Understanding the burden of traumatic injuries at the United States-Mexico border: A scoping review of the literature.

ABSTRACT: The US-Mexico border is the busiest land crossing in the world and faces continuously increasing numbers of undocumented border crossers. Significant barriers to crossing are present in many regions of the border, including walls, bridges, rivers, canals, and the desert, each with unique features that can cause traumatic injury. The number of patients injured attempting to cross the border is also increasing, but significant knowledge gaps regarding these injuries and their impacts remain. The purpose of this scoping literature review is to describe the current state of trauma related to the US-Mexico border to draw attention to the problem, identify knowledge gaps in the existing literature, and introduce the creation of a consortium made up of representatives from border trauma centers in the Southwestern United States, the Border Region Doing Research on Trauma Consortium. Consortium members will collaborate to produce multicenter up-to-date data on the medical impact of the US-Mexico border, helping to elucidate the true magnitude of the problem and shed light on the impact cross-border trauma has on migrants, their families, and the US health care system. Only once the problem is fully described can meaningful solutions be provided.

Pancreatic Neuroendocrine Tumors: The Effect of Facility Type on Patient Survival.

OBJECTIVES: During the last decades, significant progress has been made in the management of patients with pancreatic neuroendocrine tumors (pNETs). It is unclear how the type of the treating health care facility alters patient outcomes. METHODS: Data from pNETs reported to the National Cancer Database between 2004 and 2016 were examined. Types of institutions were as follows: academic/research cancer program (ARP), comprehensive community cancer program (CCCP), integrated network cancer program (INCP), and community cancer program (CCP). RESULTS: A total of 17,887 patients with pNETs were analyzed. Treatment at ARPs was significantly associated with receipt of surgery (ARP, 61.9%; CCCP, 45.6%; CCP, 29.9%; INCP, 55.5%; P < 0.001), both for patients with very early tumors ≤2 cm (ARP, 74.7%; CCCP, 66.5%; CCP, 52.4%; INCP, 71.6%; P < 0.001) and for patients with liver metastases (ARP, 21.3%; CCCP, 10.6%; CCP, 5%; INCP, 16.8%; P < 0.001). Treatment at ARPs was associated with improved survival (median overall survival: ARP, 91 mo; CCCP, 47 mo; CCP, 24.5 mo; INCP, 72 mo; P < 0.001). CONCLUSIONS: Treatment of pNETs at academic/research programs is associated with more frequent resections and best survival outcomes. This survival benefit exists for early and late stages and after adjusting for known cofactors.

The impact of minimally invasive surgery and frailty on post-hepatectomy outcomes.

BACKGROUND: The impact of patient frailty on post-hepatectomy outcomes is not well studied. We hypothesized that patient frailty is a strong predictor of 30-day post-hepatectomy complications. METHODS: The liver-targeted National Surgical Quality Improvement Program (NSQIP) database for 2014-2019 was reviewed. A validated modified frailty index (mFI) was used. RESULTS: A total of 24,150 hepatectomies were reviewed. Worsening frailty was associated with increased incidence of Clavien-Dindo grade IV complications (mFI 0, 1, 2, 3, 4 was 3.9%, 6.3%, 10%, 8.1%, 50% respectively; p < 0.001). Minimally invasive hepatectomies had a lower rate of Clavien-Dindo grade IV complications for non-frail (Laparoscopic: 1%, Robotic: 2.6%, Open: 4.6%; p < 0.001) and frail patients (Laparoscopic: 3%, Robotic: 2.3%, Open: 7.7%; p < 0.001). Frail patients experienced higher incidence of post-hepatectomy liver failure (5.4% vs 4.1% for non-frail; p < 0.001) and grade C liver failure (28% vs 21.1% for non-frail; p = 0.03). Incorporating mFI to Albumin-Bilirubin score (ALBI) improved its ability to predict Clavien-Dindo grade IV complications (AUC improved from 0.609 to 0.647; p < 0.001) and 30-day mortality (AUC improved from 0.663 to 0.72; p < 0.001). CONCLUSION: Worsening frailty correlates with increased incidence of Clavien-Dindo grade IV complications post-hepatectomy, whereas minimally invasive approaches decrease this risk. Incorporating frailty assessment to ALBI improves its ability to predict major postoperative complications and 30-day mortality.

Blunt Thoracic Aortic Injury and Contemporary Management Strategy.

