Cancer Hazard Evaluations for Contemporary Needs: Highlights From New National Toxicology Program Evaluations and Methodological Advancements.

The National Toxicology Program strives to raise awareness of cancer hazards in our environment. Identifying cancer hazards is key to primary prevention, informing public health decision making, and decreasing the global cancer burden. In December 2021, the US congressionally mandated 15th Report on Carcinogens was released, adding 8 new substances to the cumulative report. Chronic infection with Helicobacter pylori is listed as "known to be a human carcinogen." Antimony trioxide and 6 haloacetic acids found as water disinfection by-products-dichloroacetic acid, dibromoacetic acid, bromochloroacetic acid, tribromoacetic acid, bromodichloroacetic acid, chlorodibromoacetic acid-are listed as "reasonably anticipated to be a human carcinogen." A new dashboard provides interactive visualization and interrogation of the 256 listed substances, their uses, and associated cancers. Also, the National Toxicology Program recently published a Cancer Hazard Assessment Report on exposure scenarios associated with circadian disruption, concluding that persistent night shift work can cause breast cancer and certain lighting conditions may cause cancer. As highlighted in these reports and evaluations, we are evolving our approaches to meet contemporary challenges. These approaches include focusing on real-world exposures and advancing our methods to address challenges in cancer hazard assessments (eg, developing more structured approaches to evaluate mechanistic data and incorporating read-across approaches to assess chemicals lacking adequate human or animal cancer data). To promote public health, we provide information on environmental health disparities and disease prevention. Building on these efforts, we aim to continue our contributions to the war on cancer, declared 50 years ago.

Addressing transportation barriers to health care during the COVID-19 pandemic: Perspectives of care coordinators.

Prior to the COVID-19 pandemic, transportation barriers prevented millions of Americans from accessing needed medical care. Then the pandemic disrupted medical and transportation systems across the globe. This research explored ways the COVID-19 pandemic changed how people experienced transportation barriers to accessing health care. We conducted in-depth interviews with social workers, nurses, and other care coordinators in North Carolina to identify barriers to traveling for medical care during the pandemic and explore innovative solutions employed to address these barriers. Analyzing these interviews using a flexible coding approach, we found that the pandemic exacerbated existing transportation barriers and created new barriers. Yet, simultaneously, temporary policy responses expanded the utilization of telehealth. The interviews identified specific advantages of expanded telehealth, including increasing access to mental health services in rural areas, reducing COVID-19 exposure for high-risk patients, and offering continuity of care for COVID-19 patients with other health conditions. While telehealth cannot address all medical needs, such as emergency or cancer care, it may be well-suited for preliminary screenings and follow-up visits. The findings provide insights on how post-pandemic telehealth policy changes can benefit individuals facing transportation barriers to accessing health care and support more accommodating and convenient health care for patients and their families.

Mortality in hypotensive trauma patients requiring laparotomy is related to degree of hypotension and provides evidence for focused interventions.

BACKGROUND: Mortality in hypotensive patients requiring laparotomy is reported to be 46% and essentially unchanged in 20 years. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been incorporated into resuscitation protocols in an attempt to decrease mortality, but REBOA can have significant complications and its use in this patient group has not been validated. This study sought to determine the mortality rate for hypotensive patients requiring laparotomy and to evaluate the mortality risk related to the degree of hypotension. Additionally, this study sought to determine if there was a presenting systolic blood pressure (SBP) that was associated with a sharp increase in mortality to target the appropriate patient group most likely to benefit from focused interventions such as REBOA. METHODS: The trauma registry at a level I trauma center was reviewed for patients undergoing emergent laparotomy from January 2007 to June 2020. Data included demographics, mechanism of injury, physiological data, Injury Severity Score, blood products transfused, and outcomes. Group comparisons were based on initial SBP (0 to 50 mm Hg, 60 to 69 mm Hg, 70 to 79 mm Hg, 80 to 89 mm Hg, and ≥90 mm Hg). RESULTS: During the study period, 52 016 trauma patients were treated and 1174 required laparotomy within 90 min of arrival; 424 had an initial SBP of <90 mm Hg. The overall mortality rate was 18%, but mortality increased as SBP decreased (≥90=9%, 80 to 89=20%, 70 to 79=21%, 60 to 69=48%, 0 to 59=66%). Mortality increased sharply with SBP of <70 mm Hg. DISCUSSION: Mortality rate increases with worsening hypotension and increases sharply with an SBP of <70 mm Hg. Further study on focused interventions such as REBOA should target this patient group. LEVEL OF EVIDENCE: Therapeutic/care management, level III.

