The Effect of Percutaneous Retrograde Metacarpal Intramedullary Screw Insertion on the Extensor Tendon.

PURPOSE: Both limited-open and percutaneous techniques have been described for retrograde insertion of intramedullary metacarpal screws. The percutaneous approach does not allow direct visualization of the starting point at the metacarpal head. However, it limits soft tissue dissection and expedites the procedure. The purpose of our study was to determine whether percutaneous, retrograde intramedullary screw fixation causes substantial iatrogenic damage to the extensor tendon. We also investigated whether larger sized screws would cause greater tendon injury compared to smaller screws. METHODS: Eight fresh frozen cadaver hands were used for percutaneous, retrograde intramedullary screw insertion of the index, long, ring, and small finger metacarpals of each specimen. Three different types of headless compression screws were used: a small fully threaded screw, a large fully threaded screw, and a Herbert-style partially threaded screw. After insertion, dissection was carried down to the screw entry site. Extensor tendon damage was evaluated, including tendon defect size and any irregularities noted in the tendon. RESULTS: There was no statistical difference with respect to how frequently a screw perforated the extensor tendons between all four finger metacarpals. Overall, the defect width caused by the screw was minimal, ranging from 0.66 mm to 1.89 mm for all finger and screw types. The large style screw did cause the greatest mean defect width, however, this was not statistically significant. When normalized to total tendon width, the defect was less than 28% of the total tendon width, with an average of 20% for all finger and screw types. Upon gross inspection, there was no fraying or irregularity noted at the screw-tendon insertion site, and it was often difficult to identify the screw entry site through the tendon by direct visualization alone. No tendon ruptures were noted. CONCLUSIONS: This study found that percutaneous insertion of a retrograde, intramedullary metacarpal screw causes minimal extensor tendon injury. In contrast to the limited-open approach, the percutaneous technique requires less soft tissue dissection and the possibility of reduced swelling, scarring, and risk of adhesions. Moreover, it has the potential to allow for early functional rehabilitation and reduced operative time. Interestingly, none of the tendons demonstrated fraying or rupture, as one might expect to occur with blind passage of a drill and screw through a tendon. Overall, the percutaneous, retrograde intramedullary screw technique appears to cause minimal iatrogenic injury to the extensor tendon.

Iron Sequestration by Galloyl-Silane Nano Coatings Inhibits Biofilm Formation of Sulfitobacter sp.

Microbially-induced corrosion is the acceleration of corrosion induced by bacterial biofilms. The bacteria in the biofilms oxidize metals on the surface, especially evident with iron, to drive metabolic activity and reduce inorganic species such as nitrates and sulfates. Coatings that prevent the formation of these corrosion-inducing biofilms significantly increase the service life of submerged materials and significantly decrease maintenance costs. One species in particular, a member of the Roseobacter clade, Sulfitobacter sp., has demonstrated iron-dependent biofilm formation in marine environments. We have found that compounds that contain the galloyl moiety can prevent Sulfitobacter sp. biofilm formation by sequestering iron, thus making a surface unappealing for bacteria. Herein, we have fabricated surfaces with exposed galloyl groups to test the effectiveness of nutrient reduction in iron-rich media as a non-toxic method to reduce biofilm formation.

The development of ventricular fibrillation as a complication of pericardiectomy in 16 dogs.

