Whistling Scrotum: An Unusual Presentation of Pneumomediastinum in the Setting of an Open Scrotal Wound.

BACKGROUND Pneumoscrotum is a rare clinical occurrence in which air accumulates in the scrotum. The origin of air is primarily from trauma, but spontaneous pneumoscrotum can develop from gastrointestinal or pulmonary sources. Physical examination of pneumoscrotum typically includes crepitus of the perineal region and scrotal swelling and associated findings depending on the origin of the free air. However, pneumoscrotum in the setting of a scrotal wound, which allows air to pass freely outside the body, has not been previously documented in the literature. CASE REPORT A 72-year-old man who recently underwent a scrotal incision and drainage for recurrent epididymitis presented to a local emergency room with chief concerns of "whistling scrotum" and dyspnea. The chest CT revealed bilateral pneumothoraces, pneumomediastinum, and excessive subcutaneous emphysema throughout his abdomen, perineum, and scrotum. His scrotum had a dehiscent wound without any gross edema or air trapping contained within the scrotum. He received bilateral chest tubes and subcutaneous air drains with complete resolution of his pneumothoraces. The pneumoscrotum and associated subcutaneous emphysema of the perineum and thighs resolved after a prolonged period, and necessitated additional scrotal surgery. CONCLUSIONS Prompt evaluation for source control is necessary with pneumoscrotum, as the source likely requires immediate stabilization or surgical intervention. This case report describes a unique presentation of a common entity (pneumothorax) within pulmonology/critical care in a patient with an open scrotal wound from a recent scrotal procedure, which allowed the air to escape from his abdominal compartment, and resulted in his "scrotal whistling." It is unclear how the air passing through the scrotum affected the patient's presentation, such as allowing more air to build up in the subcutaneous tissues versus developing critical illness.

Upper Extremity Deep Venous Thrombosis Risk Factors, Associated Morbidity and Mortality in Trauma Patients.

BACKGROUND: The literature on upper extremity deep venous thrombosis (UEDVT) is not as abundant as that on lower extremities. This study aimed to identify the risk factors for UEDVT, associated mortality and morbidity in trauma patients and the impact of pharmacological prophylaxis therein. METHODS: A 3-year retrospective review of patients admitted to a Level 1 trauma center was conducted. Patients aged 18 years or older who had experienced a traumatic event and had undergone an upper extremity ultrasound (UEUS) were included in the study. Multiple logistic regression was used to identify independent risk factors that contributed to UEDVT. RESULTS: A total of 6,607 patients were admitted due to traumatic injuries during the study period, of whom 5.6% (373) had at least one UEUS during their hospitalization. Fifty-six (15%) were diagnosed with an UEDVT, as well as three non-fatal pulmonary emboli (PE) and four (7.1%) deaths, p = 0.03. Pharmacological prophylaxis with low-molecular-weight heparin (LMWH) or unfractionated heparin showed a protective effect against UEDVT; among the patients positive for UEDVT, 14 of 186 patients (7.5%) received LMWH, while 42 of 195 (21.5%) did not receive LMWH (p < 0.001). Multiple logistic regression revealed that the presence of upper extremity fractures, peripherally inserted central catheter (PICC) lines, and traumatic brain injury (TBI) were independent risk factors for UEDVT. CONCLUSIONS: UEDVT are associated with a higher mortality. The presence of upper extremity fractures, PICC lines, and TBI were independent risk factors for UEDVTs. Further, pharmacological prophylaxis reduces the risk of UEDVT.

Distress evaluation in a veteran affairs oncology clinic.

Distress in oncology patients (pts) has a negative impact on quality of life, survival, and healthcare satisfaction. Higher distress leads to lower compliance with treatment and follow-up [1-8]. The 2012 American College of Surgeons Commission on Cancer (CoC) standard of care for oncology pts included an assessment for distress [1]. A screening process for distress allows the healthcare team to address these issues early and refer to appropriate resources [2-9]. This project was initiated to meet National Comprehensive Cancer Network (NCCN) and CoC standard of care, identify distress in veterans with cancer, and address these concerns. Patients who attended the Tuesday oncology clinic at the Dayton VAMC were given the NCCN Distress Thermometer (DT) during triage. The treating physician addressed problems identified. The Wilcoxon signed rank test and the Friedman test were used. DTs were completed by 296 pts from March to December 2016. Mean age was 68, 93% male, 83% white, 55% married, and 93% without PTSD. The distress level was not different from T1 through T3. Number of problems decreased over three time periods. Referrals to nutrition, mental health, and social work services increased over time. Although over time periods we found no decrease in distress scores, there was a decline in number of problems. The mean distress score at all but time 4 was < 4, which is considered mild distress. The mean distress score at T4 was 4.36 (n = 14), suggesting that the few pts who return to clinic more than three times may be experiencing more difficult personal and environmental circumstances. Patient sample ranged from those undergoing intensive cancer treatment (e.g., chemotherapy) to less intensive treatment (e.g., hormone injections) to those who completed treatment.