Factors Associated With General Surgery Residents' Operative Experience During the COVID-19 Pandemic.

Importance: The suspension of elective operations in March 2020 to prepare for the COVID-19 surge posed significant challenges to resident education. To mitigate the potential negative effects of COVID-19 on surgical education, it is important to quantify how the pandemic influenced resident operative volume. Objective: To examine the association of the pandemic with general surgical residents' operative experience by postgraduate year (PGY) and case type and to evaluate if certain institutional characteristics were associated with a greater decline in surgical volume. Design, Setting, and Participants: This retrospective review included residents' operative logs from 3 consecutive academic years (2017-2018, 2018-2019, and 2019-2020) from 16 general surgery programs. Data collected included total major cases, case type, and PGY. Faculty completed a survey about program demographics and COVID-19 response. Data on race were not collected. Operative volumes from March to June 2020 were compared with the same period during 2018 and 2019. Data were analyzed using Kruskal-Wallis test adjusted for within-program correlations. Main Outcome and Measures: Total major cases performed by each resident during the first 4 months of the pandemic. Results: A total of 1368 case logs were analyzed. There was a 33.5% reduction in total major cases performed in March to June 2020 compared with 2018 and 2019 (45.0 [95% CI, 36.1-53.9] vs 67.7 [95% CI, 62.0-72.2]; P < .001), which significantly affected every PGY. All case types were significantly reduced in 2020 except liver, pancreas, small intestine, and trauma cases. There was a 10.2% reduction in operative volume during the 2019-2020 academic year compared with the 2 previous years (192.3 [95% CI, 178.5-206.1] vs 213.8 [95% CI, 203.6-223.9]; P < .001). Level 1 trauma centers (49.5 vs 68.5; 27.7%) had a significantly lower reduction in case volume than non-level 1 trauma centers (33.9 vs 63.0; 46%) (P = .03). Conclusions and Relevance: In this study of operative logs of general surgery residents in 16 US programs from 2017 to 2020, the first 4 months of the COVID-19 pandemic was associated with a significant reduction in operative experience, which affected every PGY and most case types. Level 1 trauma centers were less affected than non-level 1 centers. If this trend continues, the effect on surgical training may be even more detrimental.

Admission base deficit is superior to lactate in identifying shock and resuscitative needs in trauma patients.

BACKGROUND: Base Deficit (BD) and lactate have been used as indicators of shock and resuscitation. This study was done to evaluate the utility of BD and lactate in identifying shock and resuscitative needs in trauma patients. METHODS: A prospective observational study was performed from 3/2014-12/2018. Data included demographics, admission systolic BP, ISS, BD, lactate, blood transfusion, and outcomes. BD and lactate were modeled continuously and categorically and compared. RESULTS: 2271 patients were included. BD and lactate were moderately correlated (r2 = 0.63 p < 0.001). On univariate regression, BD and lactate were associated with transfusion requirement and mortality (p < 0.001), but on multivariate regression, only BD was associated with transfusion requirement and mortality (OR = 1.2, p < 0.001; OR = 1.1, p < 0.001, respectively). BD discriminated better than lactate for hypotension, higher ISS, increased transfusion requirements and mortality. CONCLUSIONS: Admission BD and lactate levels are correlated following injury, but BD is superior to lactate in identifying shock, resuscitative needs and mortality in severely injured trauma patients.

Prospective evaluation of admission cortisol in trauma.

