What trauma patients need: the European dilemma.

There is a need for implementation and maturation of an inclusive trauma system in every country in Europe, with patient centered care by dedicated surgeons. This process should be initiated by physicians and medical societies, based on the best available evidence, and supported and subsequently funded by the government and healthcare authorities. A systematic approach to organizing all aspects of trauma will result in health gain in terms of quality of care provided, higher survival rates, better functional outcomes and quality of life. In addition, it will provide reliable data for both research, quality improvement and prevention programs. Severely injured patients need surgeons with broad technical and non-technical competencies to provide holistic, inclusive and compassionate care. Here we describe the philosophy of the surgical approach and define the necessary skills for trauma, both surgical and other, to improve outcome of severely injured patients. As surgery is an essential part of trauma care, surgeons play an important role for the optimal treatment of trauma patients throughout and after their hospital stay, including the intensive care unit (ICU). However, in most European countries, it might not be obvious to either the general public, patients or even the physicians that the surgeon must assume this responsibility in the ICU to optimize outcomes. The aim of this paper is to define key elements in terms of trauma systems, trauma-specific surgical skills and active critical care involvement, to organize and optimize trauma care in Europe.

The role of splenic angioembolization as an adjunct to nonoperative management of blunt splenic injuries: A systematic review and meta-analysis.

BACKGROUND: Nonoperative management (NOM) of hemodynamically normal patients with blunt splenic injury (BSI) is the standard of care. Guidelines recommend additional splenic angioembolization (SAE) in patients with American Association for the Surgery of Trauma (AAST) Grade IV and Grade V BSI, but the role of SAE in Grade III injuries is unclear and controversial. The aim of this systematic review was to compare the safety and effectiveness of SAE as an adjunct to NOM versus NOM alone in adults with BSI. METHODS: A systematic literature search (Medline, Embase, and CINAHL) was performed to identify original studies that compared outcomes in adult BSI patients treated with SAE or NOM alone. Primary outcome was failure of NOM. Secondary outcomes included morbidity, mortality, hospital length of stay, and transfusion requirements. Bayesian meta-analyses were used to calculate an absolute (risk difference) and relative (risk ratio [RR]) measure of treatment effect for each outcome. RESULTS: Twenty-three studies (6,684 patients) were included. For Grades I to V combined, there was no difference in NOM failure rate (SAE, 8.6% vs NOM, 7.7%; RR, 1.09 [0.80-1.51]; p = 0.28), mortality (SAE, 4.8% vs NOM, 5.8%; RR, 0.82 [0.45-1.31]; p = 0.81), hospital length of stay (11.3 vs 9.5 days; p = 0.06), or blood transfusion requirements (1.8 vs 1.7 units; p = 0.47) between patients treated with SAE and those treated with NOM alone. However, morbidity was significantly higher in patients treated with SAE (SAE, 38.1% vs NOM, 18.6%; RR, 1.83 [1.20-2.66]; p < 0.01). When stratified by grade of splenic injury, SAE significantly reduced the failure rate of NOM in patients with Grade IV and Grade V splenic injuries but had minimal effect in those with Grade I to Grade III injuries. CONCLUSION: Splenic angioembolization should be strongly considered as an adjunct to NOM in patients with AAST Grade IV and Grade V BSI but should not be routinely recommended in patients with AAST Grade I to Grade III injuries. LEVEL OF EVIDENCE: Systematic review and meta-analysis, level III.

An Exploratory Analysis of the Geographical Distribution of Trauma Incidents in Shenzhen, China.