Right Heart Function in Critically Ill Patients at Risk for Acute Right Heart Failure: A Description of Right Ventricular-Pulmonary Arterial Coupling, Ejection Fraction and Pulmonary Artery Pulsatility Index.

BACKGROUND: The gold standard for right heart function is the assessment of right ventricular-pulmonary arterial coupling defined as the ratio of arterial to end-systolic elastance (Ea/Emax). This study demonstrates the use of the volumetric pulmonary artery (PA) catheter for estimation of Ea/Emax and describes trends of Ea/Emax, right ventricular ejection fraction (RVEF), and pulmonary artery pulsatility index (PAPi) during initial 48hours of resuscitation in the trauma surgical intensive care unit (ICU). METHODS: Review of prospectively collected data for 32 mechanically ventilated adult trauma and emergency general surgery patients enrolled within 6hours of admission to the ICU. Haemodynamics, recorded every 12hours for 48hours, were compared among survivors and non-survivors to hospital discharge. RESULTS: Mean age was 49±20 years, 69% were male, and 84% were trauma patients. Estimated Ea/Emax was associated with pulmonary vascular resistance and inversely related to pulmonary arterial capacitance and PA catheter derived RVEF. Seven (7) trauma patients did not survive to hospital discharge. Non-survivors had higher estimated Ea/Emax, suggesting right ventricular-pulmonary arterial uncoupling, with a statistically significant difference at 48hours (2.3±1.7 vs 1.0±0.58, p=0.018). RVEF was significantly lower in non-survivors at study initiation and at 48hours. PAPi did not show a consistent trend. CONCLUSIONS: Estimation of Ea/Emax using volumetric PA catheter is feasible. Serial assessment of RVEF and Ea/Emax may help in early identification of right heart dysfunction in critically ill mechanically ventilated patients at risk for acute right heart failure.

Team-Based Learning in the Surgery Clerkship: Impact on Student Examination Scores, Evaluations, and Perceptions.

OBJECTIVE: There is little evidence for effectiveness of team-based learning (TBL) in specialties such as Surgery. We developed and instituted TBLs in surgery clerkship and compared National Board of Medical Examiners (NBME) Surgery Subject Exam scores before and after implementation. We also analyzed students' feedback for their perception of TBLs. DESIGN, SETTING, AND PARTICIPATNTS: The TBLs were transitioned into the curriculum during the 2013-2014 academic year. The "before" and "after" implementation periods were 2011-2013 and 2014-2016, respectively. NBME Surgery Subject Examination scores at our institution and nationally were compared using the independent samples t test. Satisfaction with the clerkship was assessed with Association of American Medical Colleges Graduate Questionnaire data. Student feedback regarding TBL was gathered at the end of each surgery rotation and were analyzed for themes, both positive and negative. RESULTS: Mean NBME score was higher at our institution than nationally, both before (77.10 ± 8.75 vs. 75.20 ± 8.95, p = 0.032) and after (74.65 ± 8.0 vs. 73.10 ± 8.55, p = 0.071) TBL implementation. The mean score decreased following TBL implementation at our medical school (77.10 ± 8.75 vs. 74.65 ± 8.00, p = 0.039), but it was also lower nationally (75.20 ± 8.95 vs. 73.10 ± 8.55, p < 0.001). Further, students were more likely to rate the surgery clerkship as "good and/or excellent" on the Association of American Medical Colleges Graduate Questionnaire after TBL implementation (84.6% vs. 73.7%). In qualitative assessment, learners stated that TBLs were informative, helpful in studying for the shelf exam, and viewed them as an opportunity for interactive learning, and thus requested more TBLs. Areas for improvement included reading materials, directions, and organization of sessions. CONCLUSIONS: Student perception of TBL into our surgery clerkship has been both positive and provided feedback for improvement. In addition, our medical school graduates have continued to assess their surgery experience as "good" or "excellent" by a large majority. Concurrently, our NBME scores remain above the national mean. We believe our medical students benefit from a well-organized TBL and its active approach to learning during the surgery clerkship with no loss of fundamental surgery knowledge.