BACKGROUND: A low cortisol level has been shown to occur soon after trauma, and is associated with increased mortality. The purpose of this study was to investigate the impact of low cortisol levels in acute critically ill trauma patients. We hypothesized that patients would require increase vasopressor use, have a greater blood product administration, and increased mortality rate. METHODS: A blinded, prospective observational study was performed at an American College of Surgeons verified Level I trauma center. Adult patients who met trauma activation criteria, received initial treatment at Community Regional Medical Center and were admitted to the intensive care unit were included. Total serum cortisol levels were measured from the initial blood draw in the emergency department. Patients were categorized according to cortisol ≤15 µg/dL (severe low cortisol, SLC), 15.01-25 µg/dL (relative low cortisol, RLC), or >25 µg/dL (normal cortisol, NC) and compared on demographics, injury severity score, initial vital signs, blood product usage, vasopressor requirements, and mortality. RESULTS: Cortisol levels were ordered for 280 patients; 91 were excluded and 189 were included. Penetrating trauma accounted for 19% of injuries and blunt trauma for 81%. 22 patients (12%) had SLC, 83 (44%) had RLC, and 84 (44%) had NC. This study found patients with admission SLC had higher rates of vasopressor requirements, required more units of blood, and had a higher mortality rate than both the RLC and NC groups. CONCLUSION: Low cortisol level can be identified acutely after severe trauma. Trauma patients with SLC had larger blood product requirements, vasopressor use, and increase mortality. Initial cortisol levels are useful in identifying these high-risk patients. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Changes in splenic capsule with aging; beliefs and reality.

BACKGROUND: Research describing the splenic capsule and its effect on non-operative management of splenic injuries is limited. The aim of this study is to identify the current beliefs about the splenic capsule thickness and investigate changes in the splenic capsule with age. METHODS: Trauma Medical Directors were surveyed on their beliefs regarding splenic capsule thickness changes with age. Thicknesses of cadaveric splenic capsule samples were measured. RESULTS: The majority of trauma medical directors (59%) believe the capsule thickness decreases with age. There were 94 splenic specimens obtained. The splenic capsules of infants were thin and had a uniform layer of elastin fibers. With aging, the capsule becomes thick and develops a collagen layer. CONCLUSION: Most trauma directors believe the splenic capsule thickness decreases with age. However, our results demonstrate that the splenic capsule thickness increases during childhood but remains constant in adulthood.

Methodological challenges in conducting instrumentation research in non-communicative palliative care patients.

Well-designed, rigorously implemented instrumentation studies are essential to develop valid, reliable pain assessment tools in non-communicative (non-self-reporting) palliative care patients. When conducting a pain instrumentation study, a research team identified methodologic challenges surrounding informed consent, eligibility criteria, acute pain operational definitions, patient recruitment, missing data, and study-related training during a run-in phase at the beginning of the project and during the conduct of the study. The team dealt with these challenges through identifying root causes, implementing remedial measures, and collecting data to demonstrate improvement or resolution. Effective strategies included obtaining Institutional Review Board (IRB) approval for a waiver of informed consent, modifying eligibility criteria, ensuring that operational definitions and study procedures were consistent with clinical practice, decreasing time from screening to data collection to improve recruitment, increasing study nurse staffing by re-budgeting grant funds, focusing time and resources on high accruing clinical units, revising processes to minimize missing data, and developing detailed training for users of the instrument. With these multi-pronged solutions, the team exceeded the patient accrual target by 25% within the funding period and reduced missing data. While pain instrumentation studies in non-communicative patients have similar challenges to other palliative care studies, some of the solutions may be unique and several are applicable to other palliative care studies, particularly instrumentation research. The team's experience may also be useful for funders and IRBs.

Influence of Student Loan Debt on General Surgery Resident Career and Lifestyle Decision-Making.

