Comorbidity and Operative Time are Stronger Predictors than Age for Palatoplasty Adverse Airway Events, A NSQIP-P Study of 6668 Cases.

BACKGROUND: Adverse airway events (AAEs) are rare but devastating complications following palatoplasty. The purpose of this study is to evaluate patient risk factors for their effect on these complications. We hypothesize that prolonged operative time and the presence of multiple medical comorbidities are risk factors for AAEs. DESIGN: Retrospective cohort study. SETTING: Participant hospitals in the Pediatric American College of Surgeons National Surgical Quality Improvement Program year 2016-2019. PATIENTS: Cases of palatoplasty in children under 3 years of age. OUTCOMES: Adverse airway events including postoperative reintubation or any requirement of postoperative mechanical ventilation. RESULTS: A total of 6668 patients met inclusion criteria. The median operative time was 126 min (IQR 82). AAEs were identified in 107 (1.6%) patients. The incidence of risk factors was found to increase with age and AAEs were more prevalent in younger and older patients. Although patients in the older age groups had significantly higher burden of comorbidities, differences in age were not independently associated with AAEs. Following multivariable logistic regressions, operative times greater than 2 h, ASA class ≥3, >3 medical comorbidities, and black race were found to be significant independent risk factors. CONCLUSIONS: In this large, retrospective database study in palatoplasty, increased operative time, ASA classification ≥3, multiple comorbidities, and black race were independently associated with AAEs.

Reculturation: A new perspective on military-civilian transition stress.

Various forms of assistance are offered to help US Veterans achieve success in their post-military lives in recognition of their service. Despite the many successes, a significant number of Veterans continue to remain at risk for negative mental health outcomes, including suicidality and low levels of life satisfaction. These findings may be due to challenges arising from cultural identity dissonance. Problematic strategies used by Veterans to reduce this dissonance can result in a lack of belongingness, a key component in Joiner's Interpersonal Theory of Suicide. The authors suggest that research on the immigrant experience of acculturation may provide a new perspective to better understand issues of identity and sense of belonging in Veterans. Given that most Veterans return to the culture in which they grew up, the authors offer the term "reculturation." The authors propose clinical psychology focus on exploring the reculturation process of Veterans to support program engagement and suicide prevention.

Nerve blocks for occipital headaches: A systematic review and meta-analysis.

Migraine surgeons have identified six "trigger sites" where cranial nerve compression may trigger a migraine. This study investigates the change in headache severity and frequency following nerve block of the occipital trigger site. This PRISMA-compliant systematic review of five databases searched from database inception through May 2020 is registered under the PROSPERO ID: CRD42020199369. Only randomized controlled trials utilizing injection treatments for headaches with pain or tenderness in the occipital scalp were included. Pain severity was scored from 0 to 10. Headache frequency was reported as days per week. Included were 12 RCTs treating 586 patients of mean ages ranging from 33.7 to 55.8 years. Meta-analyses of pain severity comparing nerve blocks to baseline showed statistically significant reductions of 2.88 points at 5 to 20 min, 3.74 points at 1 to 6 weeks, and 1.07 points at 12 to 24 weeks. Meta-analyses of pain severity of nerve blocks compared with treatment groups of neurolysis, pulsed radiofrequency, and botulinum toxin type A showed similar headache pain severity at 1 to 2 weeks, and inferior improvements compared with the treatment groups after 2 weeks. Meta-analyses of headache frequency showed statistically significant reductions at 1 to 6-week follow-ups as compared with baseline and at 1 to 6 weeks as compared with inactive control injections. The severity and frequency of occipital headaches are reduced following occipital nerve blocks. This improvement is used to predict the success of migraine surgery. Future research should investigate spinous process injections with longer follow-up.

Post-Mastectomy Surgical Pocket Irrigation With Triple Antibiotic Solution vs Chlorhexidine Gluconate: A Randomized Controlled Trial Assessing Surgical Site Infections in Immediate Tissue Expander Breast Reconstruction.