Prevalence of Cancer in Thyroid Nodules In the Veteran Population.

A 16-year retrospective chart review found no relationship between nodule size and malignancy, emphasizing the need for individualized care.

Is nasotracheal intubation safe in facial trauma patients?

BACKGROUND: In the prehospital setting, oral intubation is preferred in facial trauma patients due to the potential for further injury during nasotracheal intubation. This study compared the complications of nasal vs. oral vs. nasal + oral intubations performed by first responder crews in facial trauma patients. Our objective was to assess patient outcomes and complications to determine the risk of nasal intubation in facial trauma patients in the prehospital setting. METHODS: Patients with facial trauma between 2008 and 13 were abstracted from the Miami Valley Hospital trauma registry: 50 were nasal only (n), 27 nasal + oral (no), and 135 oral only (o) intubation. Analysis of variance with the post-hoc Least Significance Difference Test and the chi square test were used in the analysis. RESULTS: The oral group was older [41.1 ± 17.6 (o) vs. 36.2 ± 14.1 (n) vs. 33.0 ± 15.7 (no), p = 0.032] and had a higher facial abbreviated injury severity (AIS) mean score (1.8 ± 0.6 vs. 1.3 ± 0.5 vs. 1.5 ± 0.5, p < 0.001). The three groups did not differ in mortality (n = 20% vs. o = 18% vs. no = 30%, p = 0.37). The n + o group was intubated longer (p < 0.001) and had longer ICU and hospital lengths of stay (p = 0.015 and p = 0.023). The three groups did not differ on the composite of any pulmonary complication - i.e., any one of sinusitis, pneumonia, atelectasis, and respiratory failure - 44% (no) vs. 24% (o) vs. 30% (n), p = 0.10). However, nasal + oral patients were more likely to have one or more of the eight complication studied [63% (no) vs. 28% (o) vs. 34% (n), p = 0.002], and have a longer ICU and HLOS. CONCLUSIONS: Prehospital nasal intubation is a viable short-term alternative to oral intubation in patients with facial trauma and warrants further research.

Initial impact of the Affordable Care Act on an Ohio Level I trauma center.

BACKGROUND: Hospital financial pressures and inadequate reimbursement contribute to the closure of trauma centers. Uninsured patients contribute significantly to the burden of trauma center costs. The Affordable Care Act implemented changes in 2014 to provide health care coverage for all Americans. This study analyzes the impact of the recent health care changes on an Ohio Level I trauma center financials. METHODS: We conducted an analysis of trauma charges, reimbursement, and supplemental payments at an Ohio Level I trauma center. A 3-year trauma patient cohort (2012-2014) was selected and grouped by reimbursement source (Medicare, Medicaid, other government, commercial, and self-pay/charity). A total of 9,655 patients were reviewed. Data were collected with the Transition Systems Inc. accounting system and analyzed with IBM SPSS Statistics 22.0. RESULTS: For trauma cases, the percentage of self-pay/charity patients decreased during the 2012 to 2014 period (15.1%, 15%, to 6.4%, respectively), while the percentage of Medicaid decreased from 2012 to 2013 followed by a large increase in 2014 (15.4%, 13.9%, to 24.3%, respectively). The percentage of commercially insured patients decreased slightly from 2012 to 2014 (34.2%, 32.3%, to 30.7%, respectively). Uninsured charges decreased notably (approximately $22.5 million and $21 million for 2012-2013 to approximately $8.6 million in 2014). Medicaid charges decreased from 2012 to 2013, followed by a rebound in 2014 ($50.7 million in 2012 to $37.3 million in 2013 to $54.3 million in 2014). The percentage of total charges for self-pay/charity decreased (9.5%, 10.1%, to 4.1%). The percentage of total charges for Medicaid increased (21.4%, 18.0%, to 25.9%). Mean Medicaid reimbursement per patient decreased ($19,000, $14,000, to $13,000). Mean reimbursement per uninsured patient did not vary significantly among years. Total hospital supplemental payments (trauma and nontrauma combined) decreased ($47.6 million, $49 million, to $39.2 million). CONCLUSION: In the first year following the changes implemented by the Affordable Care Act, our hospital saw self-pay/charity charges decrease, Medicaid charges increase, and total hospital supplemental payments decrease. In addition, there was a small, yet noteworthy, downward trend in the number of commercially insured patients. Although more data collection and analysis are needed, this initial financial evaluation of a Level I trauma center following the Affordable Care Act provides insight into insurance trends.

