Outcomes in robotic-assisted compared to laparoscopic-assisted colorectal surgery in a newly established colorectal tertiary center: a retrospective comparative cohort study.

The robotic platform matches or surpasses laparoscopic surgery in postoperative results. However, limited date and slow adoption are noticed in the middle east. We aimed to report outcomes of robotic and laparoscopic colorectal surgery performed by fellowship-trained robotic colorectal surgeons and compare it to larger more experienced centers. Retrospective review of prospectively collected data between 2021 and 2023 of 107 patients who had robotic-assisted or laparoscopic-assisted colorectal surgery was included in the study. The outcomes were overall morbidity, serious morbidity, mortality, conversion to open, length of hospital stay, and the quality of oncological specimen. Of 107 patients, 57 were in the robotic and 50 were in the laparoscopic surgery groups. Overall, there were no significant differences in overall morbidity (46.8 vs. 53.2%, p = 0.9), serious morbidity (10.5 vs. 8%, p = 0.7), or mortality (0 vs. 4%, p = 0.2). Regarding oncological outcomes, there were no significant difference between the two groups regarding the number of lymph node harvested (17.7 ± 6.9 vs 19.0 ± 9.7, p = 0.5), R0 resections (92.7 vs. 87.1%, p = 0.5), and the rate of complete mesorectal excision (92.7 vs. 71.4%, p = 0.19). The study found that the robotic group had an 86% reduction in conversion rate to open surgery compared to the laparoscopic group, despite including more obese and physically dependent patients (OR = 0.14, 95% CI 0.03-0.7, p = 0.01). Robotic surgery appears to be a safe and effective as laparoscopic surgery in smaller colorectal surgery programs led by fellowship-trained robotic surgeons, with outcomes comparable to those of larger programs.

Outcome of Colorectal Robotic Surgery in Newly Established Robotic Surgery Center: A Case Series.

INTRODUCTION: The robotic platform compared to laparoscopy has proven to have similar postoperative outcomes, however its adoption in the Middle East has been slow and there is limited data regarding outcomes with its use in small newly established robotic colorectal programs. Our aim was to report our experience and outcomes of robotic colorectal surgery performed by fellowship-trained robotic colorectal surgeons and compare them to larger, more experienced centers. METHODS: This is retrospective review of data collected between November 2021 and March 2023 from a tertiary health care referral center. The series included 51 patients who had elective or urgent robotic colorectal surgery. Patients who had emergency surgery were excluded. The outcomes were overall morbidity, serious morbidity, mortality, conversion to open, length of hospital stay, and quality of oncological specimen. RESULTS: The overall morbidity was 31.4% (n = 16 patients). Only 9.8% (n = 5) had serious morbidity of which three required interventions under general anesthesia. The median length of hospital stay was 6 days (IQR = 4), and there was no mortality. Of 17 rectal cancer resections, 88% had complete mesorectal excision, 15 of them were R0 resections, median lymph node harvested was 14 (IQR = 7) and two cases were converted to open. All the colon cancer resections had R0 resection, median lymph nodes harvested was 21 (IQR = 4) and none were converted to open. CONCLUSIONS: The implementation and integration of robotic colorectal surgery at a newly established center in a small country, when led by fellowship trained robotic colorectal surgeons, is safe and effective in terms of morbidity, mortality, conversion to open and specimen pathological quality.

Malignant carotid body tumor: a report of two cases.

