"Optimization of Surgical Resident Safety and Education During the COVID-19 Pandemic - Lessons Learned".

The COVID-19 pandemic has engendered rapid and significant changes in patient care. Within the realm of surgical training, the resultant reduction in clinical exposure and case volume jeopardizes the quality of surgical training. Thus, our general surgery residency program proceeded to develop a tailored approach to training that mitigates impact on resident surgical education and optimizes clinical exposure without compromising safety. Residents were engaged directly in planning efforts to craft a response to the pandemic. Following the elimination of elective cases, the in-house resident complement was effectively decreased to reduce unnecessary exposure, with a back-up pool to address unanticipated absences and needs. Personal protective equipment availability and supply, the greatest concern to residents, has remained adequate, while being utilized according to current guidelines. Interested residents were given the opportunity to work in designated COVID ICUs on a volunteer basis. With the decrease in operative volume and clinical duties, we shifted our educational focus to an intensive didactic schedule using a teleconferencing platform and targeted areas of weakness on prior in-service exams. We also highlighted critical COVID-19 literature in a weekly journal club to better understand this novel disease and its effect on surgical practice. The long-term impact of the COVID-19 pandemic on resident education remains to be seen. Success may be achieved with commitment to constant needs assessment in the changing landscape of healthcare with the goal of producing a skilled surgical workforce for public service.

Extended pharmacologic thromboprophylaxis in oncologic liver surgery is safe and effective.

Essentials The risk for venous thromboembolism after liver surgery remains high in the modern era. We evaluated the safety/efficacy of extended anticoagulation in liver surgery. This protocol reports zero venous thromboembolism events in 124 liver surgery patients. Extended anticoagulation after oncologic liver surgery is safe and effective. SUMMARY: Background The incidence of venous thromboembolism (VTE) after liver surgery remains high. Objective To evaluate the safety and efficacy of extended pharmacologic thromboprophylaxis after liver surgery for the prevention of VTE. Patient/Methods From August 2013 to April 2015, 124 patients who underwent liver resection for malignancy were placed on an extended pharmacologic thromboprophylaxis protocol. Intraoperative VTE prophylaxis included thromboembolic deterrent hoses and sequential compression devices. Once hemostasis had been ensured following hepatectomy, daily anticoagulant VTE prophylaxis was initiated for the duration of hospitalization. After hospital discharge, the large majority of patients (114, 91.9%) continued to receive anticoagulant thromboprophylaxis (enoxaparin) to complete a total course of 14 days after minor/minimally invasive hepatectomy or 28 days after major hepatectomy or a history of VTE. Results The cohort included 39 (31.2%) major hepatectomies and 38 (31.5%) minor/minimally invasive approaches. The intraoperative, postoperative and overall transfusion rates were 5.6%, 8.1%, and 10.5%, respectively. Pharmacologic thromboprophylaxis was started on postoperative day (POD) 0 for 40 (32.3%) patients and on POD 1 for 84 (67.7%) patients. During 90 days of follow-up, no postoperative symptomatic deep vein thrombosis or pulmonary embolic events were diagnosed. Standard-protocol computed tomography scans of the chest, abdomen and pelvis that were obtained for 112 (90.3%) study patients showed no pulmonary emboli, or other thoracic, splanchnic or ileofemoral vein thromboses. Two (1.6%) patients had minor bleeding events that resolved after discontinuation of enoxaparin, requiring neither blood transfusion nor reoperation. The severe complication rate was 5.6%, with no 90-day mortalities. Conclusions These preliminary data suggest that extended pharmacologic thromboprophylaxis for liver surgery patients is safe and effective.

Eukaryotic cells grown on microcarrier beads offer a cost-efficient way to propagate Chlamydia trachomatis.

The use of microcarrier cell culture as a method for the in vitro propagation of the obligate intracellular bacterial parasite, Chlamydia trachomatis, is described. The microcarrier beads proved to be a more cost-effective means to propagate C. trachomatis than traditional tissue culture flasks or roller bottles without sacrificing yields or infectivity. In addition, microcarrier cell culture was found to be a much simpler technique to study the intracellular development of these bacteria.

Anterior sacral meningocele: two case reports and discussion of surgical approach.

Virtually all patients with anterior sacral meningocele have a pelvic mass with symptoms and signs relating to pressure of the mass on adjacent structures. Constipation is a universal complaint; urinary incontinence is common. A headache often develoips when the patient stands, due to lowered spinal fluid pressure as the meningocele sac fills. A scimitar-shaped sacrum on anterioposterior plain roentgenograms of the spine is pathognomonic. The coccyx may be absent, and the lower sacral laminate may be absent or incomplete. Myelography confirms the diagnosis and should be done with large volumes of iophendylate in order to fill the sac. Only approximately 130 anterior sacral meningoceles have been reported in the literature. This article presents 2 more cases, both seen at the North Carolina Baptist Hospital. The surgical approach to both was through a sacral laminectomy; the communicating stalk was ligated and the meningocele was removed. One patient was 11 years old and had a large suprapubic pelvic mass found on routine examination. She is neurologically normal postoperatively. The other was 7 years old and had had fecal incontinence since birth. That incontinence is less severe postoperatively and the patient is neurologaically normal.