BACKGROUND: Post-mastectomy pocket irrigation solution choice is debated and primarily surgeon dependent. We compare triple antibiotic solution (TAS) with 0.05% chlorhexidine gluconate (CHG). OBJECTIVES: The purpose of this study was to determine surgical site infection (SSI) rates after utilizing TAS vs CHG for breast pocket irrigation in immediate tissue expander (TE) breast reconstruction. METHODS: A prospective, blinded, randomized controlled trial was performed in patients (18-81 years old) who underwent bilateral mastectomy with TE reconstruction. In each patient, 1 mastectomy pocket was randomized to TAS and the other to CHG. Both the TE and the pocket were irrigated in the respective solution. The primary outcome was the incidence of SSI. Secondary outcomes were rates of mastectomy flap necrosis, hematoma, and seroma. RESULTS: A total of 88 patients who underwent bilateral immediate breast reconstruction were enrolled. Demographic and operative characteristics were equivalent because each patient served as their own control. Between the TAS and CHG groups, the incidence of SSI did not differ (5 [4.5%] vs 7 [8.0%], P = 0.35), including minor infections (2 [2.3%] vs 1 [1.1%], P = 0.56), major infections (2 [2.3%] vs 6 [6.8%], P = 0.15), and those resulting in explantation (2 [2.3%] vs 5 [4.5%], P = 0.25). Necrosis, hematoma, or seroma formation also did not differ. No patients who developed SSI received radiation. CONCLUSIONS: This study does not demonstrate a statistically significant difference in SSI between TAS and CHG irrigation, though TAS approached statistical significance for lower rates of infectious complications.

Risk factors for stroke on left ventricular assist devices.

BACKGROUND: Patients with end-stage heart failure on left ventricular assist devices (LVADs) are predisposed to a high incidence of stroke. Preoperative factors associated with increased stroke risk are poorly understood. METHODS: We performed a single-center retrospective review of all patients from 2009 to 2014 in whom a rotary flow LVAD was implanted. All patients with symptoms of a cerebrovascular event underwent a non-contrast head computed tomography scan. Logistic regression was used to determine factors associated with stroke both on univariate and multivariable analysis. RESULTS: A total of 390 patients were retrospectively analyzed and of those 61 (15.6%) had a stroke at an average follow-up of 3.5 ± 1.6 years. The majority were male (72%) and were treated a priori as destination therapy (73%). The proportion of patient receiving a centrifugal flow pump was 23% compared to 77% receiving an axial flow pump. For those patients who experienced a stroke and then died, the average time from stroke to death was 158 ± 296 days. Of the 61 patients who had a stroke, 38 (62%) died (P < 0.001 compared to death rate without a stroke). On Cox regression analysis, a history of cerebrovascular accident (CVA), hyperlipidemia, and history of venous thromboembolism (VTE) were independently associated with stroke while on LVAD support. CONCLUSION: Postoperative stroke after LVAD implantation was associated with higher mortality. A history of previous CVA, VTE, and hyperlipidemia were independently associated with stroke while on LVAD support.

Elevated donor hemoglobin A1c does not impair early survival in cardiac transplant recipients.

BACKGROUND: Orthotopic heart transplantation (OHT) is the gold-standard therapy for end-stage heart failure. An increasing deficit between suitable allograft availability and clinical demand for OHT exists. The role of donor diabetes mellitus (DM) on post-transplant recipient outcomes in OHT is controversial. The purpose of this study was to examine donor hemoglobin A1c (HbA1c) levels to identify the impact of donor glycemic control on recipient survival. METHODS: Adult OHT recipients with donor HbA1c data were identified in the UNOS database from 2010 to 2015. Recipients were stratified on the basis of donor glycemic status: Hyperglycemic-donor and euglycemic-donor cohorts were defined as HbA1c levels ≥6.5% and <6.5%, respectively. Outcomes were compared between unadjusted and propensity-matched hyperglycemic versus euglycemic donors. Primary end point was three-year survival. RESULTS: Of 5342 OHT recipients, 208 (3.89%) received an allograft from a hyperglycemic donor and 5134 (96.1%) received an allograft from a euglycemic donor. There was no significant difference in survival in the hyperglycemic group before (P=.87) or after (P=.78) propensity matching. CONCLUSIONS: No difference in four-year survival was noted in recipients who received allografts from hyperglycemic donors. These results suggest that recent cumulative donor glycemic status alone may not be an important predictor of recipient outcomes.