Carotid body tumors (CBT) are neoplasms that originate from chemoreceptors of the carotid body. They are neuroendocrine tumors that are usually benign but may have malignant potential. Malignancy is diagnosed with evidence of lymph node metastasis, distant metastasis, or disease recurrence. Multiple imaging modalities are used to diagnose CBTs and the treatment of choice is surgical excision. Radiotherapy is used for unresectable tumors. In this case, series we describe two cases of malignant paragangliomas that were diagnosed and operated on at a tertiary hospital in Kuwait, by the vascular team. Malignant CBTs are rare, documentation of the cases encountered and the subsequent management and outcome is important to give us a better understanding of the disease. Case presentation: Case one- A 23-year-old woman presented with a right-sided neck mass. History, physical examination, and appropriate imaging suggested malignant paraganglioma with evidence of lymph node, vertebral, and lung metastases. Surgical excision of the tumor and regional lymph nodes was done. Histopathological assessment of the retrieved specimens confirmed the diagnosis. Case two - A 29-year-old woman presented with a left submandibular swelling. She was appropriately investigated, and the diagnosis of a malignant carotid body tumor was made with evidence of lymph node metastasis. Surgical resection of the tumor with clear margins was done and histopathological analysis of the resected specimen confirmed the diagnosis. Clinical discussion: CBT's are the most common tumors of the head and neck. Most are nonfunctioning, slow growing, and benign. They typically present in the fifth decade of life but can occur at a younger age in individuals who carry certain genetic mutations. Both cases of malignant CBT's that we encountered occurred in young women. Furthermore, the 4-year and 7-year history in case number one and two, respectively, supports the fact that CBTs are slow growing tumors. In our case series, the tumors were surgically resected. Both cases were discussed in multidisciplinary meetings and were referred for hereditary testing and radiation oncology for further management. Conclusion: Malignant carotid body tumors are rare. Prompt diagnosis and treatment is important to improve patient outcomes.

The Impact of the COVID-19 Pandemic on Surgeons' and Surgical Residents' Caseload, Surgical Skills, and Mental Health in Kuwait.

INTRODUCTION: The onset of the COVID-19 pandemic resulted in governments implementing new regulations to divert healthcare resources, which in return led to the postponement of elective and semi-elective surgical procedures. Therefore, many surgeons and as well as surgeons in training reported feeling redundant, which eventually resulted in psychological distress. This study aimed to assess the sociodemographic differences in the psychological impact resulting from the COVID-19 pandemic and outline the effect it had on surgical training. METHODS: This is a cross-sectional study conducted in Kuwait. Data were collected by distributing a questionnaire electronically to surgeons and surgeons in training. The survey included questions aimed at assessing both the effect of the pandemic on surgical training and the psychological impact it had on surgeons, assessing the latter using the Depression, Anxiety and Stress Scale-21 screening tool. RESULTS: The response rate for the study was 52%, with the majority being junior male surgeons. A majority of surgeons in training reported postponement of their scheduled academic teaching sessions (78.9%) and pre-assigned surgical rotations (65.8%). In terms of the psychological impact of the pandemic, a majority of the participants reported an element of depression and stress, 61.2% and 55%, respectively, while approximately half, 48.1%, had symptoms associated with anxiety. CONCLUSION: The COVID-19 pandemic had a negative association with the psychological well-being of a significant proportion of surgeons and associated surgical training programs.

Trans-oral endoscopic endocrine surgery vestibular approach: Pioneering the technique in the Gulf Cooperation Council Countries - A case series.

BACKGROUND: We present our experience with the first five thyroidectomies and parathyroidectomy in Kuwait performed via the transoral endoscopic vestibular approach. METHODS: Retrospective data collection for all trans-oral endoscopic vestibular approach endocrine surgeries performed at a single institution in Kuwait between November 2019 and February 2021. Information on patient demographics, perioperative management and complications were collected and reviewed. OUTCOMES: All 5 cases were completed successfully; the intended specimen was extracted successfully via the trans-oral endoscopic vestibular approach and conversion to traditional trans-cervical approach (TCA) was not required. Operative time for the parathyroidectomy case was 225 min and the average operative time for the remaining 4 cases, thyroidectomies, was 151 min. Blood loss was minimal, and length of hospital stay was between 24 and 48 h. One patient had a transient mental nerve injury, and one patient experienced a postoperative seroma which required aspiration. One case required completion thyroidectomy as histopathology revealed papillary thyroid carcinoma. CONCLUSION: Transoral vestibular approach is a scar free and safe approach to thyroidectomies and parathyroidectomies. Careful patient selection and counselling with regards to risk versus benefit is required. It is an excellent alternative to the traditional transcervical approach and offers great cosmetic results.

Acute gastric volvulus: A rare case report and literature review.