BACKGROUND: The city of Shenzhen, China, is planning to establish a trauma system. At present, there are few data on the geographical distribution of incidents, which is key to deciding on the location of trauma centres. The aim of this study was to perform a geographical analysis in order to inform the development of a trauma system in Shenzhen. METHODS: Retrospective analysis of trauma incidents attended by Shenzhen Emergency Medical Services (EMS) in 2014. Data were obtained from Shenzhen EMS. Incident distribution was explored using dot and kernel density estimate maps. Clustering was determined using the nearest neighbour index. The type of healthcare facilities which patients were taken to was compared against patients' needs, as assessed using the Field Triage Decision Scheme. RESULTS: There were 49,082 recorded incidents. A total of 3513 were classed as major trauma. Mapping demonstrates that incidents predominantly occurred in the western part of Shenzhen, with identifiable clusters. Nearest neighbour index was 0.048. Of patients deemed to have suffered major trauma, 8.5% were taken to a teaching hospital, 13.6% to a regional hospital, 42.6% to a community hospital, and 35.3% to a private hospital. The proportions of Step 1 or 2 negative patients were almost identical. CONCLUSION: The majority of trauma patients, including trauma patients who are at greater likelihood of severe injury, are taken to regional and community hospitals. There are areas with identifiable concentrations of volume, which should be considered for the siting of high-level trauma centres, although further modelling is required to make firm recommendations.

Assessing the efficacy of the fundamentals of research and career development course overseas.

BACKGROUND: As the Fundamentals of Research and Career Development Course (FRCDC) is conducted internationally, questions have arisen regarding the cultural appropriateness of the United States (US) course. We therefore assessed the US-based teaching methodology during the FRCDC in Abuja, Nigeria. We hypothesized that the US-based instructional methods would be effective. METHODS: Twenty questions were distributed to attendees of the FRCDC prior to commencement. The same 20 questions were administered at the conclusion of the course after random reordering. Differences between the pre- and post-test results were assessed for normalcy and compared using the paired t-test. RESULTS: There were 89 attendees, of whom 60 completed the pre-test and 77 completed the post-test. The pre-test group answered 12.3 ± 2.6 questions correctly, which improved to 15.0 ± 2.6 in the post-test group (P < 0.001). On the pre-test, the least common correct answers were for questions regarding type 1 and 2 error (16.7% correct), the definition of health services and outcomes research (26.7%), and how to best address missing data (26.7%). On the post-test, the questions with the least common correct answers were regarding the definition of health services and outcomes research (35%), and the components of an NIH grant (37.7%). CONCLUSIONS: Our results suggest that the FRCDC in Nigeria as given by US faculty has short-term efficacy. Attendees were able to improve their scores despite the cultural differences between them and the lecturers. Our next goal will be to demonstrate long-term efficacy at future courses in the region using similar questionnaire strategies.

Demographic and Financial Analysis of EMTALA Hand Patient Transfers.

In the United States, the Emergency Medical Treatment and Active Labor Act (EMTALA) effectively requires Level I trauma centers to accept hand trauma transfers for higher level of care if capacity exists. However, patient transfer for non-medical reasons, such as ability to pay, is still perceived as a common practice. We hypothesized that EMTALA would cause selective transfer of hand patients who were underinsured or uninsured, thus, effectively burdening a Level I trauma center. A dedicated transfer center documented the demographics and outcomes of all calls for hand trauma transfers from December 2003 to September 2005. This data registry was reviewed for age, gender, race, insurance status, and length of hospital stay. This data was compared with direct admissions to the emergency room for hand emergencies during that same time period. During the 2-year time period, a total of 151 calls for EMTALA transfer were received for hand emergencies. Our institution accepted 92 of these patients for transfer. Reasons for not accepting transfer included lack of bed availability and unavailability of the on-call surgeon due to other emergency operative cases. Compared with hand emergency patients brought directly to our emergency department during the same time period, transferred patients were younger and had a shorter length of stay. Interestingly, they were very similar in terms of sex, race, and insurance status. These data suggest that the primary motivations for EMTALA hand trauma transfers are truly complexity of patient care and specialist availability. Given the often urgent nature of hand trauma surgery and the limited resources available, expansion and development of hand and microsurgery regional centers will be vital to adequately meet demand without overburdening existing centers.