False aneurysm complicating carotid endarterectomy.

We present two cases of false aneurysm after carotid endarterectomy with primary arteriotomy closure. In both cases, infection appeared to be the precipitating cause. Both lesions were repaired with a saphenous vein patch graft, but infection in one patient persisted, and recurrence of a false aneurysm required ligation of the common carotid artery. There were no neurological sequelae in either patient. A review of the English language literature, our experience, and personal communications yielded 57 cases of false aneurysm. The overall incidence of false aneurysm after carotid endarterectomy was 0.30%. There was no significant difference in the incidence after endarterectomy alone and that after endarterectomy and patch grafting. A significant increase in neurological deficit occurred only when carotid ligation was used, with a morbidity/mortality of 50% in eight reported cases. Infection was the major cause of false aneurysm after endarterectomy; it occurred in 50% of cases closed primarily without patch grafting. Repair with a saphenous vein patch graft and monofilament synthetic suture, plus liberal use of antibiotics, should be considered in the treatment of this condition.

Intervertebral disc space infection in a child presenting as a psoas abscess: case report.

Intervertebral disc space infection in children is usually a benign, self-limiting process. We report on what is, to our knowledge, the first case of discitis in a child that developed into an anterior paraspinous abscess. This 13-year-old girl had a 3-month history of low back and leg pain and low grade fever. Roentgenograms of the spine showed collapse of the L-5, S-1 interspace with destruction of the L-5 vertebral body and, on the lateral lumbar view, an anterior soft tissue mass. Computed tomography showed a paraspinous mass to the right of the L-4 and L-5 vertebral bodies. Access to a right psoas abscess was gained through a retroperitoneal abdominal approach; draining of the abscess revealed necrotic disc material extruding from the L-5, S-1 interspace. Her recovery was uneventful. The causative organism proved to be Staphylococcus aureus.

Familial brain tumors: studies of two families and review of recent literature.

We studied two families in each of which three or more individuals were affected by brain tumors. In the first family, which had no evidence of neurofibromatosis or tuberous sclerosis, a man, his sister, and her son developed histologically proven gliomas; the man's great uncle was historically reported to have died from a brain tumor, but the exact nature of the tumor was not known. In this family two of the tumors were low grade astrocytomas of the cerebrum, whereas the third was a mixed glioma of the cerebellum. Karyotypic analysis of this tumor showed no marker chromosomes. A second family had a history of an unusual concentration of brain tumors. In one patient the tumor was a histologically verified glioma. Four other patients had historically reported brain tumors, the descriptions of which suggested gliomas. Both families showed involvement of individuals in adjacent generations, although in both instances there were skipped generations. Twins, siblings, or parents and children are the kindred groups affected in most other reported families with multiple brain tumors. The mode of inheritance of brain tumors in these two families and recent literature on the conditions associated with familial brain tumors are discussed.

Carotid plaque as a source of emboli in humans: a scanning electron microscopic study.

Ten fresh carotid plaques obtained from patients undergoing carotid endarterectomy were fixed, and their luminal surfaces were examined with a scanning electron microscope. Luminal surface defects, characterized in scanning electron microscopy as endothelial discontinuities having diameters of 50 to 1500 microns, were a frequent finding, but their presence did not correlate well with the location of ulcers seen on angiography. Potential sources of emboli found were peels of subendothelial matrix, fibrin-platelet aggregates, fibrin-red blood cell clusters, and, possibly, damaged endothelial cells. Areas of endothelial cell injury consisting of small denuded patches, sheets of endothelial cytoplasm, and distorted endothelial cell profiles were observed. These areas resembled the type of damage seen in experimental ischemic vessel lesions and were believed to be the result of carotid cross clamping. Their presence suggests that a similar mechanism may result in loss of endothelial cells and exposure of the "raw" plaque surface in vivo.

Fixation of fractures of the lower cervical spine using methylmethacrylate and wire: technique and results in 99 patients.