Thoracic aortic injury (TAI) is a leading cause of death in blunt chest trauma. Motor vehicle collisions are the commonest cause, and most patients die before receiving medical attention. Survivors who make it to the hospital also typically have other debilitating injuries with high morbidity. It is imperative to understand the nature of these injuries and implement current management strategies to improve patient outcomes. A literature review on contemporary management strategies on blunt thoracic aortic injuries was performed to evaluate the available evidence using online databases (PubMed and Google Scholar). We found that there has been an improved survival owing to the current advancement in diagnostic modalities, the use of contrast-enhanced computed tomography angiography, and contemporary management techniques with an endovascular approach. However, careful assessment of patients and a multidisciplinary effort are necessary to establish an accurate diagnosis. Minimal aortic injuries (intimal tear and aortic hematoma) can be managed medically with careful monitoring of disease progression with imaging. Endovascular approaches and delayed intervention are key strategies for optimal management of high-grade TAI.

Facility Type Affects Treatment Outcomes for Patients With Mucinous Cystic Neoplasms and Intraductal Papillary Mucinous Neoplasms of the Pancreas.

OBJECTIVE: Academic centers report better outcomes for pancreatic ductal adenocarcinoma. We hypothesized that treatment outcomes for mucinous cysts differ according to institution type. METHODS: Using the National Cancer Data Base, we analyzed data on patients with mucinous cystic neoplasms (MCNs) and intraductal papillary mucinous neoplasms (IPMNs). RESULTS: Of 3278 identified patients, 2622 (80%) had IPMNs and 656 (20%) had MCNs. While most academic/research programs (ARCPs, 84.9%) treated more than 10 patients/year, this was true for only 59% of integrated network cancer programs, 37.3% of comprehensive community cancer programs, and 0% of community cancer programs (P < 0.001). Surgery was used more often in ARCPs and for smaller tumors. The ARCPs had higher rates of margin negative resections with retrieval of 15 or more nodes with the lowest 30- and 90-day mortality rates. The median overall survival was better in ARCPs (110.3 months) than comprehensive community cancer programs (75.1 mo), community cancer programs (75.1 mo), or integrated network cancer programs (100.8 mo, P < 0.001). CONCLUSIONS: Treatment of MCNs and IPMNs of the pancreas at academic centers is associated with a higher probability of pancreatectomy, disease identification in a noninvasive stage, and better overall survival. Centralization of care for mucinous pancreatic cysts will lead to improved outcomes.

Penetrating trauma in children on the United States-Mexico border: Hispanic ethnicity is not a risk factor.

INTRODUCTION: The United States-Mexico border is perceived as dangerous by the media and current political leaders. Hispanic ethnicity, low socioeconomic status, male gender and adolescent age have previously been identified as risk factors for penetrating trauma (PT). METHODS: A retrospective review of PT was performed in a border region. Children 0-17 years old, admitted to the region's only level I trauma center between 2001 and 2016 were included. Standardized morbidity ratio was used to compare observed to expected morbidity. RESULTS: There were 417 PT admissions. 197 (47%) were non-accidental, 34 (8%) suicide attempts and 186 (45%) accidental. There were 12 homicides, 7 suicides and no accidental deaths. The region contains over 280,000 children, thus yielding a homicide rate of 0.26 per 100,000. The U.S. pediatric homicide rate was 2.6-4.0 over this period. Adolescents 13-17 years old accounted for 237 (57%) admissions, 152 (78%) of non-accidental admissions and 12 (63%) deaths. Most admissions (N = 321, 77%) and 15 of the deaths (79%) were males. Non-accidental injuries were more frequent in ZIP codes associated with low incomes. Hispanic patients accounted for 173 (88%) of non-accidental trauma. However, 40 (20%) non-accidental injuries occurred in Mexico and 157 (80%) injuries occurred in an 82% Hispanic region. Therefore, the standardized morbidity ratio for Hispanic ethnicity was 1.048 (CL 0.8-1.2, P = 0.6). CONCLUSION: On the United States-Mexico border, the pediatric homicide rate was less than 1/10 the national average. Male adolescents are at risk for non-accidental PT. In a Hispanic majority population, Hispanic ethnicity was not a risk factor for PT. It is possible that economic disparity, rather than race/ethnicity, is a risk factor for PT.

Third-Year Medical Student Impressions of Resident Teaching in Simulated and Clinical Settings.