Externalizing and internalizing subtypes of posttraumatic psychopathology and anger expression.

Subtypes of posttraumatic psychopathology were replicated and extended in 254 female veterans with posttraumatic stress disorder (PTSD). Cluster analyses on Minnesota Multiphasic Personality Inventory-2 and Personality Psychopathology Five scales (Harkness, McNulty, & Ben-Porath, ) yielded internalizing and externalizing psychopathology dimensions, with a third low psychopathology group (simple PTSD). Externalizers were higher than the internalizers and the simple PTSD groups on the antisocial, substance, and aggression scales; internalizers were higher on depression and anxiety scales. Further validation included an independent measure of psychopathology to examine anger (Buss-Durkee Hostility Inventory, [BDHI]; Buss & Durkee, ). Externalizers were higher on extreme behavioral anger scales (assault and verbal hostility); and externalizers and internalizers were higher than the simple PTSD subjects on other anger scales. Positive correlations between the BDHI scales and the PTSD symptom of "irritability and anger outbursts" were found across scales in the total sample (range: r = .19-.36), on the assault scale in externalizers (r = .59), and the verbal hostility scale in both internalizers (r = .30) and simple PTSD (r = .37) groups, suggesting the broad utility of the symptom in the diagnosis. The results demonstrate the generalizability of the internalizing/externalizing typology to the female veteran population and highlight clinically relevant distinctions in anger expression within PTSD.

Successful Intraoperative Salvage of a Venous Congested Deep Inferior Epigastric Perforator Flap Using a Cross-thoracic Saphenous Vein Graft.

For autologous breast reconstruction using the deep inferior epigastric perforator flap, the internal mammary vessels are a common choice for recipient vessels. However, if these vessels are discovered to be inadequate, this may require the utilization of alternative vessels for successful salvage. Here, we demonstrate the use of a venous conduit for flap salvage in a patient undergoing bilateral deep inferior epigastric perforator flap breast reconstruction. Intraoperative venous congestion was identified on the left side. A contributing factor was an unresolvable size discrepancy between the deep inferior epigastric and the internal mammary venae comitantes. A saphenous vein graft can be used to drain the donor inferior epigastric vein to the contralateral internal mammary venae comitantes. In this discussion, adequate venous drainage was obtained with this approach, and the flap remained viable with good Doppler signals without further complications over a year postoperatively.

Outcomes of Surgical Treatment of Migraines: A Systematic Review & Meta-Analysis.

Background: Migraine surgery at 1 of 6 identified "trigger sites" of a target cranial sensory nerve has rapidly grown in popularity since 2000. This study summarizes the effect of migraine surgery on headache severity, headache frequency, and the migraine headache index score which is derived by multiplying migraine severity, frequency, and duration. Materials and Methods: This is a PRISMA-compliant systematic review of 5 databases searched from inception through May 2020 and is registered under the PROSPERO ID: CRD42020197085. Clinical trials treating headaches with surgery were included. Risk of bias was assessed in randomized controlled trials. Meta-analyses were performed on outcomes using a random effects model to determine the pooled mean change from baseline and when possible, to compare treatment to control. Results: 18 studies met criteria including 6 randomized controlled trials, 1 controlled clinical trial, and 11 uncontrolled clinical trials treated 1143 patients with pathologies including migraine, occipital migraine, frontal migraine, occipital nerve triggered headache, frontal headache, occipital neuralgia, and cervicogenic headache. Migraine surgery reduced headache frequency at 1 year postoperative by 13.0 days per month as compared to baseline (I2 = 0%), reduced headache severity at 8 weeks to 5 years postoperative by 4.16 points on a 0 to 10 scale as compared to baseline (I2 = 53%), and reduced migraine headache index at 1 to 5 years postoperative by 83.1 points as compared to baseline (I2 = 2%). These meta-analyses are limited by a small number of studies that could be analyzed, including studies with high risk of bias. Conclusion: Migraine surgery provided a clinically and statistically significant reduction in headache frequency, severity, and migraine headache index scores. Additional studies, including randomized controlled trials with low risk-of-bias should be performed to improve the precision of the outcome improvements.