OBJECTIVE: To describe the clinical characteristics, perioperative protocols, and outcomes in dogs diagnosed with ventricular fibrillation (VF) while undergoing pericardiectomy. STUDY DESIGN: Retrospective, multi-institutional study. ANIMALS: Sixteen client-owned dogs. METHODS: Cases were accrued through a listserve request posted to 3 subspecialty veterinary societies. Dogs were included if they developed VF during a pericardiectomy performed through an open or thoracoscopic approach. Data collected included signalment, history and physical examination, surgical approach, histopathology, treatment, and outcome. RESULTS: Indications for pericardiectomy included idiopathic chylothorax (n = 7), neoplasia (4), idiopathic pericardial effusion (4), and foreign body granuloma (1). Surgical approaches included thoracoscopy (12), intercostal thoracotomy (3) and median sternotomy (1). Electrosurgical devices were used to complete at least part of the pericardiectomy in 15 of 16 dogs. Ventricular fibrillation appeared to be initiated during electrosurgical use in 8/15 dogs. However, in 5/15 dogs it was not obviously associated with electrosurgical use. In 3/16 dogs the timing of initiation of VF was unclear. In 7/16 dogs, cardiac arrhythmias were noted prior to the development of VF. Fourteen of 16 dogs died from intraoperative VF. CONCLUSION: In most dogs ventricular fibrillation was a fatal complication of pericardiectomy. Ventricular fibrillation might be associated with the use of electrosurgical devices and cardiac manipulation during pericardiectomy although a causal link could not be established from the data in this study. CLINICAL SIGNIFICANCE: Surgeons must be aware of the risk of VF during pericardial surgery. Electrosurgery might need to be used judiciously during pericardiectomy, particularly in dogs exhibiting cardiac arrythmias.

Retrospective evaluation of gastrointestinal foreign bodies and presurgical predictors for enterectomy versus enterotomy in dogs (2013-2016): 82 cases.

OBJECTIVE: To evaluate preoperative diagnostics in dogs with gastrointestinal foreign body (GIFB) obstruction and to identify clinical variables associated with the performance of simple enterotomy (EO) versus enterectomy (EC). DESIGN: Retrospective case control study from October 2013 to January 2016. SETTING: Veterinary Teaching Hospital. ANIMALS: Eighty-two client-owned dogs diagnosed at the time of surgery with GIFB obstruction. MEASUREMENTS AND MAIN RESULTS: Data were collected from medical records regarding history, initial physical examination, clinicopathologic testing, diagnostic imaging, and surgical reports. Based on univariate analysis, dogs that required EC were ill (P < 0.0001) and anorexic (P = 0.0007) for a longer duration; had a higher vomiting severity score (P = 0.005); and had worse perfusion parameters (mucous membrane color [P = 0.028] and quality [P = 0.032], poorer pulse quality [P = 0.0015], relatively lower blood pressure [P = 0.0328], greater heart rates [P = 0.0011]). Dogs undergoing EC were more likely to have altered peritoneal detail on radiographs (P = 0.0014; odds ratio [OR] = 25.5; 95% confidence interval [CI]: 2.4, 275.7) and echogenic peritoneal effusion on ultrasound (P = 0.0101; OR = 12.5; 95% CI: 1.3, 120.9), compared to the EO group. Heart rate (adjusted P = 0.028; OR = 1.07; 95% CI: 1.0, 1.1) and vomiting severity score (adjusted P = 0.028; OR = 5.6; 95% CI: 1.2, 26.1) maintained significance after multiple logistic regression. CONCLUSIONS: Multiple factors in the preoperative clinical evaluation were different between dogs undergoing EO versus EC for GIFB obstruction. However, many of these variables become insignificant with multiple logistic regression. The presence of an increased heart rate or increased vomiting severity score at presentation was independently associated with undergoing enterectomy. Prospective studies with greater number of animals are warranted to validate these results.

A Novel Use of NEMSIS to Create a PECARN-Specific EMS Patient Registry.