Simulation-based end-of-life care training during surgical clerkship: assessment of skills and perceptions.

BACKGROUND: Assessment of interpersonal and psychosocial competencies during end-of-life care training is essential. This study reports the relationship between simulation-based end-of-life care Objective Structured Clinical Examination ratings and communication skills, trust, and self-assessed empathy along with the perceptions of students regarding their training experiences. METHOD: Medical students underwent simulation-based end-of-life care OSCE training that involved standardized patients who evaluated students' communication skills and physician trust with the Kalamazoo Essential Elements Communication Checklist and the Wake Forest Physician Trust Scale. Students also completed the Jefferson Scale of Physician Empathy. Pearson correlation was used to examine the relationship between OSCE performance grades and communication, trust, and empathy scores. Student comments were analyzed using the constant comparative method of analysis to identify dominant themes. RESULTS: The 389 students (mean age 26.6 ± 2.8 y; 54.5% female) had OSCE grades that were positively correlated with physician trust scores (r = 0.325, P < 0.01) and communication skills (r = 0.383, P < 0.01). However, OSCE grades and self-reported empathy were not related (r = 0.021, P = 0.68). Time of clerkship differed for OSCE grade and physician trust scores; however, there was no trend identified. No differences were noted between the time of clerkship and communication skills or empathy. Overall, students perceived simulation-based end-of-life care training to be a valuable learning experience and appreciated its placement early in clinical training. CONCLUSIONS: We found that simulation-based OSCE training in palliative and end-of-life care can be effectively conducted during a surgery clerkship. Moreover, the standardized patient encounters combined with the formal assessment of communication skills, physician trust, and empathy provide feedback to students at an early phase of their professional life. The positive and appreciative comments of students regarding the opportunity to practice difficult patient conversations suggest that attention to these professional characteristics and skills is a valued element of clinical training and conceivably a step toward better patient outcomes and satisfaction.

Pulmonary nodule tracking using chest computed tomography in a histoplasmosis endemic area.

OBJECTIVE: In areas with endemic histoplasmosis, incidental pulmonary nodules are common. Rate of malignancy and applicability of current tracking guidelines in these regions remain unclear. METHODS: A total of 148 cases of incidental pulmonary nodules tracked with chest computed tomography were reviewed for radiologic characteristics, diagnosis, number, and size. RESULTS: Of the nodules, 87.8% were benign and 12.2% malignant; 30% of nodules >20mm were malignant. Number of nodules (P=.14) and granulomatous disease (P=.71) were not related to malignant diagnosis. CONCLUSION: Malignancy was lower than expected in nodules >20mm. Appropriate tracking guidelines for incidentally discovered nodules in histoplasmosis endemic regions must be determined.

Palliative and end-of-life care training during the surgical clerkship.

BACKGROUND: In 2000, the Liaison Committee on Medical Education required that all medical schools provide experiential training in end-of-life care. To adhere to this mandate and advance the professional development of medical students, experiential training in communication skills at the end-of-life was introduced into the third-year surgical clerkship curriculum at Wright State University Boonshoft School of Medicine. MATERIALS AND METHODS: In the 2007-08 academic year, 97 third-year medical students completed six standardized end-of-life care patient scenarios commonly encountered during the third-year surgical clerkship. Goals and objectives were outlined for each scenario, and attending surgeons graded student performances and provided formative feedback. RESULTS: All 97 students, 57.7% female and average age 25.6 ± 2.04 y, had passing scores on the scenarios: (1) Adult Hospice, (2) Pediatric Hospice, (3) Do Not Resuscitate, (4) Dyspnea Management/Informed Consent, (5) Treatment Goals and Prognosis, and (6) Family Conference. Scenario scores did not differ by gender or age, but students completing the clerkship in the first half of the year scored higher on total score for the six scenarios (92.8% ± 4.8% versus 90.5% ± 5.0%, P = 0.024). CONCLUSIONS: Early training in end-of-life communication is feasible during the surgical clerkship in the third-year of medical school. Of all the scenarios, "Conducting a Family Conference" proved to be the most challenging.