We sought to determine whether simulation-based medical education using Trauma Evaluation and Management® (TEAM®) training module contributes to a positive impression of resident and faculty teaching. Qualitative and quantitative data regarding medical students' experience of TEAM® training and their interaction with instructors were collected using anonymous surveys after the completion of the training module. A combination of yes or no responses, as well as classification of student confidence and perceptions on the utility of TEAM® training obtained using Likert-type scales, was evaluated. Qualitative data regarding student perceived strengths and weaknesses of this training and their perception of the quality of teaching were collected and analyzed. Most of the students felt the quality of teaching was better when compared with clinical settings, with 91 per cent of the respondents who provided additional feedback stating that residents were better teachers in the simulated setting. The application of TEAM® training in the surgical clerkship curriculum provides an environment to foster high-quality resident-led education.

CT Scan Reliability in Detecting Internal Hernia after Gastric Bypass.

BACKGROUND AND OBJECTIVES: Internal hernia (IH) after gastric bypass can be a life-threatening complication. Obstruction presents acutely or as chronic relapses, with symptoms of abdominal pain, nausea, and vomiting. Early detection and exploration of IH as the cause of small bowel obstruction (SBO) is critical in this surgical emergency and can reduce morbidity and mortality. We conducted a retrospective review of laparoscopic Roux-en-Y bypass (LRYGB) records to determine the specificity and sensitivity of computed tomography (CT) in identifying postoperative IH. METHODS: Records of 550 patients who underwent antecolic antegastric laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery over a 5-year period (2010-2014) were retrospectively reviewed for complications. Our study population comprised patients who returned with signs and symptoms of obstruction who underwent CT imaging followed by laparoscopic exploration. RESULTS: Thirty-four patients were found to have obstruction on CT scan at ≥6 weeks after LRYGB. Six (17.7%) were found to have IH by preoperative CT imaging before laparoscopic exploration. Of the 6 patients identified to have IH before exploration, 4 (28%) had consistent findings at operation, yielding a sensitivity of 28.6% and specificity of 90.0%. Operative findings identified other causes of SBO: adhesions (n = 17), IH (n = 14), jejunojejunostomy stenosis (n = 2), and phytobezoar (n = 1). CONCLUSIONS: IH after LRYGB is difficult to detect. Our study found CT to have a low sensitivity but a high specificity in detecting IH. Therefore, laparoscopic exploration continues to be the best diagnostic and therapeutic intervention for this complication.

Characteristics and Management of Blunt Renal Injury in Children.

BACKGROUND: Renal trauma in the pediatric population is predominately due to blunt mechanism of injury. Our purpose was to determine the associated injuries, features, incidence, management, and outcomes of kidney injuries resulting from blunt trauma in the pediatric population in a single level I trauma center. METHODS: This was a retrospective chart and trauma registry review of all pediatric blunt renal injuries at a regional level I trauma center that provides care to injured adults and children. The inclusion dates were January 2001-June 2014. RESULTS: Of 5790 pediatric blunt trauma admissions, 68 children sustained renal trauma (incidence: 1.2%). Only two had nephrectomies (2.9%). Five renal angiograms were performed, only one required angioembolization. Macroscopic hematuria rate was significantly higher in the high-grade injury group (47% vs. 16%; P = 0.031). Over half of the patients had other intra-abdominal injuries. The liver and spleen were the most frequently injured abdominal organs. CONCLUSION: Blunt renal trauma is uncommon in children and is typically of low American Association for the Surgery of Trauma injury grade. It is commonly associated with other intra-abdominal injuries, especially the liver and the spleen. The nephrectomy rate in pediatric trauma is lower compared to adult trauma. Most pediatric blunt renal injury can be managed conservatively by adult trauma surgeons.

Ethnic disparities in traumatic brain injury care referral in a Hispanic-majority population.