Background: Research networks need access to EMS data to conduct pilot studies and determine feasibility of prospective studies. Combining data across EMS agencies is complicated and costly. Leveraging the National EMS Information System (NEMSIS) to extract select agencies' data may be an efficient and cost-effective method of providing network-level data. Objective: Describe the process of creating a Pediatric Emergency Care Applied Research Network (PECARN) specific NEMSIS data set and determine if these data were nationally representative. Methods: We established data use agreements (DUAs) with EMS agencies participating in PECARN to allow for agency identification through NEMSIS. Using 2019 NEMSIS version 3.4.0 data for EMS events with patients 18 years old and younger, we compared PECARN NEMSIS data to national NEMSIS data. Analyzed variables were selected for their ability to characterize events. No statistical analyses were utilized due to the large sample, instead, differences of ±5% were deemed clinically meaningful. Results: DUAs were established for 19 EMS agencies, creating a PECARN data set with 305,188 EMS activations of which 17,478 (5.7%) were pediatric. Of the pediatric activations, 17,140 (98.1%) were initiated through 9-1-1 and 9,487 (55.4%) resulted in transport by the documenting agency. The national data included 36,288,405 EMS activations of which 2,152,849 (5.9%) were pediatric. Of the pediatric activations 1,704,141 (79.2%) were initiated through 9-1-1 and 1,055,504 (61.9%) were transported by the documenting agency. Age and gender distributions were similar between the two groups, but the PECARN-specific data under-represents Black and Latinx patients. Comparison of EMS provider primary impressions revealed that three of the five most common were similar with injury being the most prevalent for both data sets along with mental/behavioral health and seizure. Conclusion: We demonstrated that NEMSIS can be leveraged to create network specific data sets. PECARN's EMS data were similar to the national data, though racial/ethnic minorities and some primary impressions may be under-represented. Additionally, more EMS activations in PECARN study areas originated through 9-1-1 but fewer were transported by the documenting agency. This is likely related to the type of participating agencies, their ALS response level, and the diversity of the communities they serve.

Anticoagulation with Argatroban in a Patient with Heparin-Induced Thrombocytopenia and Renal Insufficiency Undergoing Orthotopic Heart Transplantation.

Unfractionated heparin is the anticoagulant of choice for cardiac surgery that requires cardiopulmonary bypass. However, it can cause serious side effects like heparin-induced thrombocytopenia (HIT), an immune-mediated process where antibodies are directed against heparin and platelet 4 complexes. In such cases, alternative pharmacologic strategies are implemented to facilitate safe bypass conditions. A woman with severe decompensated heart failure was heparinized for intra-aortic balloon pump and subsequent LVAD placement. On day 6, a fall in platelets from 113,000 to 26,000 was noted. She was diagnosed with HIT. Heparin was discontinued and replaced with an argatroban infusion for the duration of her care until heart transplantation was completed. We review the mechanism, diagnosis, and complications of HIT. We discuss cardiopulmonary bypass and its relation to heparin, HIT, and heparin alternatives. We discuss argatroban's relevant pharmacology, clinical use, advantages, and disadvantages.

The Accuracy of 3D Printed Carpal Bones Generated from Cadaveric Specimens.

BACKGROUND: Computer assisted three-dimensional (3D) printing of anatomic models using advanced imaging has wide applications within orthopaedics. The purpose of this study is to evaluate the 3D printing accuracy of carpal bones. METHODS: Seven cadaveric wrists underwent CT scanning, after which select carpal bones (scaphoid, capitate, lunate, and trapezium) were dissected in toto. Dimensions including length, circumference, and volume were measured directly from the cadaver bones. The CT images were converted into 3D printable stereolithography (STL) files. The STL files were converted into solid prints using a commercially available 3D printer. The 3D printed models' dimensions were measured and compared to those of the cadaver bones. A paired t-test was performed to determine if a statistically significant difference existed between the mean measurements of the cadavers and 3D printed models. The intraclass correlation coefficients (ICC) between the two groups were calculated to measure the degree of agreement. RESULTS: On average, the length and circumference of the 3D printed models were within 2.3 mm and 2.2 mm, respectively, of the cadaveric bones. There was a larger discrepancy in the volume measured, which on average was within 0.65 cc (15.9%) of the cadaveric bones. These differences were not statistically significant (P > 0.05). There was strong agreement between all measurements except the capitate's length and lunate's volume. CONCLUSION: 3D printing can add value to patient care and improve outcomes. This study demonstrates that 3D printing can both accurately and reproducibly fabricate boney models that closely resemble the corresponding cadaveric anatomy.

Anesthesia Resident Training Experience Minimally Impacts Emergence Time, Making Correlation of Resident Competency With This Operational Metric Difficult.