Commitment to COT verification improves patient outcomes and financial performance.

BACKGROUND: After an unsuccessful American College of Surgery Committee on Trauma visit, our level I trauma center initiated an improvement program that included (1) hiring new personnel (trauma director and surgeons, nurse coordinator, orthopedic trauma surgeon, and registry staff), (2) correcting deficiencies in trauma quality assurance and process improvement programs, and (3) development of an outreach program. Subsequently, our trauma center had two successful verifications. We examined the longitudinal effects of these efforts on volume, patient outcomes and finances. METHODS: The Trauma Registry was used to derive data for all trauma patients evaluated in the emergency department from 2001 to 2007. Clinical data analyzed included number of admissions, interfacility transfers, injury severity scores (ISS), length of stay, and mortality for 2001 to 2007. Financial performance was assessed for fiscal years 2001 to 2007. Data were divided into patients discharged from the emergency department and those admitted to the hospital. RESULTS: Admissions increased 30%, representing a 7.6% annual increase (p = 0.004), mostly due to a nearly fivefold increase in interfacility transfers. Severe trauma patients (ISS >24) increased 106% and mortality rate for ISS >24 decreased by 47% to almost half the average of the National Trauma Database. There was a 78% increase in revenue and a sustained increase in hospital profitability. CONCLUSION: A major hospital commitment to Committee on Trauma verification had several salient outcomes; increased admissions, interfacility transfers, and acuity. Despite more seriously injured patients, there has been a major, sustained reduction in mortality and a trend toward decreased intensive care unit length of stay. This resulted in a substantial increase in contribution to margin (CTM), net profit, and revenues. With a high level of commitment and favorable payer mix, trauma center verification improves outcomes for both patients and the hospital.

The challenge of eliminating cervical cancer in the United States: a story of politics, prudishness, and prevention.

Exciting strides in reducing the incidence of and mortality from cervical cancer have been made over the last century in the United States. The issues surrounding the implementation of the human papillomavirus vaccine are remarkably similar to the issues involved in the gradual adoption of the Pap test and initiation of cervical cancer screening beginning nearly a century ago. The following review of the reduction of cervical cancer morbidity and mortality demonstrates the importance of the interplay between basic science, clinical medicine, social mores, and public policy.

Insulin increases the release of proinflammatory mediators.

BACKGROUND: Strict glucose control with insulin is associated with decreased mortality in a mixed patient population in the intensive care unit. Controversy exists regarding the relative benefits of glucose control versus a direct advantageous effect of exogenous insulin. As a combined medical/surgical population differs significantly from the critically injured patient primed for secondary insult, our purpose was to determine the influence of insulin on activated macrophages. Our hypothesis was that insulin would directly abrogate the inflammatory cascade. METHODS: Differentiated human monocytic THP-1 cells were stimulated with endotoxin (lipopolysaccharide [LPS], 100 ng/mL) for 6 hours. Cells were treated +/-10(-7) M insulin for 1 hour and 24 hours. Total RNA was isolated and gene expression for TNF-alpha and IL-6 performed using Q-RT-PCR. Supernatants were assayed for TNF-alpha and IL-6 protein by ELISA. RESULTS: At 1 hour, compared with macrophages treated with LPS alone, macrophages treated with insulin produced significantly more TNF-alpha protein (11.4 +/- 5.9 pg/mL vs. 32.5 +/- 3.1 pg/mL; p < 0.03). At 24 hours compared with macrophages treated with LPS alone, macrophages treated with insulin produced significantly more TNF-alpha protein (83 +/- 2.02 pg/mL vs. 114 +/- 6.54 pg/mL; p < 0.01). However, gene expression of TNF-alpha and IL-6 was not different in LPS stimulated macrophages with and without insulin treatment at both 1 hour and 24 hours. CONCLUSION: Contrary to our hypothesis, insulin does not have direct anti-inflammatory properties in this experimental model. In fact, insulin increases proinflammatory cytokine protein levels from activated macrophages.