Historique: Le traitement de la migraine à l'une des six « zones gâchettes ¼ établies d'un nerf crânien sensoriel cible ont rapidement gagné en popularité depuis 2000. La présente étude résume l'effet du traitement chirurgical de la migraine sur la gravité et la fréquence des céphalées et sur le score de migraine obtenu par la multiplication de la gravité, de la fréquence et de la durée des migraines. Matériel et méthodologie: La présente analyse systématique de cinq bases de données fouillées depuis leur création jusqu'à mai 2020 respecte la liste PRISMA et est enregistrée sous le numéro d'identification CRD42020197085 de PROSPERO. Les chercheurs ont retenu les études cliniques sur le traitement des céphalées par des interventions chirurgicales. Ils ont évalué le risque de biais des études aléatoires et contrôlées. Ils ont également effectué des méta-analyses des résultats au moyen d'un modèle à effets aléatoires pour déterminer le changement moyen regroupé par rapport à l'état de référence et, dans la mesure du possible, pour comparer des sujets traités à des sujets témoins. Résultats: Au total, 18 études respectaient les critères, y compris six études aléatoires et contrôlées, une étude clinique contrôlée, et 11 études non contrôlées auprès de 1 143 patients ayant des pathologies incluant la migraine, la migraine occipitale, la migraine frontale, la céphalée occipitale, la céphalée frontale, la névralgie occipitale et la céphalée cervicogénique. Par rapport à l'état de départ, le traitement chirurgical de la migraine avait réduit la fréquence des céphalées de 13,0 jours par mois (I2 = 0%) un an après l'opération, la gravité des céphalées de 4,16 points sur une échelle de 0 à 10 de huit semaines à cinq ans après l'opération (I2 = 53%) et le score de migraine de 83,1 points de un à cinq ans après l'opération (I2 = 2%). Ces méta-analyses sont limitées par le petit nombre d'études pouvant être analysées, y compris des études comportant de forts risques de biais. Conclusion: Le traitement chirurgical de la migraine assure une diminution cliniquement et statistiquement significative de la fréquence et de la gravité des céphalées, ainsi que des scores de migraine. D'autres études, y compris des études aléatoires et contrôlées comportant un faible risque de biais, devront être exécutées pour mieux préciser les améliorations aux résultats cliniques.

Impact of Tissue Expander Surface Texture on Two-Stage Breast Reconstruction Outcomes: A Combined Analysis of Incidence, Timing, and Severity.

BACKGROUND: With ongoing investigations of the impact of device texturing on breast implant-related anaplastic large cell lymphoma (BIA-ALCL), studies have begun comparing complications profiles of tissue expanders. However, there is a paucity of timing and severity data of complications. The aim of this study is to provide a comparative survival analysis of post-operative complications between smooth (STE) and textured tissue expanders (TTE) in breast reconstruction. METHODS: A single institution experience with tissue expander breast reconstruction was reviewed for complications up to 1 year post 2nd stage reconstruction from 2014-2020. Demographics, comorbidities, operation-related variables, and complications were evaluated. Kaplan-Meier curves, cox proportional hazard models, and a consensus based ordinal logistic regression model were used to compare complication profiles. RESULTS: Of 919 ttal patients, 65.3% (n=600) received TTEs and 34.7% (n=319) received STEs. There was increased risk of infection (p<0.0001), seroma (p=0.046), expander malposition (p<0.0001), and wound dehiscence (p=0.019) in STEs compared to TTEs. However, there were also decreased risk of capsular contracture (p=0.005) in STEs compared to TTEs. Failure of breast reconstruction (p<0.001) and wound dehiscence (p=0.018) occurred significantly earlier in STEs compared to TTEs. Predictors for significantly higher severity complications included: smooth tissue expander use (p=0.007), shorter time to complication (p<0.0001), higher BMI (p=0.005), smoking history (p=0.025), and nipple sparing mastectomy (p=0.012). CONCLUSIONS: Differences in the timing and severity of complications contribute to the safety profiles of tissue expanders. STEs are associated increased odds of higher severity and earlier complications. Therefore, tissue expander selection may depend on underlying risk factors and severity predictors.