BACKGROUND: The average medical school debt in 2011 was $170,000, and by 2017 it increased to $190,000. High debt burden has been shown to affect career choices for residents in primary care specialties; however, it has not been well studied among surgical residents. The purpose of this multi-institutional study was to assess the amount of debt among general surgery residents and its effects on their career and lifestyle decisions. STUDY DESIGN: Surveys were distributed to 607 categorical general surgery residents at 19 different residency programs. Degree of debt was assessed and responses compared. RESULTS: Overall, 427 (70.3%) residents completed the survey, 317 (74.2%) of whom reported having student loan debt. Of those with debt, 262 (82.6%) believed that repaying debt was a significant financial burden in residency, 248 (78.3%) thought it would remain a burden after residency, 210 (66.2%) believed their debt would influence their future job choice, and 225 (71%) thought their debt would delay their ability to buy a home. Debt did not affect decisions to get married or have children. There were 109 (25.6%) residents with no debt, 131 (30.8%) with <$200,000, 103 (24.2%) with $200,000 to $300,000, and 83 (19.5%) with >$300,000. Residents with high debt were less likely to feel financially secure now (p < 0.0001) and when thinking about their future (p < 0.0001). They also had higher minimum starting salary goals (p = 0.002) and were less likely to have had assistance paying for their education (p = 0.0001). CONCLUSIONS: Surgical residents believe their debt is a significant financial burden. Furthermore, high debt significantly influences their financial security, practice location, and salary goals.

The impact of obesity on severity of solid organ injury in the adult population at a Level I trauma center.

BACKGROUND: The obese (body mass index, BMI > 30) have been identified as a subgroup of patients in regards to traumatic injuries. A recent study found that high-grade hepatic injuries were more common in obese than non-obese pediatric patients. This study seeks to evaluate whether similar differences exist in the adult population and examine differences in operative versus non-operative management between the obese and non-obese in blunt abdominal trauma. METHODS: Patient with trauma evaluated at an American College of Surgeons verified Level I trauma center from February 2013 to November 2016 were retrospectively reviewed. All patients aged >18 years with blunt mechanism of injury and a BMI listed in the trauma registry were included. Patients were excluded for incomplete data, including BMI or inability to grade hepatic or splenic injury. Data collected included age, gender, BMI, injury severity score, hospital length of stay, procedures on liver or spleen, and mortality. Organ injuries were scored using the American Association for the Surgery of Trauma grading scales, and were determined by either imaging or intraoperative findings. Obesity was classified as BMI > 30 compared with non-obese with BMI < 30. RESULTS: During the study period, 9481 patients were included. There were 322 spleen injuries and 237 liver injuries, with 64 patients sustaining both liver and splenic injuries. No differences existed in the percentage of high-grade hepatic or splenic injuries between the obese and non-obese. Obese patients with liver injuries were more likely to have procedural intervention than non-obese liver injuries and had higher rates of mortality. No differences were found in intervention for splenic injury between obese and non-obese. CONCLUSIONS: Contrary to prior studies on adult and pediatric patients with trauma, this study found no difference between obese and non-obese patients in severity of solid organ injury after blunt abdominal trauma in the adult population. However, there was an increased rate of procedural intervention and mortality for obese patients with liver injuries. LEVEL OF EVIDENCE: 3.

A predictive grading scale for acute cholecystitis.

BACKGROUND: Acute cholecystitis presents in a spectrum of severity, where acute disease may be complicated by severe inflammation, gangrene, and perforation. The goal of this study is to outline an evidence-based grading scale that predicts patient outcomes after laparoscopic cholecystectomy (LC). METHODS: A retrospective review of all patients with a preoperative diagnosis of acute cholecystitis who underwent LC from August 2011 until June 2015 at a tertiary-level hospital was performed. Patients who underwent elective cholecystectomy, incidental cholecystectomy, a planned open cholecystectomy, had gallstone pancreatitis or choledocholithiasis, and those admitted to a non-surgical service were excluded. Severity of disease was obtained from operative and pathology reports, and patients were classified according to the following grading scale:Grade I: symptomatic cholelithiasis.Grade II: acute/chronic cholecystitis.Grade III: gangrenous/necrotizing cholecystitis.Grade IV: gallbladder perforation or abscess.The groups were compared on age, gender, body mass index, severity of gallbladder disease, presence of preoperative systemic inflammatory response syndrome, hospital length of stay, length of operation, complications within 30 days, conversion to open rate, and cost of hospitalization. RESULTS: During the study period, 1252 patients who underwent laparoscopic cholecystectomy were analyzed; 677 met inclusion criteria. The most common grade was grade 2, which was present in 80% of patients, followed by grade 3, which was found in 16% of patients. Grade 4 cholecystitis occurred in 1.2% of patients and grade 1 occurred in 3.2% of patients. There were statistically significant increases in age, presence of preoperative systemic inflammatory response syndrome, hospital length of stay, conversion to open rate, cost of hospitalization, and length of operation with increased cholecystitis grade. CONCLUSIONS: The proposed grading scale is an accurate predictor of duration of operation, conversion to open rate, hospital length of stay, and cost of hospitalization. LEVEL OF EVIDENCE: III. STUDY TYPE: Prognostic.