A county hospital surgical practice: a model for acute care surgery.

BACKGROUND: Trauma surgery has changed significantly over the past decade. Nonoperative evidence-based algorithms have become common and surgical trauma volume has become increasingly difficult to maintain. The acute care surgery (ACS) model, which integrates trauma, critical care, and emergency surgery, has been proposed as a future model of trauma practice. METHODS: Database information from an academic, county-based, trauma center was reviewed. A performance improvement surgical procedure database and level I trauma registry from 2005 were used to evaluate one center's ACS practice. RESULTS: There were 2,276 cases performed by 7 full-time and 5 part-time surgeons. Elective cases accounted for 64% (1,480) of caseload, emergency/urgent general surgery accounted for 32% (719) of cases, and emergency trauma surgeries accounted for 4% (96 procedures in 77 patients). In all, 23% were performed after hours. The ACS model supported controllable hours, adequate surgical volume, excellent patient care, and an appealing clinical practice. CONCLUSION: Surgical practice in a county-run trauma hospital can be similar to the ACS model, with positive results in terms of clinical volume and physician satisfaction. As clinical practices shift to the ACS model, there are lessons to be learned from currently existing, thriving, long-standing similar prototypes.

Requests for 692 transfers to an academic level I trauma center: implications of the emergency medical treatment and active labor act.

BACKGROUND: The Emergency Medical Treatment and Active Labor Act (EMTALA) effectively requires Level I trauma centers (TC) to accept all transfers for a higher level of care if capacity exists. We hypothesized that EMTALA would burden a Level I TC by a selective referral of a poor payer mix of primarily nonoperative patients. METHODS: All transfer calls (December 2003 and September 2005) to our Level I TC are handled by a dedicated transfer center. Calls were reviewed for age, surgical service requested, and outcome of request. The trauma registry was queried to compare Injury Severity Scale (ISS) score, hospital stay (LOS), operations, mortality, and payer status for transfer and primary catchment patients. RESULTS: In all, 821 calls were received; 77 calls were cancelled by the referring hospital and 52 were for consultation only. Of the 692 transfer requests, 534 (77%) were accepted, 134 (19%) were denied for no capacity, and only 24 (4%) were declined by TC as not clinically indicated. Transferred patients were younger (32.0 +/- 1.49 versus 38.9 +/- 0.51, p < 0.05), had similar ISS scores (13.6 +/- 0.62 versus 13.7 +/- 0.26) and LOS (7.0 +/- 0.70 versus 7.4 +/- 0.25), but were somewhat more likely to require an operation than direct admissions (58% versus 51%, p < 0.05). Although trauma (24%) and neurosurgery (24%) were the most commonly requested services, followed by orthopedics (20%), orthopedics accounted for 60% of operations on transferred patients compared with 10% to 13% for trauma and neurosurgery (mostly spine). There was no difference in the payer status of transfer and direct admit patients. CONCLUSIONS: Contrary to our assumptions, EMTALA patients had an identical payer mix and similar operative need compared with our primary catchment patients. They do represent a large additional patient load (20% of admissions) and differentially impact specialists, mostly operative for orthopedics and complex nonoperative care for trauma and neurosurgery. These data suggest that the primary motivations for transfer are specialist availability and complexity of care rather than financial concerns. As TCs provide backup specialty call coverage for a wide geographic area, this further supports the need for trauma systems development.

Risk factors for hepatic morbidity following nonoperative management: multicenter study.