HIV screening of patients presenting for routine medical care in a primary care setting.

BACKGROUND: HIV screening is recommended for all patients between the ages of 13 and 64 years. OBJECTIVE: To increase the rate of HIV screening in a primary care setting by routinely offering HIV screening to all patients. METHODS: All patients seen over a 3-month period in the authors' clinic were offered HIV screening by a medical assistant. RESULTS: During the 3-month study period, 17% of patients offered HIV testing accepted screening, a large increase from the less than 1% rate of an earlier time period. CONCLUSION: HIV screening can be increased by routinely offering the test to all patients in the office. Use of trained health care professionals other than physicians may increase the number of patients screened.

Distal-third clavicle fracture fixation: a biomechanical evaluation of fixation.

BACKGROUND: Approximately 25% of distal clavicle fractures are unstable. Unstable patterns have longer times to union and higher nonunion rates. Stable restoration of the distal clavicle is important in decreasing the nonunion rate in distal clavicle fractures. The purpose of this study was to biomechanically compare operative constructs for the treatment of unstable, comminuted distal-third clavicle fractures in a cadaveric model using a locking plate and coracoclavicular reconstruction. We hypothesized that the combination of coracoclavicular reconstruction and a distal clavicle locking plate is biomechanically superior to either construct used individually. MATERIALS AND METHODS: An unstable distal clavicle fracture was created in 21 thawed fresh-frozen cadaveric specimens. The 21 specimens were divided into 3 treatment groups of 7: distal-third locking plate, acromioclavicular (AC) TightRope (Arthrex, Naples, FL, USA), and distal-third locking plate and AC TightRope together. After fixation, each specimen was cyclically tested with recording of displacement to determine the stiffness and stability of each construct, followed by load-to-failure testing in tension and compression to determine the maximum load. RESULTS: The combined construct of the locking distal clavicle plate and coracoclavicular reconstruction resulted in increased stiffness, maximum resistance to compression, and decreased displacement compared with either construct alone. CONCLUSION: Greater fracture stability was achieved with the combination of the AC TightRope and locking clavicle plate construct than with either alone, suggesting a possibility for increased fracture-healing rates.

Comparison of hemodynamic measurements from invasive and noninvasive monitoring during early resuscitation.

BACKGROUND: Measurements obtained from the insertion of a pulmonary artery catheter (PAC) in critically ill and/or injured patients have traditionally assisted with resuscitation efforts. However, with the recent utilization of ultrasound in the intensive care unit setting, transthoracic echocardiography (TTE) has gained popularity. The purpose of this study is to compare serial PAC and TTE measurements and document levels of serum biomarkers during resuscitation. METHODS: Over a 25-month period, critically ill and/or injured patients admitted to a Level I adult trauma center were enrolled in this 48-hour intensive care unit study. Serial PAC and TTE measurements were obtained every 12 hours (total = 5 points/patient). Serial levels of lactate, Δ base, troponin-1, and B-type natriuretic peptide were obtained. Pearson correlation coefficient and intraclass correlation (ICC) assessed relationship and agreement, respectively, between PAC and TTE measures of cardiac output (CO) and stroke volume (SV). Analysis of variance with post hoc pairwise determined differences over time. RESULTS: Of the 29 patients, 69% were male, with a mean age of 47.4 years ± 19.5 years and 79.3% survival. Of these, 25 of 29 were trauma with a mean Injury Severity Score of 23.5 ± 10.7. CO from PAC and TTE was significantly related (Pearson correlations, 0.57-0.64) and agreed with moderate strength (ICC, 0.66-0.70). SV from PAC and TTE was significantly related (Pearson correlations, 0.40-0.58) and agreed at a weaker level (ICC, 0.41-0.62). Tricuspid regurgitation was noted in 80% and mitral regurgitation in 50% to 60% of patients. CONCLUSION: Measurements of CO and SV were moderately strong in correlation and agreement which may suggest PAC measurements overestimate actual values. The significance of tricuspid regurgitation and mitral regurgitation during early resuscitation is unknown.

Timing of C-arm drape contamination.