INTRODUCTION: Anesthesia residents are deemed competent based on subjective and objective metrics. Knowledge acquisition and procedural skill is often difficult to accurately measure. Inspecting tangible metrics of perioperative efficiency may provide a source for reliable evaluation. METHODS: Retrospective case-log database review yielded 3072 surgical cases involving residents over 5 years. Primary variable investigated was the time from surgery completion to exit from operating room. Other variables recorded included day of week, attending anesthesiologist name, attending surgeon name, patient age, sex, American Society of Anesthesiologists physical status (ASA PS) classification, and inpatient versus day surgery status. RESULTS: After controlling for procedure duration time, inpatient status, ASA PS, surgeon, and attending anesthesiologist, resident training time had high statistical significance. In the fully adjusted model, 1 year of resident training was associated with a reduction in emergence time by 28 seconds. A 1-hour increase in procedure time was associated with an increase in emergence time of 34 seconds. CONCLUSIONS: Although a statistically significant correlation between anesthesia resident training time and emergence time was demonstrated, the clinical significance is likely low given the relatively small amount of actual time saved. We caution the value of using perioperative metrics (e.g., emergence time) for evaluating anesthesia resident competency, until such metrics have undergone significant validation.

Operating room first case start times: a metric to assess systems-based practice milestones?

BACKGROUND: Resident competence in peri-operative care is a reflection on education and cost-efficiency. Inspecting pre-existing operating room metrics for performance outliers may be a potential solution for assessing competence. Statistical correlation of problematic benchmarks may reveal future opportunities for educational intervention. METHODS: Case-log database review yielded 3071 surgical cases involving residents over the course of 5 years. Surgery anticipated and actual start times were evaluated for delays and residents were assessed using the days of resident training performed at the time of each corresponding case. Other variables recorded included day of week, attending anesthesiologist name, attending surgeon name, patient age, sex, American Society of Anesthesiologists physical status classification (ASA PS), and in-patient versus day surgery status. Mixed-effect, multi-variable, linear regression determined independent determinants of delay time. RESULTS: The analysis identified day of the week (F = 25.65, P < 0.0001), days of training (F = 8.39, P = 0.0038), attending surgeon (F = 2.67, P < 0.0001), and anesthesiology resident (F = 1.67, P = 0.0012) as independent predictors of delay time for first-start cases, with an overall regression model F = 3.09, r2 = 0.186, and P < 0.0001. CONCLUSIONS: The day of the week and attending surgeon demonstrated significant impact of case delay compared to resident days trained. If a learning curve for first-case start punctuality exists for anesthesiology residents, it is subtle and irrelevant to operating room efficiency. The regression model accounted for only 19% of the variability in the outcome of delay time, indicating a multitude of additional unidentified factors contributing to operating room efficiency.

[Acute postoperative sepsis mimicking symptomology suspicious for malignant hyperthermia: case report]. / Sepse aguda pós­operatória simulando sintomatologia suspeita para hipertermia maligna: relato de caso.

BACKGROUND: Sepsis is a life-threatening organ dysfunction with non-specific clinical features that can mimic other clinical conditions with hyper metabolic state such as malignant hyperthermia. Perioperatively anesthesia providers come across such scenarios, which are extremely challenging with the need for urgent intervention. OBJECTIVE: To illustrate the need for early intervention and consultation for added assistance to approach and rule out malignant hyperthermia and other possible causes during such a scenario. CASE REPORT: A 63-year-old male underwent an uneventful elective flexible cystoscopy and transrectal ultrasound-guided prostate biopsy. Postoperatively he developed symptoms raising suspicion for malignant hyperthermia. Immediately malignant hyperthermia protocol was initiated that included administration of dantrolene and consultation of malignant hyperthermia association hotline along with other diagnostic and interventional management aimed at patient optimization. While early administration of dantrolene helped in hemodynamically stabilizing the patient, the consultation with other providers and malignant hyperthermia association hotline along with repeated examinations and lab works helped in ruling out malignant hyperthermia as the possible diagnosis. The patient later recovered in the intensive care unit where he was treated for the bacteremia that grew in his blood cultures. CONCLUSIONS: Sepsis shares clinical symptoms that mimic malignant hyperthermia. While sepsis rapidly progresses to secondary injuries, malignant hyperthermia is life threatening. Providing ideal care requires good clinical judgment and a high level of suspicion where timely and appropriate care such as early administration of dantrolene and consultation of malignant hyperthermia association hotline for added assistance can influence positive outcomes.