HYPOTHESIS: Early risk factors for hepatic-related morbidity in patients undergoing initial nonoperative management of complex blunt hepatic injuries can be accurately identified. DESIGN: Multicenter historical cohort. SETTING: Seven urban level I trauma centers. PATIENTS: Patients from January 2000 through May 2003 with complex (grades 3-5) blunt hepatic injuries not requiring laparotomy in the first 24 hours. INTERVENTION: Nonoperative treatment of complex blunt hepatic injuries. MAIN OUTCOME MEASURES: Complications and treatment strategies. RESULTS: Of 699 patients with complex blunt hepatic injuries, 453 (65%) were treated nonoperatively. Overall, 61 patients (13%) developed 87 hepatic complications including bleeding (38), biliary (bile peritonitis, 7; bile leak, 9; biloma, 11; biliary-venous fistula, 1; and bile duct injury, 1), abdominal compartment syndrome (5), and infections (abscess, 7; necrosis, 2; and suspected abdominal sepsis, 6), which required 86 multimodality treatments (angioembolization, 32; endoscopic retrograde cholangiopancreatography and stenting, 9; interventional radiology drainage, 16; paracentesis, 1; laparotomy, 24; and laparoscopy, 4). Hepatic complications developed in 5% (13 of 264) of patients with grade 3 injuries, 22% (36 of 166) of patients with grade 4 injuries, and 52% (12 of 23) of patients with grade 5 injuries. Univariate analysis revealed 24-hour crystalloid, total and first 24-hour packed red blood cells, fresh frozen plasma, platelet, and cryoprecipitate requirements and liver injury grade to be significant but only liver injury grade (grade 4 odds ratio, 4.439; grade 5 odds ratio, 12.001) and 24-hour transfusion requirement (odds ratio, 6.446) predicted complications by multivariable analysis. CONCLUSIONS: Nonoperative management of high-grade liver injuries is associated with significant morbidity and correlates with grade of liver injury. Screening patients with transfusion requirements and high-grade injuries may result in earlier diagnosis and treatment of hepatic-related complications.

Dramatic shift in the primary management of traumatic thoracic aortic rupture.

HYPOTHESIS: Traumatic thoracic aortic injury (TAI) is traditionally treated with immediate surgery. Previously published studies have established the safety and efficacy of treating TAI with endovascular stents. Our hypothesis was that stents are supplanting operative repair as the primary therapy for TAI. DESIGN: Retrospective cohort. SETTING: University level I trauma center. PATIENTS AND METHODS: Blunt trauma patients admitted to a level I trauma center diagnosed with TAI between September 1997 and November 2003 were identified from an institutional trauma registry (N = 25). Data were abstracted from medical records and analyzed. Three groups were defined: surgical repair (cardiopulmonary bypass or clamp and sew) (n = 10); medical management (n = 8); and endovascular stent (n = 7). RESULTS: Prior to 2002, 9 (75%) of 12 patients were treated by surgical repair, 2 (17%) by medical management, and 1 (8%) by endovascular stent. Since 2002, 1 patient (8%) was treated by surgical repair, 6 (46%) by medical management, and 6 (46%) by endovascular stent. Injury Severity Scores were comparable between the surgical cohort (mean +/- SEM score, 34.9 +/- 3.4), stent placement (35.1 +/- 3.7), and medical management (29.9 +/- 2.8) (P = .48). Overall survival was 80% with no differences in morbidity or mortality. The stented group had shorter hospital lengths of stay compared with surgical management (28 vs 46 days) (P<.05). The 1 operative case since 2002 was a combined arch/innominate injury that anatomically precluded stent placement. CONCLUSION: Initial reports suggested thoracic aortic stents as an alternative for injured patients with prohibitive operative risks. Our data suggest stent placement is quickly evolving into the primary therapy for TAI across all Injury Severity Score profiles.

Potential targets to encourage a surgical career.

