A rural, community-based program can train surgical residents in advanced laparoscopy.

BACKGROUND: Advanced laparoscopy requires mastery of complex surgical skills. A steep learning curve, lack of an adequate number of cases, and a shortage of experienced staff are reasons cited as barriers to the acquisition of these skills by surgical residents. We hypothesize that advanced laparoscopy can be taught during residency without additional fellowship training. STUDY DESIGN: ast surgical residents who completed training at our rural, community-based, 140-bed hospital from 1992 to 2000 were contacted by mailed surveys and a followup telephone interview. Advanced laparoscopy was defined as cases other than cholecystectomy, appendectomy, and diagnostic laparoscopy. Five attending surgeons routinely perform advanced laparoscopy. RESULTS: The response rate to the survey was 93.3% with 15 of 18 graduates currently practicing general surgery and 100% of the surgeons performing advanced laparoscopy. Laparoscopic herniorrhaphy, splenectomy, colectomy, Nissen fundoplication, and adrenalectomy were performed by 12 (85.7%), 10 (71.4%), 11 (78.6%), 13 (92.9%), and 9 (64.3%) surgeons, respectively. Eight (57.1%) surgeons reported confidence to perform advanced laparoscopy immediately after residency. All graduating chief residents from the last 3 years expressed this confidence. On average each of two chief residents from the past 3 academic years graduated with 99 basic and 50 advanced laparoscopic cases. CONCLUSIONS: A rural, community-based program can train residents to perform advanced laparoscopy. Increasing the volume of advanced cases handled by resident correlates with increasing confidence in graduates.

The pineal gland hormone melatonin improves survival in a rat model of sepsis/shock induced by zymosan A.

BACKGROUND: Melatonin has demonstrated protective effects in severe sepsis/shock in the animal model. Zymosan A causes inflammation and shock leading to death in rats. We hypothesized that daily afternoon melatonin administration would improve rat survival after an intraperitoneal (IP) zymosan injection. METHODS: Adult male rats, maintained on a 12L:12D photoperiod, received a single IP injection of either zymosan (500 mg/kg) or paraffin vehicle at 1200 hours. At 1700 hours and daily thereafter, zymosan-injected rats received subcutaneous injections of either melatonin (0.8 mg/kg) or saline (SAL). Any surviving animals were killed on day 10 to obtain wet organ weights. RESULTS: Three independent experiments produced similar results. In each zymosan+SAL group, all animals died by day 4. In the melatonin-treated groups combined, 33/45 rats survived (73.33%, P<.00002). Posthumous body weight was greater in melatonin-treated animals compared with the zymosan+SAL groups (P<.001). Mean splenic weight in the melatonin-treated groups was twice that of the control groups (P<.001). CONCLUSION: Melatonin administered in the late afternoon after a lethal dose of zymosan significantly improved animal survival. Melatonin has no known adverse effects in humans and may represent a novel treatment for sepsis/shock.

Time to deterioration of the elderly, anticoagulated, minor head injury patient who presents without evidence of neurologic abnormality.

BACKGROUND: Generally accepted guidelines regarding the care of the elderly, anticoagulated minor head injury patient do not exist within the trauma literature. METHODS: Charts were reviewed on all anticoagulated, minor head injury patients older than 65 years between January 1993 and May 2000. Postinjury course was examined for neurologic changes, times, coagulation/radiographic studies, reversal, operative intervention, and outcome. RESULTS: Thirty-two patients were identified. Twenty-four patients were discharged from the Emergency Department. Three of the remaining eight patients had initial Glasgow Coma Scale scores of 15, 15, and 14 but became comatose over a mean course of 3.83 hours. A fourth patient presented comatose 6 hours postinjury, down from "acting normal." Three of these four patients died. CONCLUSION: Elderly, anticoagulated patients with minor head trauma risk neurologic deterioration within 6 hours of injury, despite an initially normal neurologic examination. Early cranial computed tomographic scanning and close observation for a minimum of 6 hours are indicated.