BACKGROUND: Functional outcomes after traumatic brain injury (TBI) can be significantly improved by discharge to posthospitalization care facilities. Many variables influence the discharge disposition of the TBI patient, including insurance status, patient condition, and patient prognosis. The literature has demonstrated an ethnic disparity in posthospitalization care referral, with Hispanics being discharged to rehabilitation and nursing facilities less often than non-Hispanics. However, this relationship has not been studied in a Hispanic-majority population, and thus, this study seeks to determine if differences in neurorehabilitation referrals exist among ethnic groups in a predominately Hispanic region. METHODS: This study is a retrospective cohort that includes 1128 TBI patients who presented to University Medical Center El Paso, Texas, between the years 2005 and 2015. The patients' age, sex, race, residence, admission Glasgow Coma Scale (GCS), GCS motor, Injury Severity Score (ISS), hospital and intensive care unit length of stay (LOS), mechanism of injury, and discharge disposition were analyzed in univariate and multivariate models. RESULTS: Our study population had an insurance rate of 55.5%. Insurance status and markers of injury severity (hospital LOS, intensive care unit LOS, ISS, GCS, and GCS motor) were predictive of discharge disposition to rehabilitation facilities. The study population was 70% Hispanic, yet Hispanics were discharged to rehabilitation facilities (relative risk: 0.56, P: 0.001) and to long-term acute care/nursing facilities (relative risk: 0.35, P < 0.0001) less than non-Hispanics even after LOS, ISS, ethnicity, insurance status, and residence were adjusted for in multivariate analysis. CONCLUSIONS: This study suggests that patients of different ethnicities but comparable traumatic severity and insurance status receive different discharge dispositions post-TBI even in regions in which Hispanics are the demographic majority.

Trauma patients warrant upper and lower extremity venous duplex ultrasound surveillance.

BACKGROUND: Due to the high incidence of thromboembolic events (deep venous thrombosis [DVT] and pulmonary embolus [PE]) after injury, many trauma centers perform lower extremity surveillance duplex ultrasounds. We hypothesize that trauma patients are at a higher risk of upper extremity DVTs (UEDVTs) than lower extremity DVTs (LEDVTs), and therefore, all extremities should be evaluated. MATERIALS AND METHODS: A retrospective chart and trauma registry review of Intensive Care Unit trauma patients with upper and LEDVTs detected on surveillance duplex ultrasound from January 2010 to December 2014 was carried out. Variables reviewed were age, gender, injury severity score, injury mechanism, clot location, day of clot detection, presence of central venous pressure catheter, presence of inferior vena cava filter, mechanical ventilation, and fracture. RESULTS: A total of 136 patients had a DVT in a 5-year period: upper - 71 (52.2%), lower - 61 (44.9%), both upper and lower - 4 (2.9%). Overall, 75 (55.2%) patients had a UEDVT. Upper DVT vein: Brachial (62), axillary (26), subclavian (11), and internal jugular (10). Lower DVT vein: femoral (58), popliteal (14), below knee (4), and iliac (2). 10.3% had a PE: UEDVT - 5 (6.7%) and LEDVT - 9 (14.8%) P = 0.159. CONCLUSIONS: The majority of the DVTs in the study were in the upper extremities. For trauma centers that aggressively screen the lower extremities with venous duplex ultrasound, surveillance to include the upper extremities is warranted.

Association of Atlanto-Occipital Dislocation, Retroclival Hematoma, and Hydrocephalus: Management and Survival in a Pediatric Patient.

Atlanto-occipital dislocation (AOD) is an injury with high morbidity and mortality. We present a case of survival of a pediatric patient with the diagnoses of AOD, retroclival hematoma, and resulting hydrocephalus. The patient's cervical spine was stabilized until occipital-cervical fusion provided definitive treatment, and the hydrocephalus was treated with a ventriculostomy. The patient survived with no neurological deficits. A better understanding and awareness of the radiologic criteria of AOD will lead to earlier recognition of AOD and improved outcomes, even in the presence of complications from AOD. Surgical fixation should be used for definitive treatment of injuries with AOD.

Reversal of Newer Direct Oral Anticoagulant Drugs (DOACs).

Anticoagulation therapy is indicated for management of various clinical conditions to prevent adverse events and introduction of direct oral anticoagulants (DOACs) has ushered in a new era in anticoagulation therapy. Major advantages of DOACS include fewer drug interactions and that they do not need periodic monitoring. Several patients who were not on anticoagulation before due to older age, polypharmacy/drug interaction concerns, and logistics of periodic monitoring are now on anticoagulation with DOACs. Despite their many advantages, a challenge while prescribing DOACs is very limited availability of specific reversal agents and lack of understanding or guidance about the treatment strategy in case of major life threatening bleeding or need for urgent surgery. So far only one reversal agent has been approved by the Food and Drug Administration (FDA), idarucizumab for one of the DOACs i.e., dabigatran. Several other reversal agents are under final phases of development such as andexanet alfa and PER977 (ciraparantag) and will help in developing specific strategies for reversal of these agents. In this article, we review current strategies to manage bleeding with DOACs and provide guidance to clinicians of inhibiting LF activity in vitro and in cells, as well as in animal models of anthrax infection.

