10,944 (14%), ventral hernia repair $10,739 versus $13,441 (25%), right colectomy $12,516 versus $15,027 (20%), left colectomy $14,157 versus $17,493 (24%), sigmoidectomy $13,504 versus $16,652 (23%), abdominoperineal resection $17,708 versus $19,605 (11%), and TAH $9368 versus $9923 (6%). Hysterectomy was the only procedure performed primarily using RAS and it was found to have the lowest increase in costs. Increased costs were associated with even higher increases in charges, especially in investor-owned private hospitals. CONCLUSION: RAS is more costly when compared to conventional laparoscopic surgery. Additional costs may be lower in centers that perform a higher volume of RAS. Further analysis of long-term outcomes (including reoperations and readmissions) is needed to better compare the life-long treatment costs for both surgical approaches.

Predictors of discharge destination in patients with major traumatic injury: Analysis of Oklahoma Trauma Registry.

BACKGROUND: The ability to predict the need for discharge of trauma patients to a facility may help shorten hospital stay. This study aimed to determine the predictors of discharge to a facility and develop and validate a predictive scoring model, utilizing the Oklahoma Trauma Registry (OTR). METHODS: A multivariate analysis of the OTR 2005-2013 determined independent predictors of discharge to a facility. A scoring model was developed, and positive and negative predictive values (PPV and NPV) were evaluated for 2014 patients. RESULTS: 101,656 patients were analyzed. The scoring model included age≥50 years, lower extremity fracture, ICU stay≥5 days, pelvic fracture, intracranial hemorrhage, congestive heart failure, cardiac dysrhythmia, history of CVA or TIA, and ISS≥15, spine fracture, diabetes mellitus, hypertension, ischemic heart disease, and chronic obstructive pulmonary disease. Applying the model to 2014 patients, PPV for predicting discharge to a facility was 84.9% for scores≥15, and NPV was 90.5% for scores<8. CONCLUSION: A scoring model including age, trauma severity, types of injury, and comorbidities could predict discharge of trauma patients to a facility. Further studies are needed to refine the efficacy of the model.

Ten-year trends in traumatic injury mechanisms and outcomes: A trauma registry analysis.

BACKGROUND: The Oklahoma Trauma Registry (OTR) collects data from all state-licensed acute care hospitals. This study investigates trends and outcomes of trauma in Oklahoma using OTR. METHODS: 107,549 patients (2005-2014) with major severity and one of the following criteria were included: length of hospital stay ≥48 h, dead on arrival or death in the hospital, hospital transfer, ICU admission, or surgery on the head, chest, abdomen, or vascular system. Patient characteristics, mechanisms of injury, and outcomes of trauma were analyzed. RESULTS: Hospital admissions due to falls increased with an annual percent change of 4.0% (95%CI: 3.1%-4.9%) while hospital admissions due to motor vehicle crashes decreased. The number of overall deaths per year remained stable except for the fall-related deaths, which increased proportionate to the increase in the incidence of fall. Fall-related mortality was 4.2% and intracranial bleeding was present in 60% in these patients. CONCLUSION: Falls are significantly increasing as a mechanism of trauma admissions and trauma-related deaths in Oklahoma. Analysis of state-based trauma registries can identify trends in etiologies of injuries and may indicate a reference point to prioritize preventive plans.

Vascular access flow reduction for arteriovenous fistula salvage in symptomatic patients with central venous occlusion.

PURPOSE: Vascular access patients with central vein (CV) stenosis or occlusion may have significant symptoms. Treatment is generally by balloon angioplasty, with or without stenting. However, CV lesions may not be correctable and when treated, tend to recur. Surgical bypass of CV obstruction is a major procedure and ligation of the access may leave the patient dependent on catheter dialysis. We review a precision inflow banding procedure to limit vascular access flow and pressure for symptomatic patients with CV obstruction while preserving access functionality. MATERIALS AND METHODS: All individuals with symptomatic CV occlusive disease who underwent an autogenous vascular access inflow restriction procedure by the two senior authors were identified. All had failed attempts to correct CV lesions by angioplasty and stent placement. A precision banding procedure was used for access inflow reduction with the addition of real-time intravascular flow monitoring. RESULTS: Twenty-two patients were identified. Ages were 22-72 years (mean=43 years). Nine patients (40.9%) were women, and 8 (36.4%) obese. Mean access flow was 1640 mL/minute before banding decreased to 820 mL/minute after banding (P< .01). All patients had access salvage. Swelling resolved promptly in 20 patients and was markedly improved in two individuals. Three patients underwent aneurysm repair with simultaneous inflow banding and decreased intra-access pressure after flow restriction. Two fistulas failed at eight and 13 months. Mean follow-up was 8 months. CONCLUSIONS: The symptoms of hemodialysis vascular access patients associated with non-correctable central venous lesions resolved successfully and their access was maintained using a precision inflow banding procedure.

Extending outflow brachial vein length for transposition arteriovenous fistulas.