BACKGROUND: Our goal was to identify factors that can be targeted during medical education to encourage a career in surgery. STUDY DESIGN: We conducted a cross-sectional survey of first and fourth year classes in a Liaison Committee on Medical Education-accredited medical school. Students scored 19 items about perceptions of surgery using a Likert-type scale. Students also indicated their gender and ranked their top three career choices. RESULTS: There were 121 of 210 (58%) first year and 110 of 212 (52%) fourth year students who completed the survey. First year students expressed a positive correlation between surgery and career opportunities, intellectual challenge, performing technical procedures, and obtaining a residency position, although length of training, work hours, and lifestyle during and after training were negatively correlated with choosing surgery. Fourth year student responses correlated positively with career and academic opportunities, intellectual challenge, technical skills, role models, prestige, and financial rewards. Factors that correlated negatively were length of training, residency lifestyle, hours, call schedule, and female gender of the student respondent. Forty-four percent of first year male students expressed an interest in surgery versus 27% of fourth year male students (p < 0.04). Eighteen percent of first year female students expressed an interest in surgery versus 5% of fourth year female students (p < 0.006). CONCLUSIONS: Lifestyle issues remain at the forefront of student concerns. Intellectual challenge, career opportunities, and technical skills are consistently recognized as strengths of surgery. Additionally, fourth year students identify role models, prestige, and financial rewards as positive attributes. Emphasizing positive aspects may facilitate attracting quality students to future careers in surgery.

Predicting depression following mild traumatic brain injury.

CONTEXT: Minimizing negative consequences of major depression following traumatic brain injury is an important public health objective. Identifying high-risk patients and referring them for treatment could reduce morbidity and loss of productivity. OBJECTIVE: To develop a model for early screening of patients at risk for major depressive episode at 3 months after traumatic brain injury. DESIGN: Prediction model using receiver operating characteristic curve. SETTING: Level I trauma center in a major metropolitan area. PARTICIPANTS: Prospective cohort of 129 adults with mild traumatic brain injury. MAIN OUTCOME MEASURES: Center for Epidemiologic Studies Depression Scale score and current major depressive episode module of the Structured Clinical Interview for the DSM-IV. RESULTS: A prediction model including higher 1-week Center for Epidemiologic Studies Depression Scale score, older age, and computed tomographic scans of intracranial lesions yielded 93% sensitivity and 62% specificity. CONCLUSION: This study supports the feasibility of identifying patients with mild traumatic brain injury who are at high risk for developing major depressive episode by 3 months' postinjury, which could facilitate selective referral for potential treatment and reduction of negative outcomes.

Interleukin-6 infusion blunts proinflammatory cytokine production without causing systematic toxicity in a swine model of uncontrolled hemorrhagic shock.

BACKGROUND: Serum elevations of interleukin-6 (IL-6) correlate with multiple organ dysfunction syndrome and mortality in critically injured trauma patients. Data from rodent models of controlled hemorrhage suggest that recombinant IL-6 (rIL-6) infusion protects tissue at risk for ischemia-reperfusion injury. Exogenous rIL-6 administered during shock appears to abrogate inflammation, providing a protective rather than a deleterious influence. In an examination of this paradox, the current study aimed to determine whether rIL-6 decreases inflammation in a clinically relevant large animal model of uncontrolled hemorrhagic shock, (UHS), and to investigate the mechanism of protection. METHODS: Swine were randomized to four groups (8 animals in each): (1) sacrifice, (2) sham (splenectomy followed by hemodilution and cooling to 33 degrees C), (3) rIL-6 infusion (sham plus UHS using grade 5 liver injury with packing and resuscitation plus blinded infusion of rIL-6 [10 mcg/kg]), and (4) placebo (UHS plus blinded vehicle). After 4 hours, blood was sampled, estimated blood loss determined, animals sacrificed, and lung harvested for RNA isolation. Quantitative reverse transcriptase-polymerase chain reaction was used to assess granulocyte colony-stimulating factor (G-CSF), IL-6, and tumor necrosis factor-alpha (TNFalpha) messenger ribonucleic acid (mRNA) levels. Serum levels of IL-6 and TNFalpha were measured by enzyme-linked immunoassay (ELISA). RESULTS: As compared with placebo, IL-6 infusion in UHS did not increase estimated blood loss or white blood cell counts, nor decrease hematocrit or platelet levels. As compared with the sham condition, lung G-CSF mRNA production in UHS plus placebo increased eightfold (*p < 0.05). In contrast, rIL-6 infusion plus UHS blunted G-CSF mRNA levels, which were not significantly higher than sham levels (p = 0.1). Infusion of rIL-6 did not significantly affect endogenous production of either lung IL-6 or mRNA. As determined by ELISA, rIL-6 infusion did not increase final serum levels of IL-6 or TNFalpha over those of sham and placebo conditions. CONCLUSIONS: Exogenous rIL-6 blunts lung mRNA levels of the proinflammatory cytokine G-CSF. The administration of rIL-6 does not increase the local expression of IL-6 nor TNFalpha mRNA in the lung. Additionally, rIL-6 infusion does not appear to cause systemic toxicity.