Can Diffusion Tensor Imaging Apparent Diffusion Coefficient Diagnose Carpal Tunnel Syndrome? A Systematic Review and Meta-Analysis.

Magnetic resonance diffusion tensor imaging (DTI) can detect microstructural changes in peripheral nerves. Studies have reported that the median nerve apparent diffusion coefficient (ADC), a quantification of water molecule diffusion direction, is sensitive in diagnosing carpal tunnel syndrome (CTS). Five databases were searched for studies using ADC to investigate CTS. Apparent diffusion coefficient (measured in mm2/s) were pooled in random-effects meta-analyses. Twenty-two studies met criteria yielding 592 patients with CTS and 414 controls. Median nerve ADC were measured at the level of the distal radioulnar joint (CTS ADC: 1.11, 95% CI: 1.07-1.15, I2 = 54%; control ADC: 1.04, 95% CI: 1.01-1.07, I2 = 57%), pisiform (CTS ADC: 1.39, 95% CI: 1.37-1.42, I2 = 0%; control ADC: 1.27, 95% CI: 1.23-1.31, I2 = 59%), hamate (CTS ADC: 1.40, 95% CI: 1.36-1.43, I2 = 58%; control ADC: 1.27, 95% CI: 1.25-1.28, I2 = 47%), and as an combination of several measurements (CTS ADC: 1.40, 95% CI: 1.37-1.47, I2 = 100%; control ADC: 1.39, 95% CI: 1.24-1.53, I2 = 100%). Median nerve ADC is decreased in individuals with CTS compared to controls at the levels of the hamate and pisiform. ADC cut-offs to diagnose CTS should be established according to these anatomic levels and can be improved through additional studies that include use of a wrist coil.

Implantable, Bioresorbable Radio Frequency Resonant Circuits for Magnetic Resonance Imaging.

Magnetic resonance imaging (MRI) is widely used in clinical care and medical research. The signal-to-noise ratio (SNR) in the measurement affects parameters that determine the diagnostic value of the image, such as the spatial resolution, contrast, and scan time. Surgically implanted radiofrequency coils can increase SNR of subsequent MRI studies of adjacent tissues. The resulting benefits in SNR are, however, balanced by significant risks associated with surgically removing these coils or with leaving them in place permanently. As an alternative, here the authors report classes of implantable inductor-capacitor circuits made entirely of bioresorbable organic and inorganic materials. Engineering choices for the designs of an inductor and a capacitor provide the ability to select the resonant frequency of the devices to meet MRI specifications (e.g., 200 MHz at 4.7 T MRI). Such devices enhance the SNR and improve the associated imaging capabilities. These simple, small bioelectronic systems function over clinically relevant time frames (up to 1 month) at physiological conditions and then disappear completely by natural mechanisms of bioresorption, thereby eliminating the need for surgical extraction. Imaging demonstrations in a nerve phantom and a human cadaver suggest that this technology has broad potential for post-surgical monitoring/evaluation of recovery processes.

Postamputation Residual Limb Pain Severity and Prevalence: A Systematic Review and Meta-Analysis.

Background: Individuals with an extremity amputation are predisposed to persistent pain that reduces their quality of life. Residual limb pain is defined as pain that is felt in the limb after amputation. Methods: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review of 5 databases from inception to June 2020 was performed and is registered under the PROSPERO ID: CRD42020199297. Included studies were clinical trials with residual limb pain assessed at a minimum follow-up of 1 week. Meta-analyses of residual limb pain prevalence and severity were performed with subgroups of extremity and amputation etiology. Results: Twenty clinical trials met criteria and reported on a total of 1347 patients. Mean patient ages ranged from 38 to 77. Residual limb pain prevalence at 1 week, 1 month, 3 months, 6 months, 1 year, and 2 years, respectively, was 50%, 11%, 23%, 27%, 22%, and 24%. Mean residual limb pain severity at the 6 months or longer follow-up was 4.19 out of 10 for cancer amputations, 2.70 for traumatic amputations, 0.47 for vasculopathy amputations, 1.01 for lower extremity amputations, and 3.56 for upper extremity amputations. Conclusions: Residual limb pain severity varies according to the etiology of amputation and is more common after upper extremity amputation than lower extremity amputations. The most severe pain is reported by patients undergoing amputations due to cancer, followed by traumatic amputations, while vascular amputation patients report lower pain severity. Promising methods of reducing long-term pain are preoperative pain control, nerve or epidural blocks, use of memantine, calcitonin-containing blocks, and prophylactic nerve coaptations.