INTRODUCTION AND IMPORTANCE: Gastric volvulus is the abnormal gastric rotation upon itself. It carries a considerable risk for gastric strangulation which may lead to gangrene and perforation, which can be fatal. It commonly presents with non-specific and vague abdominal symptoms making prompt diagnosis and management imperative. This is a case report describing a case of acute organo-axial gastric volvulus. CASE PRESENTATION: A 74-year-old female, with no comorbidities, presented to our department with non-specific abdominal symptoms. Gastric outlet obstruction was suspected. The patient was reviewed by the gastroenterologist and was offered an urgent upper endoscopy. The upper endoscopy findings described a gastric volvulus, and a Computed Tomography (CT) scan was done to confirm the diagnosis. The patient underwent exploratory/diagnostic laparoscopy and successful reduction and fixation followed. There was no evidence of tissue compromise or ischemia. The patient was discharged on post-operative day 4 following an unremarkable postoperative course. CLINICAL DISCUSSION: Acute gastric volvulus is a surgical emergency which can be associated with a high morbidity and mortality, if complications occur. The most important factor in diagnosing acute volvulus of the stomach is a high index of suspicion of the clinical symptoms and should be confirmed by imaging. Contrast enhanced computed tomography (CT) scan is the preferred imaging modality. Urgent surgical intervention is needed to prevent potentially fatal complications. CONCLUSION: Acute Gastric Volvulus is rare and carries the risk of significant morbidity and mortality. Prompt recognition and treatment is required to prevent complications.

Total Thyroidectomy vs Thyroid Lobectomy for Localized Papillary Thyroid Cancer in Children: A Propensity-Matched Survival Analysis.

BACKGROUND: Current guidelines recommend total thyroidectomy (TT) and radioablation for most papillary thyroid cancer (PTC) in children. These guidelines have been criticized as aggressive, especially for early-stage PTC, as it likely does not influence patient survival and results in life-long thyroid hormone replacement. We sought to study whether the extent of thyroidectomy (TT vs thyroid lobectomy [TL]) influences overall and disease-specific survival in children with localized PTC. METHODS: The National Cancer Database and the Surveillance, Epidemiology, and End Results registries were queried. Patients 18 years or younger with low-risk PTC between 2004 and 2016 were included. Using a 1:1 propensity score matching, patients who underwent TT were matched for age, sex, race, year of diagnosis, and tumor size with a similar cohort of patients who underwent TL. Primary end points were overall survival and disease-specific survival. RESULTS: There were 3,500 patients identified as surgically treated for PTC, of which 1,325 patients met inclusion criteria for matching. Three hundred and twenty-six patients were matched. One hundred and sixty-three patients had TT; 140 were female and mean age was 16 years (interquartile range [IQR] 13 to 17 years). One hundred and sixty-three patients had TL; 140 were female and mean age was 16 years (IQR 14 to 17 years). Median follow-up was 5.0 years (IQR 2.8 to 8 years) and 8.3 years (IQR 3.6 to 14.4 years) in the National Cancer Database and Surveillance, Epidemiology, and End Results cohorts, respectively. There was no statistically significant difference in overall survival or disease-specific survival in patients with PTC < 4 cm, regardless of whether patients underwent TT or TL (p = 0.32 for National Cancer Database registry and p = 0.67 for Surveillance, Epidemiology, and End Results registry). CONCLUSIONS: This study suggests that the extent of thyroidectomy does not influence survival for pediatric patients with early-stage PTC and that TL might be adequate in this patient population.

Amyloid goiter - A rare case report and literature review.

INTRODUCTION: Amyloid goiter is a rare presentation of thyroid swelling, which occurs with either primary or secondary amyloidosis. This condition must be differentiated from other types of goiters or malignancies. Even though the thyroid is extensively involved by amyloid, patients are usually euthyroid, but many different presentations and overlaps have been reported. Currently the treatment is surgical resection of the thyroid gland. CASE PRESENTATION: We report a case of a 53-year-old previously healthy male who presented with a 2 year history of a progressively enlarging painless neck swelling. The patient was euthyroid and denied any associated symptoms. The patient subsequently underwent an uneventful total thyroidectomy along with an unremarkable follow up and was diagnosed with primary amyloidosis involving only the thyroid gland confirmed by histopathology. DISCUSSION AND CONCLUSION: Amyloid goiter is a rare entity; a high index of suspicion is required in patients with an enlarging thyroid gland and a concomitant history of chronic inflammatory processes or plasma cell dyscrasia. FNA biopsy should be performed to exclude the top differential of primary thyroid malignancy. Thyroidectomy is necessary for definitive diagnosis and symptom relief. Every effort should be made to delineate the extent of the disease, and in those previously healthy plasma cell dyscrasia should be excluded.