Surgical stabilization of traumatic fracture-dislocations of the lower cervical spine with wire and methylmethacrylate remains a controversial procedure. Yet, the resultant immediate fixation with minimal patient morbidity seems to indicate that this method provides an ideal stabilization construct. We describe and report the outcome of a technique of posterior cervical fixation with methylmethacrylate and wire for stabilization of traumatic fractures of the lower cervical spine. Over a 12-year period, 124 fracture-dislocations of the lower cervical spine in 99 patients (mean age, 32 years; range, 15-76 years) were treated at this institution using a posterior methylmethacrylate and wire technique. Eighty-two patients had a posterior element fracture; 28 had a vertebral compression with posterior ligamentous injury; and 14 had a ligamentous injury alone. Thirty-six patients were neurologically intact upon admission, while the rest had radiculopathy or partial or complete myelopathy. Ninety-one patients were available for follow-up [mean, 18.6 months; range, 1-100 months (8.33 years)]. Eighty-eight patients (97%) had a stable fixation and 77 (85%) had resumed preoperative activity or were working but with a residual deficit. Complications included fixation failure requiring a second operation in 3 patients, nonlethal pulmonary embolism in 2 patients, lethal pulmonary embolism in 1 patient, and a superficial wound infection in 3 patients (none affected the underlying fixation construct). These results indicate that this technique is a safe, simple, and effective method for stabilizing the lower cervical spine that allows rapid patient mobility with minimal morbidity.

Low morbidity and mortality of carotid endarterectomy performed with regional anesthesia.

Various anesthetic and surgical techniques have been recommended with or without cerebral function monitoring in attempts to reduce the risk of carotid endarterectomy, but there is no consensus as to the ideal method for performing this procedure. General anesthesia is now the most common anesthetic technique used, but of 337 carotid endarterectomies performed by the author's service from 1981 through 1985, 305 (91%) were conducted with regional anesthesia. This paper presents the morbidity and mortality rates for those patients. There were two perioperative transient ischemic attacks (0.66%), two perioperative strokes (0.66%), and two perioperative deaths (0.66%). No patient in the series suffered a myocardial infarction within 30 days after endarterectomy. This series demonstrates that carotid endarterectomy can be performed with good results using regional anesthesia, which facilitates intraoperative cerebral function monitoring. Regional anesthesia is associated with a very low incidence of postoperative hypertension and perioperative myocardial infarction.

Posterior cervical fusion in chidren.

Six cases of posterior cervical fusion with rib grafts in children are reported. Four of the children had sustained cervical spine injuries in accidents, and two had congenital absence of the odontoid. Three-level fusions (C1-3) were done in four children, and four-level fusions (C1-4) in two. One child died of unrelated causes 3 months after the operation. The other five children have been followed for 5 to 13 years. All are doing well and each has a remarkably supple, stable neck and no neurological deficit.

Symptomatic subependymoma of the cervical spinal cord. Report of two cases.

Subependymomas are relatively unusual tumors with a distinctive histological appearance. They are generally considered to be benign, and they are often found incidentally at autopsy. Most are located intracranially, and the most common site of origin is the fourth ventricle. Only two cases of subependymoma of the spinal cord have been reported previously. The authors present two additional cases of subependymoma of the cervical cord; both were symptomatic, and both were treated by microsurgical removal.

Intact arch spondylolisthesis. A review of 50 cases and description of surgical treatment.

Over the past 11 years, the authors have treated 50 cases of intact arch spondylolisthesis. There were 38 female and 12 male patients, and all but 11 were older than 60 years of age. Almost all had severe low-back pain made worse by standing or walking. Other common manifestations were unilateral leg pain, numbness or weakness of the leg, and evidence of mild cauda equina compression. Severe cauda equina compression was rare. Myelography invariably showed an extradural dorsal compression. A waist deformity was characteristic in many patients, but 12 had a complete block. In 15 patients (30%) the myelographic impression was that of a herniated intervertebral disc. Most subluxations were of L-4 on L-5. At operation, the facets were found to be thickened, distorted, and irregular. All patients were treated with a wide decompression and laminectomy, which included a medial facetectomy of the inferior and superior facets. An intervertebral disc was removed in 10 patients. Follow-up monitoring of 41 patients (for an average period of 36 months) showed that 26 (63%) were pain-free, 11 had less pain, and four were unimproved. Five other patients with short follow-up periods (average 5 months) were all improved.

Hemodynamic status following regional and general anesthesia for carotid endarterectomy.

We prospectively studied 23 patients undergoing carotid endarterectomy under regional (n = 13) or general (n = 10) anesthesia to determine the hemodynamic basis of increased frequency in the need for postoperative vasopressor support when regional anesthesia was used. Anesthesia and postoperative care were conducted without reference to hemodynamic data from pulmonary artery catheterization. Although mean arterial pressure was similar in the two groups postoperatively, 11 of the 13 patients undergoing regional anesthesia and 3 of the 10 patients undergoing general anesthesia required phenylephrine postoperatively. No patient required therapy postoperatively to reduce a systolic pressure exceeding 160 mm Hg. Mean arterial pressure remained below the preoperative baseline value in both groups (p < 0.05 with general anesthesia; p = 0.06 with regional anesthesia) during follow-up. In the general anesthesia group, systemic vascular resistance declined significantly below baseline (p < 0.05) following the operation, accompanied by a decline in mean arterial pressure (p < 0.05) and a higher cardiac output. Intraoperative fluid requirements were greater during general anesthesia than during regional anesthesia (p < 0.01). Pulmonary artery occlusion pressure was lower postoperatively than at baseline in both groups (p < 0.05). Pulmonary artery occlusion pressure was higher in the general anesthesia group despite the greater use of phenylephrine in the regional anesthesia group.