Factors associated with general surgery residents' decisions regarding fellowship and subspecialty stratified by burnout and quality of life.

BACKGROUND: Although most surgery residents pursue fellowships, data regarding those decisions are limited. This study describes associations with interest in fellowship and specific subspecialties. METHODS: Anonymous surveys were distributed to 607 surgery residents at 19 US programs. Subspecialties were stratified by levels of burnout and quality of life using data from recent studies. RESULTS: 407 (67%) residents responded. 372 (91.4%) planned to pursue fellowship. Fellowship interest was lower among residents who attended independent or small programs, were married, or had children. Residents who received AOA honors or were married were less likely to choose high burnout subspecialties (trauma/vascular). Residents with children were less likely to choose low quality of life subspecialties (trauma/transplant/cardiothoracic). CONCLUSIONS: Surgery residents' interest in fellowship and specific subspecialties are associated with program type and size, AOA status, marital status, and having children. Variability in burnout and quality of life between subspecialties may affect residents' decisions.

Career Goals, Salary Expectations, and Salary Negotiation Among Male and Female General Surgery Residents.

Importance: In general surgery, women earn less money and hold fewer leadership positions compared with their male counterparts. Objective: To assess whether differences exist between the perspectives of male and female general surgery residents on future career goals, salary expectations, and salary negotiation that may contribute to disparity later in their careers. Design, Setting, and Participants: This study was based on an anonymous and voluntary survey sent to 19 US general surgery programs. A total of 606 categorical residents at general surgery programs across the United States received the survey. Data were collected from August through September 2017 and analyzed from September through December 2017. Main Outcomes and Measures: Comparison of responses between men and women to detect any differences in career goals, salary expectation, and perspectives toward salary negotiation at a resident level. Results: A total of 427 residents (70.3%) responded, and 407 responses (230 male [58.5%]; mean age, 30.0 years [95% CI, 29.8-30.4 years]) were complete. When asked about salary expectation, female residents had lower expectations compared with men in minimum starting salary ($249 502 [95% CI, $236 815-$262 190] vs $267 700 [95% CI, $258 964-$276 437]; P = .003) and in ideal starting salary ($334 709 [95% CI, $318 431-$350 987] vs $364 663 [95% CI, $351 612-$377 715]; P < .001). Women also had less favorable opinions about salary negotiation. They were less likely to believe they had the tools to negotiate (33 of 177 [18.6%] vs 73 of 230 [31.7%]; P = .03) and were less likely to pursue other job offers as an aid in negotiating a higher salary (124 of 177 [70.1%] vs 190 of 230 [82.6%]; P = .01). Female residents were also less likely to be married (61 of 177 [34.5%] vs 116 of 230 [50.4%]; P = .001), were less likely to have children (25 of 177 [14.1%] vs 57 of 230 [24.8%]; P = .008), and believed they would have more responsibility at home than their significant other (77 of 177 [43.5%] vs 35 of 230 [15.2%]; P < .001). Men and women anticipated working the same number of hours, expected to retire at the same age, and had similar interest in holding leadership positions, having academic careers, and pursuing research. Conclusions and Relevance: This study found no difference in overall career goals between male and female residents; however, female residents' salary expectations were lower, and they viewed salary negotiation less favorably. Given the current gender disparities in salary and leadership within surgery, strategies are needed to help remedy this inequity.

Identifying Which Place Characteristics are Associated with the Odds of Recent HIV Testing in a Large Sample of People Who Inject Drugs in 19 US Metropolitan Areas.