Severe ischemic complications in Covid-19-A case series.

INTRODUCTION: Covid-19 has the propensity to result in a wide array of manifestations. Recently, thromboembolic complications of Covid-19 have been denoted in literature. We report 5 cases of Covid-19 positive patients with no significant comorbidities who developed 1st time episodes of either; acute limb ischemia or bowel ischemia. MATERIAL AND METHODS: This is a retrospective observational study analyzing the clinical characteristics and outcomes of five Covid-19 positive patients. Five patients aged 38-60 presented to our institution from 1st April to 1st June and were diagnosed with Covid-19 pneumonia, subsequently developing severe vascular complications. None of our patients included had any history of thromboembolism nor risk factors that could justify the presentations. PRESENTATION OF CASES: Patient 1; presented with bowel ischemia as a first presentation. Patient 2 and 3 developed unsalvageable lower limb ischemia secondary to partial to complete occlusion of infra-renal aorta. Patient 4 presented with acute upper limb ischemia due to complete occlusion of the axillary and brachial artery. Patient 5 developed bilateral lower limb unsalvageable ischemia secondary to aortic bifurcation occlusion. All patients tested Covid-19 positive upon admission, and received standard care. DISCUSSION AND CONCLUSION: The thromboembolic complications seen in our cases were devastating and resulted in significant mortality and morbidity. All vessels affected were medium-large vessels. None of our cases had any significant predisposing medical conditions or history of thromboembolic or ischemic events. A high index of suspicion is necessary when evaluating such patients regardless of thromboembolic history. Appropriate anticoagulation regimens are essential. Our cases add to the currently increasing severe thromboembolic complications of Covid-19.

Patient Eligibility for Transoral Endocrine Surgery Procedures in the United States.

Importance: Transoral endocrine surgery (TES) allows thyroid and parathyroid operations to be performed without leaving any visible scar on the body. Controversy regarding the value of TES remains, in part owing to the common belief that TES is only applicable to a small, select group of patients. Knowledge of the overall applicability of these procedures is essential to understand the operation, as well as to decide the amount of effort and resources that should be allocated to further study the safety, efficacy, and value of these operations. Objective: To determine what percentage of US patients undergoing thyroid and parathyroid surgery are eligible for TES using currently accepted exclusion criteria. Design, Setting, and Participants: Cross-sectional study of 1000 consecutive thyroid and parathyroid operations (with or without neck dissection) performed between July 1, 2015, and July 1, 2018, at 3 high-volume academic US thyroid- and parathyroid-focused surgical practices (2 general surgery, 1 otolaryngology-head and neck endocrine surgery). Eligibility for TES was determined by retrospectively applying previously published exclusion criteria to the cases. Main Outcomes and Measures: The primary outcome was the percentage of thyroid and parathyroid cases eligible for TES. Secondary outcomes were a subgroup analysis of the percentage of specific types of cases eligible and the reasons for ineligibility. Results: The mean (SD) age of the 1000 surgical patients was 53 (15) years, mean (SD) body mass index (calculated as weight in kilograms divided by height in meters squared) was 29 (7), and 747 (75.0%) of the patients were women. Five hundred fifty-eight (55.8%) of the patients were eligible for TES. Most patients with thyroid nodules with cytologically indeterminate behavior (165 of 217 [76.0%]), benign thyroid conditions (166 of 240 [69.2%]), and primary hyperparathyroidism (158 of 273 [57.9%]) were eligible for TES, but only 67 of 231 (29.0%) of patients with thyroid cancer were eligible. Among all 1000 cases reviewed, previous neck operation (97 of 441 [22.0%]), nonlocalized primary hyperparathyroidism (78 of 441 [17.7%]), and need for neck dissection (66 of 441 [15.0%]) were the most common reasons for ineligibility. Conclusions and Relevance: More than half of all patients undergoing thyroid and parathyroid surgery in this study were eligible for TES. This broad applicability suggests that a prospective multicenter trial is reasonable to definitively study the safety, outcomes, and cost of TES.

Keeping primary aldosteronism in mind: Deficiencies in screening at-risk hypertensives.