The effects of regional and general anesthesia on blood pressure control after carotid endarterectomy.

We retrospectively reviewed the influence of preoperative blood pressure control and regional vs. general anesthetic techniques on the incidence of intraoperative and postoperative (recovery room and intensive care unit) hypotension and hypertension in 249 carotid endarterectomy patients. Preoperative blood pressure was classified as uncontrolled hypertension (systolic blood pressure >/= 170 mm Hg and/or diastolic blood pressure >/= 95 mm Hg), controlled hypertension (blood pressure <170/95 mm Hg on chronic antihypertensive therapy), or normotension (blood pressure <170/95 mm Hg without antihypertensive therapy). Hypotension, as defined by the requirement for vasopressor administration to maintain a systolic blood pressure of at least 120 mm Hg, occurred more frequently after regional than after general anesthesia (p < 0.05). Postoperative hypertension was defined as a systolic blood pressure >/= 200 mm Hg and/or a diastolic blood pressure >/= 110 mm Hg in the recovery room or in the Intensive Care Unit. Preoperative hypertension was not associated with acute postoperative hypertension in the intensive care unit in either the regional anesthesia (n = 190) or the general anesthesia (n = 59) groups, although with either type of anesthesia, preoperative hypertension was associated with an increased incidence of hypertension in the recovery room (p < 0.01 regional; p < 0.005 general).

The report to Congress on the appropriate federal role in assuring access by medical students, residents, and practicing physicians to adequate training in nutrition.

The Congress has had a long-time concern about the adequacy of nutrition education provided medical students and physicians during their training. Attempts over three decades to address this deficiency have been largely ineffective. Yet, recent changes in the delivery of health care from inpatient to outpatient services require physicians be competent in both applied nutrition and patient counseling. The importance of patient counseling is underscored by the surveys of the National Center for Health Statistics which reveal that overweight for the U.S. population has increased between the early 60s and the late 80s. These findings suggest that the Healthy People 2000 objective of reducing the prevalence of overweight may not be met. Congress evidenced its concern about the nutrition education in the medical curriculum in Section 302 of the National Nutrition Monitoring and Related Research Act of 1990 that required a report on the subject from the Secretary of Health and Human Services. The Division of Medicine in the Health Resources and Services Administration, an agency of the Public Health Service, responded by compiling the report. The report to Congress focuses on two issues--why it has been so difficult to increase the nutrition content of medical school curriculums and, if the Federal Government intervenes, what strategies might be effective.

Stroke, myocardial infarction, and survival during long-term follow-up after carotid endarterectomy.

Epidemiological data on 211 patients undergoing 256 carotid endarterectomies were reviewed, and current data for the 205 perioperative survivors were analyzed by the actuarial method. The median follow-up period was 7.0 years (range: 1 month to 23.2 years). Seven percent of patients were lost to follow-up. Actuarial survival was 77% (5 years) and 49% (10 years), but lower than for the general population. Late stroke occurred in 27 patients (13%) (fatal in 9), being ipsilateral to an endarterectomy in only 10 (4.9%). The annual ipsilateral stroke rate (0.41%), comparable to that of the general population, suggests protection from subsequent stroke. Myocardial infarction occurred in 69 patients (34%), and accounted for 49% of late deaths.

Intraventricular hemorrhage from pituitary apoplexy.

The case of a patient with a massive intraventricular hemorrhage arising from a pituitary chromophobe adenoma is described. This rare and disastrous complication was ascribed to the large suprasellar extension of the tumor and its close proximity to the floor of the third ventricle. Hemorrhage in the tumor extended along the path of least resistance and ruptured into the third ventricle. A partially treated hyperviscosity syndrome and chemotherapy for an unrelated malignancy (multiple myeloma) may have predisposed the patient to the necrosis and hemorrhage in the pituitary tumor.

Oculomotor palsy with pupillary sparing in a patient with chronic subdural hematoma.

A patient with adult-onset diabetes mellitus developed an oculomotor palsy with pupillary sparing. Five days after her initial evaluation, she presented in a confused state with a complete oculomotor palsy. Computed cranial tomography revealed a chronic subdural hematoma. We recommend that noninvasive radiographic intracranial investigation be considered in elderly patients with adult-onset diabetes mellitus who present with headache and pupil-sparing oculomotor palsy.