BACKGROUND: Surgical site infection remains a concern in orthopedic surgery, and contamination of C-arm covers is a potentially modifiable risk factor. METHODS: A single-cohort study was conducted using 30 consecutive patients undergoing operative fracture fixation. Cultures were obtained from the C-arm cover after initial draping and every 20 min thereafter. The total number of persons in the operating room (person-hours/h of study time) and the number of door openings were recorded. The C-arm position changes and the time to contamination were monitored. RESULTS: The median time from the start of the operation to contamination was 20 min. There was a 17% contamination rate on initial draping, 50% at 20 min, 57% at 40 min, and 80% by 80 min. The C-arms in five cases were not contaminated during the surgery. Time to contamination correlated significantly with lateral position changes (correlation [r]=0.64; p=0.003) but was not related to C-arm position changes (r=0.22; p=0.34), number of door openings (r=0.20; p=0.39), or person-hours/h (r=0.04; p=0.85). CONCLUSIONS: Contamination of the C-arm drape occurs often and early during surgery for orthopedic fractures. We recommend minimal contact with the C-arm to avoid contamination of the surgical field.

Functional and radiographic long-term outcomes of hemiarthroplasty for proximal humeral fractures.

BACKGROUND: Hemiarthroplasty is the preferred surgical procedure for 3- and 4-part proximal humeral fractures. Our retrospective study examined functional and radiographic outcomes at 2- and 5-year follow-up in patients who received a hemiarthroplasty for 3- and 4-part proximal humeral fractures. MATERIALS AND METHODS: Forty-seven consecutive patients of a single surgeon treated with a cemented shoulder hemiarthroplasty between 2000 and 2006 were followed up. Standard surgical technique was used in all cases. Postoperative radiographs were compared with radiographs at 2 and 5 years along with active range of motion and functional outcomes scores. RESULTS: Twenty-five patients were examined at 2 years and twenty-two at 2 and 5 years. The mean age was 61 years. The mean acromiohumeral distance decreased from 10.3 mm postoperatively to 8.5 mm at 2 years and 6.7 mm at 5 years (P ≤ .001). More patients had stem osteolysis and tuberosity reabsorption at 2 and 5 years compared with postoperatively (P = .016 and P ≤ .001, respectively). The University of California, Los Angeles score decreased from 26.0 to 22.3 (P = .045); the Constant score decreased from 61.1 to 50.1 (P = .01); the Simple Shoulder Test 12 score decreased from 7.7 to 6.2 (P = .018); and the American Shoulder and Elbow Surgeons score decreased from 70.4 to 58.8 (P = .015). Pain scores increased from 2- to 5-year follow-up (P = .018). The range-of-motion measures changed little from the 2-to 5-year follow-up. CONCLUSIONS: Hemiarthroplasty has a high rate of long-term complications. Increases in acromiohumeral distance, stem osteolysis, and tuberosity reabsorption were observed between 2- and 5-year follow-up. Pain scores and functional outcomes worsened. No improvement in range of motion was observed.

Assuring the research competence of orthopedic graduates.

OBJECTIVES: To assure that orthopaedic residents have the knowledge needed to critically appraise the medical/surgical literature and the skills needed to design and conduct musculoskeletal and orthopaedic research. SETTING: Residency program of the Department of Orthopaedic Surgery, Sports Medicine and Rehabilitation at Wright State University Boonshoft School of Medicine, Dayton, Ohio. PARTICIPANTS: Established in 2005, members of the residency program's Research Team (RT) include orthopaedic faculty and residents, university faculty and graduate students, community scientists, and department staff. METHODS: The membership and responsibilities of the Research Team are described. The goals of the three-month research rotation during the second year of residency and the activities of the assigned resident are reported. The work of the two research residents during the second year of their six-year program is explained. Helpful educational resources are noted, the role of the faculty research mentor defined, funding sources listed, and the financial support for RT members and research staff presented. RESULTS: The scholarly activity of orthopaedic surgery residents increased substantially from the five-year period before the implementation of the Research Team (September 2000 through August 2005) to the four-year period after initiation of the RT (September 2005 through November 2009). For peer-reviewed scholarship activity, publications on which residents were authors increased from 1 to 10 per year, national presentations at professional meetings increased from 6 to 11 per year, and local and regional presentations increased from 2 to 4 per year. CONCLUSIONS: The Research Team is an effective strategy for assuring that orthopaedic residents have the knowledge and skills to evaluate clinical care evidence and to conduct musculoskeletal and orthopaedic research.