BACKGROUND: Primary aldosteronism is a common but underdiagnosed cause of hypertension. Patients with this disorder have worse morbidity compared with those with essential hypertension, but with timely diagnosis and appropriate intervention these patients are potentially cured and may have reversal of target organ damage. The goal of this study was to determine if hypertensive patients considered high risk were checked for primary aldosteronism. METHODS: We reviewed electronic health records to identify patients age 18 years or older with coexisting hypertension and hypokalemia or hypertension and sleep apnea, then determined if they had been investigated with measurement of aldosterone or renin. We built regression models to identify explanatory variables for screening in these 2 high-risk groups. RESULTS: Of nearly 37,000 patients with hypertension and hypokalemia, only 2.7% were ever screened for primary aldosteronism. Most opportunities for case detection were during inpatient hospitalizations, yet in this setting, patients were less likely than clinic patients be screened. Similarly, 3.0% of hypertensive patients with sleep apnea were screened since the inclusion of this group in case detection recommendations. CONCLUSION: Uptake of practice guidelines by hospital physicians, fueled by support from their specialty societies, may help to identify many more patients with unrecognized primary aldosteronism.

Preoperative calcitriol reduces postoperative intravenous calcium requirements and length of stay in parathyroidectomy for renal-origin hyperparathyroidism.

BACKGROUND: Patients undergoing subtotal parathyroidectomy for renal-origin hyperparathyroidism often develop postoperative hypocalcemia, requiring calcitriol and intravenous calcium (Postop-IVCa). We hypothesized that in subtotal parathyroidectomy for renal-origin hyperparathyroidism, preoperative calcitriol treatment reduces the use of postoperative administration of intravenous calcium. METHODS: A retrospective chart review compared subtotal parathyroidectomy for renal-origin hyperparathyroidism patients who received preoperative calcitriol treatment with those patietns who did not receive preoperative calcitriol treatment at one institution. Preoperative calcitriol treatment loading doses were 0.5 mcg twice daily for 5 days. All patients received postoperative calcitriol and oral calcium carbonate. Postoperative administration of intravenous calcium was given for symptoms, calcium <7.0 mg/dL, or surgeon preference. The Fisher exact test was used to compare proportions. The Wilcoxon test was used to compare continuous data. Multivariable logistic regression adjusted for confounders. RESULTS: Included were 81 patients who received subtotal parathyroidectomy for renal-origin hyperparathyroidism (41 patients who received preoperative calcitriol treatment, 40 patients who did not receive preoperative calcitriol treatment). Preoperative calcitriol treatment use increased over time (0% 2004-2010, 69% 2011-2016). Groups who received preoperative calcitriol treatment and groups who did not receive preoperative calcitriol treatment were similar in preoperative serum calcium, vitamin D, parathyroid hormone, and median age (P > .05 for all). Patients who received preoperative calcitriol treatment less often required postoperative administration of intravenous calcium (34% vs 90% of patients who did not receive preoperative calcitriol treatment, P < .001). Median length of stay was 2.0 days shorter for patients who received preoperative calcitriol treatment versus patients who did not receive preoperative calcitriol treatment patients (P < .001). Factors associated with postoperative administration of intravenous calcium included not receiving preoperative calcitriol treatment, low preoperative calcium, and high preoperative parathyroid hormone. After multivariable adjustment, preoperative calcitriol treatment remained independently associated with reduced postoperative administration of intravenous calcium (OR 0.02, P < .001). CONCLUSION: Preoperative calcitriol therapy lowered use of postoperative administration of intravenous calcium by 56% and length of stay by 50% in subtotal parathyroidectomy for renal-origin hyperparathyroidism patients. We believe preoperative calcitriol treatment should become standard of care for subtotal parathyroidectomy for renal-origin hyperparathyroidism.

Time to resuscitate a sacred cow...with normal saline.