Contexte: Les personnes subissant une amputation d'un membre sont prédisposées à des douleurs persistantes réduisant leur qualité de vie. La douleur du membre résiduel est définie comme étant la douleur ressentie dans le membre après l'amputation. Méthodes: Une revue systématique conforme à PRISMA de 5 bases de données depuis leur création jusqu'en juin 2020 a été effectuée et enregistrée sous l'ID PROSPERO: CRD42020199297. Les études incluses étaient des essais cliniques avec douleur du membre résiduel évaluée à un suivi minimum de 1 semaine. Des méta-analyses sur la prévalence et la sévérité de la douleur du membre résiduel ont été réalisées avec des sous-groupes en fonction du membre et de la cause de l'amputation. Résultats: 20 essais cliniques satisfaisaient les critères et portaient sur un total de 1347 patients. Les âges moyens des patients étaient compris entre 38 et 77 ans. La prévalence de la douleur du membre résiduel à 1 semaine, 1 mois, 3 mois, 6 mois, 1 an et 2 ans était, respectivement, de 50%, 11%, 23%, 27%, 22%, et 24%. La sévérité moyenne de la douleur du membre résiduel aux suivis de 6 mois ou plus a été de 4,19 sur 10 pour les amputations pour cancer, 2,70 pour les amputations post traumatisme, 0,47 pour les amputations liées à une vasculopathie, 1,01 pour les amputations du membre inférieur et 3,56 pour les amputations du membre supérieur. Conclusions: La sévérité de la douleur du membre résiduel varie en fonction du motif de l'amputation, et elle est plus fréquente après une amputation du membre supérieur qu'après des amputations du membre inférieur. La douleur la plus sévère a été décrite par des patients subissant une amputation à cause d'un cancer, suivie des amputations traumatiques, alors que les patients ayant subi une amputation pour cause vasculaire signalent une sévérité plus faible. Des méthodes prometteuses de réduction de la douleur à long terme sont le contrôle préopératoire de la douleur, les blocs nerveux et épiduraux, l'utilisation de la mémantine, de blocs contenant de la calcitonine et la coaptation prophylactique des nerfs.

Goal-Oriented Attention Self-Regulation Training Improves Executive Functioning in Veterans with Post-Traumatic Stress Disorder and Mild Traumatic Brain Injury.

Difficulties in executive-control functions are common sequelae of both traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD). The goal of this study was to assess whether a cognitive rehabilitation training that was applied successfully in civilian and military TBI would be effective for military Veterans with comorbid PTSD and mild TBI (mTBI). In the previous study, Veterans with a history of mild to severe TBI improved significantly after goal-oriented attentional self-regulation (GOALS) training on measures of attention/executive function, functional task performance, and emotional regulation. The objective of this study was to assess effects of GOALS training in Veterans with comorbid PTSD and mTBI. Forty Veterans with a current PTSD diagnosis and history of mTBI (6+ months post) were randomized to either five weeks of GOALS or Brain-Health Education (BHE) training matched in time and intensity. Evaluator-blinded assessments at baseline and post-training included neuropsychological and complex functional task performance, and self-report measures of emotional functioning/regulation. After GOALS but not BHE training, participants significantly improved from baseline on primary outcome measures of: overall complex attention/executive function neuropsychological performance composite (F = 12.35, p = 0.001; Cohen d = 0.48), and overall mood disturbance -POMS emotional regulation self-report (F = 4.29, p = 0.05, Cohen d = 0.41). In addition, GOALS but not BHE participants indicated a significant decrease in PTSD symptoms (PCL-M Total Score) (F = 4.80, p = 0.05, Cohen d = 0.60), and demonstrated improvement on complex functional task performance-GPS Learning and Memory (F = 5.06, p = 0.05, Cohen d = 0.56]. Training in attentional self-regulation applied to participant-defined goals may improve cognitive functioning in Veterans with comorbid PTSD and mTBI. Improving cognitive control functioning may also improve functioning in other domains such as emotional regulation and functional performance, potentially making it particularly relevant for Veterans with a history of mTBI and comorbid psychiatric symptoms.