Resuscitation with lactated ringer's does not increase inflammatory response in a Swine model of uncontrolled hemorrhagic shock.

Lactated Ringer's (LR) and normal saline (NS) are widely and interchangeably used for resuscitation of trauma victims. Studies show LR to be superior to NS in the physiologic response to resuscitation. Recent in vitro studies demonstrate equivalent effects of LR and NS on leukocytes. We aimed to determine whether LR resuscitation would produce an equivalent inflammatory response compared with normal saline (NS) resuscitation in a clinically relevant swine model of uncontrolled hemorrhagic shock. Thirty-two swine were randomized. Control animals (n = 6) were sacrificed following induction of anesthesia for baseline data. Sham animals (n = 6) underwent laparotomy and 2 h of anesthesia. Uncontrolled hemorrhagic shock animals (n = 10/group) underwent laparotomy, grade V liver injury, and blinded resuscitation with LR or NS to maintain baseline blood pressure for 1.5 h before sacrifice. Lung was harvested, and tissue mRNA levels of interleukin-6 (IL-6), granulocyte colony-stimulating factor (G-CSF), and tumor necrosis factor-alpha (TNF-alpha) were determined using quantitative reverse transcriptase polymerase chain reaction (Q-RT-PCR). Sections of lung were processed and examined for neutrophils sequestered within the alveolar walls. Cytokine analysis showed no difference in IL-6 gene transcription in any group (P = 0.99). Resuscitated swine had elevated G-CSF and TNF-alpha gene transcription, but LR and NS groups were not different from each other (P= 0.96 and 0.10, respectively). Both resuscitation groups had significantly more alveolar neutrophils present than controls (P < 0.01) and shams (P < 0.05) but were not different from one another (P= 0.83). LR and NS resuscitation have equivalent effects on indices of inflammation in the lungs in our model of uncontrolled hemorrhagic shock.

Preclinical students: who are surgeons?

BACKGROUND: The purpose of the present study was to determine how preclinical medical students formulate their career choice and to determine the origin of negative perceptions regarding surgery as a career. MATERIALS AND METHODS: A qualitative study was performed with second-year medical students voluntarily participating in focus group study. Students with and without an interest in surgery attended. Topics discussed included factors influencing career choice, priorities, perceptions, exposure, and interactions with surgeons. Three investigators conducted independent content analysis. RESULTS: Career choices for students interested in surgery originated primarily from premedical school experiences/interactions with surgeons. In contrast, students not interested in surgery made career choices during medical school and choices were shaped primarily by second-year preceptors. The main priority for students interested in surgery was personal happiness that was perceived as being significantly dependent upon career satisfaction. Students not interested in surgery tended to separate happiness derived from career versus family. Negative perceptions toward surgery were developed and reinforced by media, preceptors, and classmates. All students had minimal exposure to surgeons during preclinical years and generally agreed that increased involvement with surgeons would be beneficial, particularly through preclinical preceptorships. CONCLUSIONS: Career choices of preclinical students interested in surgery were made prior to entering medical school, suggesting that outreach programs to high schools and colleges may beneficial. Negative perceptions about surgery develop through a variety of sources, including fellow classmates, preceptors, and the media. Surgeons need to take responsibility for these perceptions.