Normal saline (NS) is not used for trauma resuscitation because of its potential for acidosis. Lactated Ringer's (LR) is preferred instead. However, the two crystalloids have never been compared in trauma patients. We hypothesized that NS would be an acceptable fluid for resuscitation in the trauma patient. In 2011, a Level I trauma center switched resuscitation fluid from LR to NS. Admissions before and after the change were retrospectively reviewed. Demographics, vitals, blood work, and fluid intake were recorded over 24 hours. Acidosis level, stratified by Injury Severity Score (ISS), was compared. Four hundred ten patients were included, 207 in the LR cohort and 203 in the NS. Chloride (LR 105.26 ± 4.75 vs NS 106.48 ± 4.19), base excess (-2.53 ± 3.77 vs -3.28 ± 4.15), pH (7.37 ± 0.08 vs 7.36 ± 0.07), and bicarbonate (22.83 ± 3.45 vs 21.65 ± 5.06) were statistically different but not clinically significant. This was also true when results were stratified by ISS. In addition, there was no difference in the number of blood gases drawn between the groups (584 vs 544, P = nonsignificant). NS resuscitation is a safe, viable alternative to LR in the trauma population studied. Its use carries a potentially substantial cost savings on a national level.

Sticking our neck out: is magnetic resonance imaging needed to clear an obtunded patient's cervical spine?

BACKGROUND: Evaluating the cervical spine in the obtunded trauma patient is a subject fraught with controversy. Some authors assert that a negative computed tomography (CT) scan is sufficient. Others argue that CT alone misses occult unstable injuries, and magnetic resonance imaging (MRI) will alter treatment. This study examines the data in an urban, county trauma center to determine if a negative cervical spine CT scan is sufficient to clear the obtunded trauma patient. METHODS: Records of all consecutive patients admitted to a level 1 trauma center from January 2000 to December 2011 were retrospectively analyzed. Patients directly admitted to the intensive care unit with a Glasgow Coma Scale score ≤13, contemporaneous CT and MRI, and a negative CT reading were included. The results of the cervical spine MRI were analyzed. RESULTS: A total of 309 patients had both CT and MRI, 107 (35%) of whom had negative CTs. Mean time between CT and MRI was 16 d. Of those patients, seven (7%) had positive acute traumatic findings on MRI. Findings included ligamentous injury, subluxation, and fracture. However, only two of these patients required surgical intervention. None had unstable injuries. CONCLUSIONS: In the obtunded trauma patient with a negative cervical spine CT, obtaining an MRI does not appear to significantly alter management, and no unstable injuries were missed on CT scan. This should be taken into consideration given the current efforts at cost-containment in the health care system. It is one of the larger studies published to date.

Identifying pitfalls in chest tube insertion: improving teaching and performance.

OBJECTIVE: Chest tube thoracostomies are common surgical procedures, but little is known about how practitioners learn the skill. This study evaluates the frequency with which correctly performed tasks are executed by subjects during chest tube thoracostomies. DESIGN: In this prospective study, we developed a mobile-learning module, containing stepwise multimedia guidance on chest tube insertion. Next, we developed and tested a 14-item checklist, modeled after key skills in the module. Participants, defined as "novice" (fewer than 10 chest tubes placed) or "expert" (10 or more placed), were assigned to either the video or control group. A trained clinician used the checklist to rate participants while they inserted a chest tube on a TraumaMan simulator. SETTING: University of Miami, Miller School of Medicine, a tertiary care academic institution. PARTICIPANTS: Current medical students, residents, and the United States Army Forward Surgical Team members rotating through the institution. One hundred twenty-eight subjects entered and finished the study. RESULTS: One hundred twenty-eight subjects enrolled in the study; 86 (67%) were residents or US Army Forward Surgical Team members, 66 (77%) were novices, and 20 (23%) were experts. Novices most frequently connected the tube to suction (91%), adequately dissected the soft tissue (82%), and scrubbed or anesthetized appropriately (80%). They least frequently completed full finger sweeps (33%), avoided the neurovascular bundle (35%), and performed a controlled pleural puncture (39%). Comparing the novice video group with the novice control group, the video group was more likely to correctly perform a finger sweep (42%, p<0.001) and clamp the distal end of the chest tube (42%, p<0.001). Of all the steps, experts least frequently completed full finger sweeps (70%) and avoided the neurovascular bundle (75%). Comparing the expert video group with the expert control group, the video group was more likely to correctly perform finger sweeps, the incision, and clamping the distal chest tube (20%, p = not significant). CONCLUSIONS: Avoiding the neurovascular bundle, controlled pleural entry, and finger sweeps are most often performed incorrectly among novices. This information can help instructors to emphasize key didactic steps, possibly easing trainees' learning curve.