This exploratory analysis investigates relationships of place characteristics to HIV testing among people who inject drugs (PWID). We used CDC's 2012 National HIV Behavioral Surveillance (NHBS) data among PWID from 19 US metropolitan statistical areas (MSAs); we restricted the analytic sample to PWID self-reporting being HIV negative (N = 7477). Administrative data were analyzed to describe the 1. Sociodemographic Composition; 2. Economic disadvantage; 3. Healthcare Service/Law enforcement; and 4. HIV burden of the ZIP codes, counties, and MSAs where PWID lived. Multilevel models tested associations of place characteristics with HIV testing. Fifty-eight percent of PWID reported past-year testing. MSA-level per capita correctional expenditures were positively associated with recent HIV testing among black PWID, but not white PWID. Higher MSA-level household income and imbalanced sex ratios (more women than men) in the MSA were associated with higher odds of testing. HIV screening for PWID is suboptimal (58%) and needs improvement. Identifying place characteristics associated with testing among PWID can strengthen service allocation and interventions in areas of need to increase access to HIV testing.

Association of General Surgery Resident Remediation and Program Director Attitudes With Resident Attrition.

IMPORTANCE: Previous studies of resident attrition have variably included preliminary residents and likely overestimated categorical resident attrition. Whether program director attitudes affect attrition has been unclear. OBJECTIVES: To determine whether program director attitudes are associated with resident attrition and to measure the categorical resident attrition rate. DESIGN, SETTING, AND PARTICIPANTS: This multicenter study surveyed 21 US program directors in general surgery about their opinions regarding resident education and attrition. Data on total resident complement, demographic information, and annual attrition were collected from the program directors for the study period of July 1, 2010, to June 30, 2015. The general surgery programs were chosen on the basis of their geographic location, previous collaboration with some coauthors, prior work in surgical education and research, or a program director willing to participate. Only categorical surgical residents were included in the study; thus, program directors were specifically instructed to exclude any preliminary residents in their responses. MAIN OUTCOMES AND MEASURES: Five-year attrition rates (2010-2011 to 2014-2015 academic years) as well as first-time pass rates on the General Surgery Qualifying Examination and General Surgery Certifying Examination of the American Board of Surgery (ABS) were collected. High- and low-attrition programs were compared. RESULTS: The 21 programs represented different geographic locations and 12 university-based, 3 university-affiliated, and 6 independent program types. Programs had a median (interquartile range [IQR]) number of 30 (20-48) categorical residents, and few of those residents were women (median [IQR], 12 [5-17]). Overall, 85 of 966 residents (8.8%) left training during the study period: 15 (17.6%) left after postgraduate year 1, 34 (40.0%) after postgraduate year 2, and 36 (42.4%) after postgraduate year 3 or later. Forty-four residents (51.8%) left general surgery for another surgical discipline, 21 (24.7%) transferred to a different surgery program, and 18 (21.2%) exited graduate medical education altogether. Each program had an annual attrition rate ranging from 0.73% to 6.0% (median [IQR], 2.5% [1.5%-3.4%]). Low-attrition programs were more likely than high-attrition programs to use resident remediation (21.0% vs 6.8%; P < .001). Median (IQR) Qualifying Examination pass rates (93% [90%-98%] vs 92% [86%-100%]; P = .92) and Certifying Examination pass rates (83% [68%-84%] vs 81% [71%-86%]; P = .47) were similar. Program directors at high-attrition programs were more likely than their counterparts at low-attrition programs to agree with this statement: "I feel that it is my responsibility as a program director to redirect residents who should not be surgeons." CONCLUSIONS AND RELEVANCE: The overall 5-year attrition rate of 8.8% was significantly lower than previously reported. Program directors at low-attrition programs were more likely to use resident remediation. Variations in attrition may be explained by program director attitudes, although larger studies are needed to further define program factors affecting attrition.

Time is now: venous thromboembolism prophylaxis in blunt splenic injury.