Acute postoperative sepsis mimicking symptomology suspicious for malignant hyperthermia: case report / Sepse aguda pós-operatória simulando sintomatologia suspeita para hipertermia maligna: relato de caso

Abstract Background: Sepsis is a life-threatening organ dysfunction with non-specific clinical features that can mimic other clinical conditions with hyper metabolic state such as malignant hyperthermia. Perioperatively anesthesia providers come across such scenarios, which are extremely challenging with the need for urgent intervention. Objective: To illustrate the need for early intervention and consultation for added assistance to approach and rule out malignant hyperthermia and other possible causes during such a scenario. Case report: A 63-year-old male underwent an uneventful elective flexible cystoscopy and transrectal ultrasound-guided prostate biopsy. Postoperatively he developed symptoms raising suspicion for malignant hyperthermia. Immediately malignant hyperthermia protocol was initiated that included administration of dantrolene and consultation of malignant hyperthermia association hotline along with other diagnostic and interventional management aimed at patient optimization. While early administration of dantrolene helped in hemodynamically stabilizing the patient, the consultation with other providers and malignant hyperthermia association hotline along with repeated examinations and lab works helped in ruling out malignant hyperthermia as the possible diagnosis. The patient later recovered in the intensive care unit where he was treated for the bacteremia that grew in his blood cultures. Conclusions: Sepsis shares clinical symptoms that mimic malignant hyperthermia. While sepsis rapidly progresses to secondary injuries, malignant hyperthermia is life threatening. Providing ideal care requires good clinical judgment and a high level of suspicion where timely and appropriate care such as early administration of dantrolene and consultation of malignant hyperthermia association hotline for added assistance can influence positive outcomes.

Resumo Justificativa: A sepse é uma disfunção orgânica fatal com características clínicas inespecíficas que podem imitar outras condições clínicas com quadro hipermetabólico, como a hipertermia maligna. Os cenários são extremamente desafiadores para a anestesia perioperatória e requerem intervenção urgente. Objetivo: Ilustrar a necessidade de intervenção e consulta precoces para uma assistência adicional na abordagem e exclusão de hipertermia maligna e outras possíveis causas durante tal cenário. Relato de caso: Paciente do sexo masculino, 63 anos, submetido à cistoscopia eletiva com cistoscópio flexível e biópsia transretal da próstata guiada por ultrassom sem intercorrências. No pós-operatório, o paciente desenvolveu sintomas que levantaram a suspeita de hipertermia maligna. O protocolo de hipertermia maligna foi imediatamente iniciado, inclusive a administração de dantrolene e uma consulta pela linha direta da associação de hipertermia maligna, juntamente com outros diagnósticos e manejos intervencionistas com vistas ao aprimoramento do paciente. Enquanto a administração precoce de dantrolene ajudou na estabilização hemodinâmica do paciente, a consulta com outros anestesistas e com a Associação de Hipertermia Maligna, juntamente com repetidos exames físicos e laboratoriais, ajudou a excluir a hipertermia maligna como o possível diagnóstico. O paciente recuperou-se mais tarde na unidade de terapia intensiva, onde recebeu tratamento para a bacteremia detectada em suas hemoculturas. Conclusões: A sepse compartilha sintomas clínicos que mimetizam a hipertermia maligna. Enquanto a sepse progride rapidamente para lesões secundárias, a hipertermia maligna é uma ameaça à vida. Proporcionar o tratamento ideal requer um bom julgamento clínico e um alto nível de suspeita quanto aos cuidados oportunos e apropriados, como a administração precoce de dantrolene e a consulta pela linha direta da Associação de Hipertermia Maligna para assistência adicional, que podem resultar em desfechos positivos.

