Using ACGME General Surgery Milestones to Define the Competent Foundational Surgical Resident.

OBJECTIVE: In transitioning to competency-based surgical training, the need to clearly define competency is paramount. The purpose of this study is to define the well-prepared foundational resident using the ACGME General Surgery Milestones as our conceptual framework. DESIGN: Participants reflected on their expectations of a well-prepared resident at the end of PGY1, then assigned milestone levels reflecting this level of competence for General Surgery Milestones 1.0 and 2.0. Subcompetency scores were averaged among residents and faculty. The level of the well-prepared foundational resident was determined based on the highest level within one standard deviation of faculty, resident, and total group averages. SETTING: This took place during a dedicated education retreat at a single, large academic general surgery residency program. PARTICIPANTS: Key faculty stakeholders and a representative sample of residents (PGY 1-5) within our institution participated. RESULTS: Eight faculty and five residents completed Milestones 1.0 and 2.0 scoring. Mean scores between faculty and residents were compared. For 1.0, mean scores for Practice-Based Learning and Improvement 3 (PBLI 3) and Interpersonal Communication Skills 3 (ICS 3) were discernably lower for residents than for faculty (PBLI 3 1.3 (0.3) v 0.9 (0.2), p = 0.01; ICS3 1.6 (0.6) v 1.1 (1), p = 0.01). Scores of 2.0 were comparable across all subcompetency domains. With this broad agreement, Milestone-based competency standards were determined. Descriptive narratives of the KSAs were created for each subcompetency, combining the determined Milestones 1.0 and 2.0 levels. CONCLUSIONS: We were able to clearly define the competent foundational resident using the ACGME Milestones as a conceptual framework. These Milestone levels reflect the culture and expectations in our department, providing a foundation upon which to build a program of assessment. This methodology can be readily replicated in other programs to reflect specific expectations of the program within the larger ACGME frameworks of competency.

Hypoglossal and Glossopharyngeal Nerve Palsy After Anterior Cervical Decompression and Fusion: A Case Report.

CASE: A 69-year-old man underwent a C3-4 anterior cervical discectomy and fusion and developed postoperative hypoglossal and glossopharyngeal palsies that resolved with symptomatic treatment. CONCLUSION: Cranial nerve palsy is a rare and possibly under-reported injury after higher-level cervical spine surgery. Conscientious positioning and awareness of these nerves during surgical exposure are crucial to minimizing cranial nerve palsies. Proper workup to identify these palsies and differentiate them from other complications is necessary to guide proper treatment.

Intensity Distribution of Collegiate Cross-Country Competitions.

The primary purpose of the current investigation was to perform an intensity distribution analysis of a collegiate cross-country (CC) competition, with a secondary purpose to compare race times (RT) with modeled performance times (MPT). Participants completed an incremental treadmill test to determine gas exchange threshold (GET), while the three-minute all-out test was conducted on a 400 m outdoor track to determine critical velocity (CV) and D prime (D'). GET and CV were used as physiological markers for the intensity zones based on heart rate (HR) and running velocity (RV), while CV and D' were used to determine modeled performance times. Participants wore a Global Positioning System (GPS) watch and heart rate (HR) monitor during competition races. Statistically, less time was spent in HR Zone 1 (12.1% ± 13.7%) compared to Zones 2 (37.6% ± 30.2%) and 3 (50.3% ± 33.7%), while a statically greater amount of time was spent in RV Zone 2 (75.0% ± 20.7%) compared to Zones 1 (8.4% ± 14.0%) and 3 (16.7% ± 19.1%). RTs (1499.5 ± 248.5 seconds (s)) were statistically slower compared to MPTs (1359.6 ± 192.7 s). The observed differences in time spent in each zone are speculated to be related to the influence of environmental conditions on internal metrics and difference in the kinetics of HR and running velocity. Differences in RTs and MPTs are likely due to the MPT equation modeling all-out performance and not considering race strategies.

Acute Oxygen Consumption Response to Fast Start High-Intensity Intermittent Exercise.

The current investigation compared the acute oxygen consumption (VO2) response of two high-intensity interval exercises (HIIE), fast start (FSHIIE), and steady power (SPHIIE), which matched w prime (W') depletion. Eight cyclists completed an incremental max test and a three-minute all-out test (3MT) to determine maximal oxygen consumption (VO2max), critical power (CP), and W'. HIIE sessions consisted of 3 X 4 min intervals interspersed by 3 min of active recovery, with W' depleted by 60% (W'target) within each working interval. SPHIIE depleted the W'target consistently throughout the 3 min intervals, while FSHIIE depleted the W'target by 50% within the first minute, with the remaining 50% depleted evenly across the remainder of the interval. The paired samples t-test revealed no differences in the percentage of training time spent above 90% of VO2max (PT ≥ 90% VO2max) between SPHIIE and FSHIIE with an average of 25.20% and 26.07%, respectively. Pairwise comparisons indicated a difference between minute 1 peak VO2, minute 2, and minute 3, while no differences were present between minutes 2 and 3. The results suggest that when HIIE formats are matched based on W' expenditure, there are no differences in PT ≥ 90% VO2max or peak VO2 during each interval.

The Superficial Vein-Only DIEP Flap.

BACKGROUND: The deep inferior epigastric artery perforator (DIEP) flap, often considered the standard in autologous breast reconstruction, is reliant on robust arterial inflow and venous outflow. Venous outflow issues remain a critical part in determining the success of the DIEP flap. Previously, the superficial inferior epigastric vein (SIEV) has been used to augment venous outflow, or as a salvage option when flow through the deep inferior epigastric vein is compromised or insufficient. The authors describe a variant of the DIEP flap, the superficial vein-only DIEP flap, using the deep inferior epigastric artery and the SIEV as a viable alternative when indicated. METHODS: The authors conducted a retrospective review of all patients undergoing autologous breast reconstruction performed by the senior author (B.C.) from July of 2015 to March of 2020 to identify DIEP flaps whose only source of venous outflow was the SIEV, excluding those performed as salvage maneuvers. RESULTS: The authors identified 30 patients (35 flaps) and describe their characteristics, flap characteristics, complications, and details of the flap harvest. Notably, the authors experienced complications in 26.7 percent of flaps, of which 62.5 percent were minor, with no flap loss. This was comparable to the complication rate observed in the standard DIEP flap population. CONCLUSIONS: The authors believe the superficial vein-only DIEP flap is an excellent option for the appropriate patient. It is an added tool to make abdominally based breast reconstruction more reliable and successful. The use of the SIEV in a superficial vein-only flap should be considered as part of any routine DIEP flap reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.