Knowledge and usability of a trauma training system for general surgery residents.

BACKGROUND: Resident work-hour restrictions challenge educators to supplement residents' surgical education. We evaluated a computer-based trauma surgery system's ability to increase residents' surgical knowledge. METHODS: Modules on thoracic and abdominal surgical approaches were evaluated. Surgical residents with 1 or more years of experience completed the pretest, an interactive module, the post-test, and a usability survey. RESULTS: Fifteen participants completed both modules. Thoracic module pretest and post-test scores were 56 ± 11 (mean ± standard deviation) and 90 ± 10, respectively (P < .0001). Mean abdominal module scores were 48 ± 20 and 85 ± 14, respectively (P < .0001). The usability survey showed that 87% of participants would use these modules to supplement their trauma training, 93% could easily distinguish anatomic detail, and 100% thought that procedures were shown clearly. CONCLUSIONS: This novel computer-based trauma education training system improved residents' knowledge of anatomy, surgical incisions, exposures, and technique. As innovative didactic tools arise in postgraduate medical education, it is crucial to document their effects on educational processes, learning satisfaction, and knowledge outcomes.

The impact of caregiver support on mortality following burn injury in the elderly.

Advances in burn care have decreased mortality in the past 20 years, but affecting elderly mortality rates (>65 years) remain challenging. This study evaluates the impact of home caregiver support on elderly burn patients' mortality. The authors retrospectively reviewed patients aged 65 and older admitted to their burn center from July 1995 to October 2004. Patient demographics, Injury Severity Score, TBSA, and patients' primary caregiver were collected. The outcomes were mortality, disposition, and length of stay and these were evaluated using univariate and subsequently multivariate regression. Significance was calculated at P ≤ .05. A total of 112 patients were included in the analysis. The mean age was 76±8. Male patients constituted 47%, whereas 53% were female patients, and mean TBSA was 21±16%. Thirty patients' primary caregiver was a spouse, for 38 it was a child, and 44 had no caregiver. Fifty-eight patients survived (51.7%), and 54 patients died (48.3%). Only 21% of the survivors had a child as their primary caregiver; however, 48% of the nonsurvivors had a child as the primary caregiver (P ≤ 0.05). On multivariate analysis, age, TBSA, and child as primary caregiver were all independent predictors of mortality. Having a child as a caregiver provided the largest impact, with an odds ratio of 4.4 (95% confidence interval, 1.2-15.62; P = .02).

Use of mobile learning module improves skills in chest tube insertion.

BACKGROUND: Just-In-Time Learning is a concept increasingly applied to medical education, and its efficacy must be evaluated. MATERIALS AND METHODS: A 3-minute video on chest tube insertion was produced. Consenting participants were assigned to either the video group, which viewed the video on an Apple® iPod Touch immediately before chest tube insertion, or the control group, which received no instruction. Every participant filled out a questionnaire regarding prior chest tube experience. A trained clinician observed participants insert a chest tube on the TraumaMan® task simulator, and assessed performance using a 14-item skills checklist. RESULTS: Overall, 128 healthcare trainees participated, with 50% in the video group. Participants included residents (34.4%, n = 44), medical students (32.8%, n = 42), and U.S. Army Forward Surgical Team members (32.8%, n = 42). Sixty-nine percent of all participants responded that they had never placed a chest tube, but 7% had placed more than 20. Only 25% of the participants had previously used TraumaMan®. Subjects who viewed the video scored better on the skills checklist than the control group (11.09 ± 3.09 versus 7.17 ± 3.56, P < 0.001, Cohen's D = 1.16). Medical students (9.33 ± 2.65 versus 4.52 ± 3.64, P < 0.001), Forward Surgical Team members (10.07 ± 2.52 versus 8.57 ± 3.22, P < 0.001), anesthesia residents (8.25 ± 2.56 versus 5.9 ± 2.23, P = 0.017), and subjects who had placed fewer than 10 chest tubes (9.7 ± 3 versus 6.6 ± 3.9, P < 0.001) performed significantly better with the video. CONCLUSIONS: The procedural animation video is an effective medium for teaching procedural skills. Embedding the video on a mobile device, and allowing trainees to access it immediately before chest tube insertion, may enhance and standardize surgical education for civilians and military personnel.