Treatment of an osteoporotic Hoffa fracture.

Two patients with Hoffa fracture of the knee, both suffering from poliomyelitis are reported. Both had unicondylar coronal plane fracture of the medial femoral condyle. The patients were treated with open reduction and screw fixation. Due to poor screw purchase, reoperation was necessary in one patient. The results were satisfactory in both patients.

Rural General Surgery Experience as a Valuable Adjunct to an Academic Based General Surgery Residency.

OBJECTIVE: Few general surgery residencies offer rural rotations. We aim to evaluate the contribution of our institution's rural rotation to meeting the Accreditation Council for Graduate Medical Education (ACGME) minimum case requirements for graduation, and residents' perceptions of the educational value of this rotation. DESIGN: ACGME case log data were obtained from categorical general surgery residents who had completed at least 1 month-long rural surgery rotation and 1 month-long general surgery rotation at our academic medical center within the same clinical year. Cases were classified per ACGME defined categories. For each category, the number of cases per month per resident was calculated, and the means for each educational setting were compared using the paired t-test. Residents also completed a 10-question Likert scale survey regarding their perceptions of the rotation. SETTING: Residents rotated at Vidant Medical Center, a tertiary AMC1 affiliated with East Carolina University in Greenville, NC, and at Vidant Chowan, a critical access hospital within the Vidant Health hospital system located in Edenton, NC. PARTICIPANTS: Categorical general surgery residents eligible to rotate through the rural surgery rotation and the general surgery rotation at the AMC. RESULTS: Eleven total residents completed 23 months of rural surgery (mean 2.1 months per resident) and 39 months at the AMC (mean 3.5 months per resident). Significantly more endoscopic cases, hernia repairs, breast cases, and vascular cases were performed on the rural surgery rotation. More abdominal and alimentary tract cases in addition to endocrine, thoracic, and head/neck cases were performed at the AMC. Frequencies of biliary and soft tissue cases were not significantly different. Survey responses regarding the rural rotation were universally positive including more hands-on experience, increased satisfaction with patient care and continuity, and operative confidence and competence. CONCLUSIONS: At our institution, residents benefit from an enriching rural surgery rotation that provides case numbers different from the comparative AMC general surgery rotation.

Leaning forward: Early arterial access promotes resuscitative endovascular balloon occlusion of the aorta utilization in battlefield casualties.

Uncontrolled noncompressible torso hemorrhage remains a leading cause of potentially preventable death on the battlefield. The utilization of resuscitative endovascular balloon occlusion of the aorta (REBOA) has gained considerable traction in civilian and military trauma care. Establishment of arterial access remains the rate-limiting step in endovascular aortic occlusion. The decision to place arterial access, including size, location, and the appropriate clinician and scenario all must be considered to achieve the optimal patient outcome. This report is submitted by the Joint Medical Augmentation Unit, an elite surgical/resuscitation team that provides medical care in the most far-forward, austere environments in the special operations community. The authors highlight two cases where early arterial access, REBOA utilization, and massive blood transfusion with damage-control surgery were associated with patient survival. We also address the prehospital application of REBOA in battlefield trauma. LEVEL OF EVIDENCE: Special Report, Level V.

Deployed Military Medical Personnel: Impact of Combat and Healthcare Trauma Exposure.