Amplification of the proinflammatory transcription factor cascade increases with severity of uncontrolled hemorrhage in swine.

INTRODUCTION: Hypotension causes diffuse liver injury accompanied by increased local production of interleukin-6 (IL-6) in swine models of uncontrolled hemorrhagic shock (HS). IL-6 is transcriptionally up-regulated by nuclear factor (NF)-kappaB and results in activation of signal transducer and activator of transcription-3 (Stat3) in a murine model of controlled HS. Our objectives were: 1). to determine if increased IL-6 production and NF-kappaB and Stat3 activation occurs in a swine model of uncontrolled HS, and 2). to assess whether or not levels of IL-6 mRNA and activity of NF-kappaB and Stat3 correlate with shock severity. MATERIALS AND METHODS: Swine were assigned to four groups: 1). control animals (n = 6): no intervention, 2). sham operation (n = 6): celiotomy and splenectomy, 3). uncontrolled hemorrhagic shock (UHS) (n = 6): sham plus grade V vascular liver injury and resuscitation, 4). profound uncontrolled hemorrhagic shock (PUHS) (n = 8): UHS after dilutional hypothermia. Following euthanasia at 2 h, livers were harvested, total RNA isolated, and IL-6 mRNA levels quantified by Q-RT-PCR (ABI Prism 7700, Applied Biosystems International, Foster City, CA). Protein was extracted for measurement of NF-kappaB and Stat3 activity by electrophoretic mobility shift assay (EMSA). RESULTS: Compared to shams, IL-6 mRNA levels increased 4.5-fold in UHS and 90-fold in PUHS (P < 0.001). Compared with shams; NF-kappaB activity increased 2-fold in both UHS and PUHS (P < 0.05). Stat3 activity was equivalent (not significant) in UHS when compared with shams but increased 5.3-fold in PUHS. (P < 0.05). CONCLUSION: These findings suggest that regional proinflammatory cytokine production results from and perpetuates a proinflammatory transcription factor cascade in a swine model of uncontrolled hemorrhagic shock and indicate that this process is proportional to the severity of shock.

Brief intervention by surgeons can influence students toward a career in surgery.

BACKGROUND: General surgery training programs are experiencing an alarming decrease in applicants. The purpose of the current study was to determine whether exposing students to surgery through a brief intervention early in their medical education could influence perceptions toward surgery as a career choice. METHODS: First-year medical students were asked to rank 19 items coded on a Likert-type scale from 1 (not important) to 8 (very important) regarding their beliefs about surgery as a career both before and after a brief 1-h intervention with a panel of surgeons. Each panelist spoke about his or her professional and personal lives, followed by a question and answer period. Survey data were analyzed by Wilcoxon sign-rank and Spearman rank correlation. RESULTS: Of 210 first year students, 121 (58%) students voluntarily attended and completed the presurvey and 94 (45%) the post, of which 82 were matched responses. Preintervention responses revealed that career opportunities, intellectual challenge, and the ability to obtain a residency position were positively correlated with surgery (P < 0.007) whereas length of training, lifestyle during residency, lifestyle after training, and work hours during residency were negatively correlated (P < 0.01). The following factors were significantly influenced by the intervention: academic opportunities, patient relationships, prestige, and gender distribution became more important whereas concern about debt and length of training became less important. CONCLUSIONS: Positive encounters with surgeons can favorably influence the perceptions of first-year medical students toward a career in surgery. In addition to addressing lifestyle issues, surgeons can and must make a concerted effort to interact with medical students early in their education and foster their interest throughout their career.