Cecal bascule after spinal cord injury: A case series report.

INTRODUCTION: Cecal bascule is a rare cause of intestinal obstruction associated with upward and anterior folding of the ascending colon. We report three patients who presented with spinal cord injury complicated with a cecal bascule. Diagnosis and management of cecal bascule is discussed. PRESENTATION OF CASES: Patient 1: 59-year-old male sustained a traumatic brain injury and cervical spinal cord injury after a motorcycle crash. He had abdominal distension and the diagnosis of cecal bascule was made. Cecopexy was performed. Patient 2: 51-year-old male sustained an unstable C7 vertebral fracture with a cord contusion and quadriplegia after a diving incident. After an unsuccessful medical management of the colonic distension, the patient was taken for a laparotomy and cecal bascule was found. A cecostomy and a cecopexy were performed. Patient 3: 63-year-old male was transferred after a fall. He had diffuse degenerative changes in the thoracic and lumbar spine. He was found to have a perforated cecal bascule. He had a right hemicolectomy with an ileocolic anastomosis. DISCUSSION: We suggest the possibility of spinal cord injury being a risk factor for cecal bascule. Currently, right hemicolectomy is recommended for the treatment of cecal bascule. Cecopexy is also acceptable treatment option for a case in which the patient will be undergoing an operation with an insertion of hardware. CONCLUSION: The diagnosis of cecal bascule should be considered for trauma patients with cecal distention without delay in order to prevent disastrous complications.

Cardiac Trauma.

Cardiac trauma is a leading cause of death in the United States and occurs mostly due to motor vehicle accidents. Blunt cardiac trauma and penetrating chest injuries are most common, and both can lead to aortic injuries. Timely diagnosis and early management are the key to improve mortality. Cardiac computed tomography and cardiac ultrasound are the 2 most important diagnostic modalities. Mortality related to cardiac trauma remains high despite improvement in diagnosis and management.

Cultural adaptation of a brief motivational intervention for heavy drinking among Hispanics in a medical setting.

BACKGROUND: Hispanics, particularly men of Mexican origin, are more likely to engage in heavy drinking and experience alcohol-related problems, but less likely to obtain treatment for alcohol problems than non-Hispanic men. Our previous research indicates that heavy-drinking Hispanics who received a brief motivational intervention (BMI) were significantly more likely than Hispanics receiving standard care to reduce subsequent alcohol use. Among Hispanics who drink heavily the BMI effectively reduced alcohol use but did not impact alcohol-related problems or treatment utilization. We hypothesized that an adapted BMI that integrates cultural values and addresses acculturative stress among Hispanics would be more effective. METHODS/DESIGN: We describe here the protocol for the design and implementation of a randomized (approximately 300 patients per condition) controlled trial evaluating the comparative effectiveness of a culturally adapted (CA) BMI in contrast to a non-adapted BMI (NA-BMI) in a community hospital setting among men of Mexican origin. Study participants will include men who were hospitalized due to an alcohol related injury or screened positive for heavy drinking. By accounting for risk and protective factors of heavy drinking among Hispanics, we hypothesize that CA-BMI will significantly decrease alcohol use and alcohol problems, and increase help-seeking and treatment utilization. DISCUSSION: This is likely the first study to directly address alcohol related health disparities among non-treatment seeking men of Mexican origin by comparing the benefits of a CA-BMI to a NA-BMI. This study stands to not only inform interventions used in medical settings to reduce alcohol-related health disparities, but may also help reduce the public health burden of heavy alcohol use in the United States. TRIAL REGISTRATION: Trial registration clinicaltrials.gov identifier NCT02429401; Registration date: April 28, 2015.

Hepatic "BOLSA" a novel method of perihepatic wrapping for hepatic hemorrhage "BOLSA".