Introduction: Limited research has been conducted on the impact of deployment-related trauma exposure on post-traumatic stress symptoms in military medical personnel. This study evaluated the association between exposure to both combat experiences and medical duty stressors and post-traumatic stress symptoms in deployed military medical personnel. Materials and Methods: U.S. military medical personnel (N = 1,138; 51% male) deployed to Iraq between 2004 and 2011 were surveyed about their exposure to combat stressors, healthcare stressors, and symptoms of post-traumatic stress disorder (PTSD). All participants were volunteers, and the surveys were completed anonymously approximately halfway into their deployment. The Combat Experiences Scale was used as a measure of exposure to and impact of various combat-related stressors such as being attacked or ambushed, being shot at, and knowing someone seriously injured or killed. The Military Healthcare Stressor Scale (MHSS) was modeled after the Combat Experiences Scale and developed for this study to assess the impact of combat-related healthcare stressors such as exposure to patients with traumatic amputations, gaping wounds, and severe burns. The Post-traumatic Stress Disorder Checklist-Military Version (PCL-M) was used to measure the symptoms of PTSD. Results: Eighteen percent of the military medical personnel reported exposure to combat experiences that had a significant impact on them. In contrast, more than three times as many medical personnel (67%) reported exposure to medical-specific stressors that had a significant impact on them. Statistically significant differences were found in self-reported exposure to healthcare stressors based on military grade, education level, and gender. Approximately 10% of the deployed medical personnel screened positive for PTSD. Approximately 5% of the sample were positive for PTSD according to a stringent definition of caseness (at least moderate scores on requisite Diagnostic and Statistical Manual for Mental Disorders criteria and a total PCL-M score ≥ 50). Both the MHSS scores (r(1,127) = 0.49, p < 0.0001) and the Combat Experiences Scale scores (r(1,127) = 0.34, p < 0.0001) were significantly associated with PCL-M scores. However, the MHSS scores had statistically larger associations with PCL-M scores than the Combat Experiences Scale scores (z = 5.57, p < 0.0001). The same was true for both the minimum criteria for scoring positive for PTSD (z = 3.83, p < 0.0001) and the strict criteria PTSD (z = 1.95, p = 0.05). Conclusions: The U.S. military has provided significant investments for the funding of research on the prevention and treatment of combat-related PTSD, and military medical personnel may benefit from many of these treatment programs. Although exposure to combat stressors places all service members at risk of developing PTSD, military medical personnel are also exposed to many significant, high-magnitude medical stressors. The present study shows that medical stressors appear to be more impactful on military medical personnel than combat stressors, with approximately 5-10% of deployed medical personnel appearing to be at risk for clinically significant levels of PTSD.

Are There Detrimental Effects From Proficiency-Based Training in Fundamentals of Laparoscopic Surgery Among Novices? An Exploration of Goal Theory.

INTRODUCTION: Goal theory states that novices may experience unintended, detrimental learning effects, with decreased performance, when given performance goals on complex tasks. In these situations, it may be more appropriate to give novices learning goals to help avoid these negative consequences. The purpose of this study was to see whether this tenant of goal theory applied to novices learning 2 tasks of fundamentals of laparoscopic surgery (FLS). MATERIALS AND METHODS: Medical and physician assistant students were randomized to a performance goals group and a learning goals group. The performance goals consisted of the published proficiency standards of FLS. Both groups were pretested on perception of surgery, self-efficacy, and general affect. Each group underwent a practice session for the peg transfer task. They were tested and scored per the published standards of FLS. The participants completed NASA Task Load Index, task complexity, and postaffect questionnaires related to the peg transfer task. This was repeated with the suture with intracorporeal knot task. Posttest perception of surgery and self-efficacy questionnaires were completed. RESULTS: In total, 48 students participated in the study: 23 in the performance goals group and 25 in the learning goals group. Most of the participants (n = 40) were first-year medical and physician assistant students. There were no significant differences between the groups in perception of surgery, affect, goal commitment, subjective task complexity, subjective workload, and self-efficacy. There were no differences between the groups concerning overall FLS score for both the peg transfer and suturing tasks. Both groups exhibited significant increases in self-efficacy and perception of surgery (p < 0.05). CONCLUSION: FLS skills can be given to novice learners without concern for detrimental effects as might be expected by other work on goal theory. Given that performance was the same for both groups, surgical educators may have multiple pathways to educational success when incorporating goals into training programs for basic surgical skills.