UV-cured gel polymer electrolytes with improved stability for advanced aqueous Li-ion batteries.

We report the development of a new class of "water-in-salt" electrolytes based on UV photopolymerized acrylic polymers. Incorporation of "water-in-bisalt" in a polymer matrix reduces water activity, expands the electrochemical stability window to 4.1 V, and dramatically improves cycle life in full cells with lithium titanate anodes compared to liquid water-based electrolytes.

Advanced Filtration Membranes for the Removal of Perfluoroalkyl Species from Water.

Perfluorooctane sulfonic acid (PFOS) and perfluorooctanoic acid (PFOA) are two perfluoroalkyl substances that have been shown to result in several adverse health effects, including birth defects, kidney/testicular cancer, as well as liver and thyroid damage. The surfactant nature of PFOS and PFOA in water makes these compounds extremely difficult to remove from drinking water. In this paper, an efficient method to remove PFOS and PFOA from drinking water using linear fluorinated silane-functionalized aluminum oxide hydroxide (γ-AlOOH) nanowhiskers was developed. Filters functionalized with linear fluorinated silanes containing 13-17 fluorine atoms were able to remove >90% of the PFOS/PFOA at a very high flux of 1223 L/m2·h. However, due to the hydrophobicity of these linear fluorinated silanes, high pressure drop was also noted across the membrane thickness during the filtration process. To reduce the back-pressure drop, linear fluorinated silanes with appended hydrophilic poly(ethylene glycol) units were synthesized, and it was further demonstrated that the new hydrophilic linear fluorinated silane dramatically reduced the pressure drop of the γ-AlOOH filter while maintaining 99.9% PFOS and PFOA reduction. Adsorption tests were performed to understand the removal mechanism.

Goal-directed fluid therapy in the perioperative setting.

Improvement in patient outcomes has become a significant consideration with our limited resources in the surgical setting. The implementation of enhanced recovery pathway protocols has resulted in significant benefits to both the patients and hospitals, such as shorter length of hospital stays, reduction in the rate of complications, and fewer hospital readmissions. An emerging component and a key element for the success of Enhanced Recovery After Surgery (ERAS) protocols has been the concept of goal-directed fluid therapy (GDT). GDT related to ERAS protocols attempts to minimize complications associated with fluid imbalance during surgery. We performed a literature search for articles that included the terms enhanced recovery and GDT. We evaluated methods for appropriate volume status assessment, such as heart rate, blood pressure, end-tidal CO2, central venous pressure, urine output, stroke volume, cardiac output, and their derivatives. Some invasive, minimally invasive, and non-invasive monitors of hemodynamic evaluation are now being used to assess volume status and predict fluid responsiveness and fluid need during various surgical procedures. Regardless of monitoring technique, it is important for the clinician to effectively plan and implement preoperative and intraoperative fluid goals. Excess crystalloid fluid should be avoided. In some low-risk patients undergoing low-risk surgery, a "zero-balance" approach is encouraged. For the majority of patients undergoing major surgery, GDT is recommended. Optimal perioperative fluid management is an important component of the ERAS pathways and it can reduce postoperative complications.

Outcomes and prognostic variables associated with central division hepatic lobectomies: 61 dogs.