INTRODUCTION: Severe traumatic liver hemorrhage quickly leads to exsanguination. Perihepatic packing is frequently used in damage control surgery. This method can be unsuccessful and accompanied by complications. Vicryl mesh wraps have been described in the treatment of liver hemorrhage. In this report, we describe an enhanced technique of hepatic wrapping in a case of hepatic bleeding after liver biopsy in a coagulopathic patient. The technique is called the hepatic "BOLSA" (Bag on Liver Supporting Anti-Hemorrhage). PRESENTATION OF CASE: A 59 year old male presented in the recovery room after liver biopsy of a mass, followed by angio-embolization of the hepatic mass 9h earlier. The patient was acidotic, coagulopathic, and demonstrated intra-abdominal hypertension. Computed tomography demonstrated perihepatic fluid. The patient continued hemorrhaging despite attempts to correct coagulopathy by transfusion. Multiple operating room visits were required where a combination of packing and hemostatic agents could not stop hepatic venous parenchymal hemorrhage. Mesh wrap consisting of Vicryl and PDS suture were used to create the "BOLSA" to achieve hemostasis. DISCUSSION: Perihepatic packing compromises pulmonary excursion, elevates intra-abdominal pressure, is a risk factor for sepsis, and requires an additional trip to the operating room for removal. The use of Vicryl mesh wrap obviates these complications. Previously described mesh wraps require anchoring. The self-supporting structure of the BOLSA simplifies construction and application. CONCLUSION: The BOLSA is an effective tool in treatment of severe liver hemorrhage in coagulopathic patients. It is the modern simplification of hepatic wrapping and the solution to the side effects of perihepatic packing.

Blunt traumatic bladder rupture: a 10-year perspective.

The purpose of this study was to determine the incidence, features, and associated injuries of intraperitoneal (IP) and extraperitoneal (EP) bladder rupture (BR) resulting from blunt trauma. A retrospective study from September 2001 to August 2011 was performed for blunt traumatic BR in adults. Demographics, mean Injury Severity Score (ISS), mean length of stay (LOS), incidence, mortality, operative repair, and associated injuries were evaluated. Of 15,168 adult blunt trauma admissions over 10 years, 54 patients had BR (EP = 22, IP = 27, EP + IP = 5; incidence = 0.36%). Sixty-three per cent were male. The mean age, ISS, and LOS were 40 years, 29, and 15 days, respectively. The mortality rate was 11 per cent. Fifty-two per cent of BR was the result of a motor vehicle crash. Most BRs were diagnosed by computed tomography cystogram. Eighty per cent had pelvic fracture. Hollow viscus injury was present in 34.5 per cent of patients. Colonic injury was seen in 24 per cent and 9.3 per cent had a rectal injury. Although BR is rare in adult blunt trauma, it is associated with high ISS, LOS, and mortality. Pelvic fractures are essentially present in all patients with EP BR. Hollow viscus injuries, especially colonic and rectal injuries, are more prominent in IP BR.

Case based review questions, review sessions, and call schedule type enhance knowledge gains in a surgical clerkship.

INTRODUCTION: Medical students in surgical clerkships must gain surgical knowledge while doing clinical rotations. We developed a self-learning program, which is case based, the Case Review Question (CRQ) system. Our hypothesis was that students who used CRQs would score higher on the summative test, Surgery NBME (National Board of Medical Examiners). METHODS: The setting is a surgical clerkship in a Liaison Council for Medical Education (LCME) approved Medical School, with summative examination using the NBME shelf examination in Surgery. Each CRQ document is a series of 20 to 25 questions based on cases. The cases are a paragraph, with pertinent medical facts and extra facts as distracters. The students are encouraged to use these questions to guide study. Students must come to a review session to hear the answers and a discussion. We review the NBME Surgery shelf examination scores taken before and after this program was initiated, along with changes in rotation group size, call schedule type, and other changes. RESULTS: CRQs, review sessions, and call schedule changes improved scores. NBME examination average rose from 77.12 to 82.01 (p = 0.004) after the CRQ program was initiated. Call schedule revision improved scores: intermittent call NBME score was 80.98, whereas night float schedule mean NBME was 84.66 (p < 0.001). During night float call, the CRQ program was already in effect, so that there is no non-CRQ program comparison group. Students scored higher in the second semester, throughout the study. First semester students scored a mean of 79.11, whereas second semester students scored 84.195 (p < 0.001). By the end of the study, there were no failures on the NBME examination, even in the first semester. The factors of presence of the CRQ program, review sessions, call schedule type, and which semester were all significant in a correlation matrix against NBME scores and in a regression analysis (p < 0.001). CONCLUSIONS: The CRQ program of case-based self-study was associated with higher scores on the NBME shelf examination, as a summative test of medical knowledge in surgery.