PURPOSE: Transposition arteriovenous fistulas (T-AVF) play an important role in establishing autogenous vascular access for many hemodialysis patients. When the basilic vein is not available, one of the paired brachial veins offers a reliable T-AVF option, generally as a two-staged operation. Uncommonly, the brachial vein outflow conduit dissipates into multiple small branches communicating with the paired brachial vein or occasionally with a residual proximal segment of the basilic vein. We utilized parallel outflow vein component segments to create additional outflow vein length necessary for successful T-AVFs in these patients. MATERIALS AND METHODS: We identified four patients where a vein length extension technique utilizing parallel and overlapping vein segments with an end-to-end anastomosis gained adequate length for successful T-AVFs. All transpositions were based on a first stage AVF with access outflow established into a brachial vein. CASE REPORTS: Three of the operations utilized paired brachial vein segments and one gained needed access outflow length with a brachial vein anastomosis to a residual proximal basilic vein segment. All four patients had functional T-AVFs at 4, 5, 7, and 14 month follow-up. None of the patients developed arm swelling. CONCLUSIONS: Creating a longer transposition AVF venous outflow segment using parallel and overlapping vein segments with an end-to-end anastomosis gained the adequate length needed for successful T-AVFs in these four patients.

Clinical effects of in situ photoimmunotherapy on late-stage melanoma patients: a preliminary study.

Metastatic melanoma is a skin cancer with poor prognosis. In situ photoimmunotherapy (ISPI) is a promising modality for the treatment of metastatic melanoma that combines local, selective photothermal therapy with immunological stimulation. A preliminary clinical study was conducted to evaluate the safety and therapeutic effects of ISPI for late-stage melanoma patients using imiquimod as the immune modifier. Eleven patients received ISPI in one or multiple 6-week treatment cycles applied to a 200-cm2 treatment site, which usually contained multiple cutaneous metastases. ISPI consisted of three main components applied directly to the cutaneous metastases: 1) local application of topical imiquimod; 2) injection of indocyanine green (ICG); and 3) an 805 nm laser for local irradiation. All patients completed at least one cycle of treatment. The most common adverse effects were rash and pruritus at the treatment sites. No grade 4 toxicity was observed. Complete response was observed in six patients. All lesions in the treatment area of the patients responded to ISPI, eight of which achieved complete local response (CLR). CLR was observed in the non-treatment site (regional) lesions in four patients. Five patients were still alive at the time of last follow-up. The probability of 12-month overall survival was 70%. This study demonstrates that ISPI with imiquimod is safe and well tolerated. The patient response rate is promising. ISPI can be easily applied on an outpatient basis and can be combined with other modalities to improve the therapeutic response of metastatic melanoma.

Primary breast lymphoma: the role of mastectomy and the importance of lymph node status.

OBJECTIVE: To construct and analyze a database comprised of all reported cases of primary breast lymphoma (PBL) that include treatment and follow-up information published during the last 3 decades. SUMMARY BACKGROUND DATA: PBL accounts for 0.4% of breast malignancies and 2% of extranodal lymphomas. Surgical therapy has varied from biopsy to radical mastectomy. Chemotherapy and radiation therapy have been used as adjuvant or primary therapy. A standard consensus treatment of PBL is not available. METHODS: We reviewed all published PBL reports from June 1972 to March 2005. A database was compiled by abstracting individual patient information, limiting our study to those reports that contained specific treatment and outcome data. Patient demographics such as survival, recurrence, and time to follow-up were recorded, in addition to surgical, radiation, and/or chemotherapy treatment(s). RESULTS: We found 465 acceptable patients reported in 92 publications. Age range was 17 to 95 years (mean, 54 years). Mean tumor size was 3.5 cm. Diffuse large cell (B) lymphoma was the most common histologic diagnosis (53%). Disease-free survival was 44.5% overall. Follow-up ranged from one to 288 months (mean, 48 months). Treatment by mastectomy offered no survival benefit or protection from recurrence. Treatment that included radiation therapy in stage I patients (node negative) showed benefit in both survival and recurrence rates. Treatment that included chemotherapy in stage II patients (node positive) showed benefit in both survival and recurrence rates. Histologic tumor grade predicted survival. CONCLUSIONS: Mastectomy offers no benefit in the treatment of PBL. Nodal status predicts outcome and guides optimal use of radiation and chemotherapy.

Pulmonary endothelial permeability is increased by fluid from packed red blood cell units but not by fluid from clinically-available washed units.

BACKGROUND: Massive transfusions are a risk factor for acute respiratory distress syndrome (ARDS) in severely injured patients. Neutrophil priming has been proposed to be an integral part of the early inflammatory response to trauma. To complement that work, we studied another major cell type involved in inflammation: the endothelial cell. Our hypothesis was that soluble factors from units of leukoreduced packed red blood cells (PRBC) directly increase pulmonary endothelial permeability. We also determined whether fluid from clinically-available washed PRBC units affects endothelial permeability. METHODS: As a measure of permeability, transendothelial electrical resistance (TER) was determined across monolayers of a human pulmonary microvascular endothelial cell line after addition of full-strength, diluted, and washed PRBC fluid. Monolayers were stained with phalloidin to assess intercellular space. Storage solution Adsol-1 was tested alone to determine additive component effects on TER. RESULTS: PRBC fluid decreased TER and increased intercellular space, both of which indicate an increase in endothelial monolayer permeability. PRBC fluid diluted to 2% and washed PRBC fluid did not decrease TER and thereby did not change endothelial permeability. Likewise, Adsol-1 did not duplicate the dramatic decrease in TER seen with the PRBC fluid. CONCLUSIONS: Fluid from stored PRBC units contains a soluble, transferable factor that directly increases endothelial permeability. Fluid from washed PRBC units, currently available for patients with immunoglobulin A allergies, does not. This study complements previous work of others that demonstrated that neutrophil priming by PRBC fluid is abrogated by washing. Now that two cell types have been shown to respond more favorably to washed PRBC in vitro, clinical studies should be initiated to investigate whether use of washed PRBC reduces ARDS following transfusions in trauma patients.