OBJECTIVE: To determine the outcome and prognostic variables associated with long-term survival and complications in dogs undergoing hepatic lobectomy of the central division. STUDY DESIGN: Multi-institutional retrospective case series. ANIMALS: Sixty-one client-owned dogs with central division masses. METHODS: Medical records of dogs undergoing hepatic lobectomy of the central division from January 1, 2000 to January 1, 2015 were reviewed for signalment, clinical signs, preoperative staging, preoperative cytology or biopsy results, date of procedure, location of mass, surgical technique, whether cholecystectomy or cholecystopexy was performed, complications, histopathologic diagnosis and margin evaluation, date of local recurrence or detection of metastatic disease, and survival. RESULTS: Hilar resection was associated with increased intraoperative and postoperative complications. Intraoperative complications occurred in 29 dogs, with 20 dogs experiencing intraoperative hemorrhage. Nineteen dogs required transfusions. Immediate postoperative complications occurred in 20 dogs. Perioperative mortality rate was 11%, and 2-week mortality rate was 14.7%. The median survival time for dogs with hepatocellular carcinoma (HCC) was not reached. The 1- and 3-year censored survival rates for dogs with HCC was 82.1% and 82.1%, respectively. Margin status did not impact survival time. CONCLUSION: Hepatic lobectomy of the central division was associated with hemorrhage in approximately 33% of dogs, but there was a relatively low perioperative mortality rate. Hepatic lobectomy for HCC resulted in long-term survival, regardless of margin status. CLINICAL SIGNIFICANCE: Surgeons should anticipate the requirement for blood products in dogs that may require hepatic lobectomy of the central division. Long-term survival can be expected after surgical treatment of HCC, regardless of margin status.

Success and Challenge When Returning to Clinical Practice: A Case Series in Anesthesiologist Re-Entry.

INTRODUCTION: Anesthesiologists returning to clinical practice pose unique challenges for licensing and credentialing boards. Few institutions provide re-education. We describe the physician refresher/re-entry program at our College of Medicine. METHODS: We launched the physician re-entry program in 2006. This individualized program re-educates physicians who left clinical practice for any reason and are seeking to return. We report results achieved for 12 anesthesiologists who successfully completed the course between August 2012 and February 2018. RESULTS: Seven men and five women left their practices for various reasons, which included relocation, family or medical reasons, substance use, and burnout. None left practice for medical negligence. Range away from clinical activity was 0-10 years. Five had active licenses. Seven were US graduates and five were international. Nine of 12 achieved their goals. Of the 3 others, 1 did not pursue her goal, another did not obtain a residency, and the other just finished the program. Seven out of 9 (78%) achieved their goal within 1 year of course completion. DISCUSSION: Despite our small sample size, our experience to successfully return inactive physicians to the workforce adds to the scant literature and experience in refreshing inactive physicians. Our trainees return to practice serving communities across the country and are now a pivotal part of the anesthesiology workforce. Thus, this program not only services individual physicians, but the whole community affected by their absence.

Using operating room turnover time by anesthesia trainee level to assess improving systems-based practice milestones.

BACKGROUND: Operating room (OR) metrics are frequently cited when optimizing cost efficacy and quality of care (Weiss et al, Characteristics of operating room procedures in U.S. hospitals, 2011: Statistical brief #170, 2013; Macario A, Anesthesiology 105:237-240, 2006; Childers et al, JAMA Surg 153:e176233, 2018). Little has been reported to evaluate how anesthesia trainees change anesthesia-related efficiencies in the OR. Statistical correlation may demonstrate awareness and implementation of efficient systems-based practice. METHODS: Utilizing computerized OR information systems, specific data regarding anesthesia controlled turnover times were collected (546 data points) over the course of 4 months. The type of surgery performed, patient's American Society of Anesthesiologists (ASA) physical status and OR turnover times were compared for clinical anesthesia (CA) trainee levels CA1, CA2, CA3 and CRNAs. Standard descriptive statistics were computed. Analysis of variance (ANOVA) was performed to compare the average turnover time. RESULTS: Average OR turnover time was 31 min ranging from 8 to 60 min. There was a significant difference between the OR turnover time of CA-1 (32 min) compared to CA-3 (29 min) (p = 0.017) and CA-1 compared to CRNA (30 min) (p = 0.016). OR turnover time was significantly shorter in CA-3 and CRNA. The analysis showed no differences between OR turnover time of ASA categories. CONCLUSIONS: These findings posit that trainees improve efficiency over time, but that education may for a time come at the expense of productivity. This trend may demonstrate a more profound understanding and mastery of a learner progressing in the graduate medical education system. This interplay plays a key role in clinical and academic shared success.