BACKGROUND: The safety and timing of venous thromboembolism (VTE) prophylaxis in patients with blunt splenic injuries is not well known. We hypothesized that early initiation of VTE prophylaxis does not increase failure of nonoperative management or transfusion requirements in these patients. METHODS: A retrospective review of trauma patients with blunt splenic injury was performed. Patients were compared based on initiation and timing of VTE prophylaxis (<24 hours, 24 to 48 hours, 48 to 72 hours, and >72 hours). Patients who received VTE prophylaxis were matched with those who did not. Primary outcomes included were operation or angioembolization. RESULTS: A total of 497 patients (256 received VTE prophylaxis and 241 did not) were included. There was no difference in the number of interventions based on presence of or time to VTE prophylaxis initiation. CONCLUSIONS: Early initiation (<48 hours) of VTE prophylaxis is safe in patients with blunt splenic injuries treated nonoperatively, and may be safe as early as 24 hours.

Pain Assessment in Noncommunicative Adult Palliative Care Patients.

Palliative care patients who have pain are often unable to self-report their pain, placing them at increased risk for underrecognized and undertreated pain. Use of appropriate pain assessment tools significantly enhances the likelihood of effective pain management and improved pain-related outcomes. This paper reviews selected tools and provides palliative care clinicians with a practical approach to selecting a pain assessment tool for noncommunicative adult patients.

Of duty hour violations and shift work: changing the educational paradigm.

BACKGROUND: Successful surgical education balances learning opportunities with Accreditation Council on Graduate Medical Education (ACGME) duty hour requirements. We instituted a night shift system and hypothesized that implementation would decrease duty hour violations while maintaining quality education. METHODS: A system of alternating teams working 12-hour shifts was instituted and was assessed via an electronic survey distributed at 2, 6, and 12 months after implementation. Resident duty hour violations and resident case volume were evaluated for 1 year before and 2 years after implementation of the night shift system. RESULTS: Survey data revealed a decrease in the perception that residents had problems meeting duty hour restrictions from 44% to 14% at 12 months (P = .012). Total violations increased 26% in the 1st year, subsequently decreasing by 62%, with shift length violations decreasing by 90%. Resident availability for didactics was improved, and average operative cases per academic year increased by 65%. CONCLUSIONS: Night shift systems are feasible and help meet duty hour requirements. Our program decreased violations while increasing operative volume and didactic time.

Variations in Symptom Severity Patterns Among Oropharyngeal and Laryngeal Cancer Outpatients During Radiation Treatment: A Pilot Study.

BACKGROUND: Pain, difficulty swallowing, dry mouth, taste change, appetite loss, and mouth sores are associated with radiotherapy (RT). Knowledge of individual symptom patterns (ISPs) and differences among patients during RT can provide vital information for evaluation and delivery of patient-tailored care. OBJECTIVE: The objectives of this study were to identify and describe ISPs and symptom duration, resolution, and peak severity among outpatients with oropharyngeal and laryngeal cancer. METHODS: This was an analysis of data from a larger study using Visual Graphical Analysis to examine 21 outpatients' ISPs over RT. Individual symptom patterns for 6 severe symptoms were grouped by ISP and evaluated by a panel of experts. RESULTS: Three types of ISPs were identified. The majority of patients displayed a problematic ISP type for pain and difficulty swallowing. When the ISPs of a patient's 6 symptoms were displayed together, the presence of several ISP types was noted. A majority experienced at least 1 symptom pattern that was problematic, indicating the uniqueness of each patient's symptom experience. CONCLUSIONS: During cancer treatment, patients experience multiple symptoms that change in severity over a course of care. Visualizing the patterns of patient-reported symptoms provided information regarding 6 severe symptoms experienced by patients. IMPLICATIONS FOR PRACTICE: Identifying ISPs provided information about symptom variations among patients with oropharyngeal and laryngeal cancer, which can influence symptom management strategies used by providers. Study techniques used can be useful for nurses when managing patients' symptoms. In the future, information using real-time data visualized as patterns could be used to manage multiple symptoms experienced by patients during treatment.

An acute care surgery fellowship benefits a general surgical residency.

BACKGROUND: There has been a trend toward subspecialization among general surgery graduates, and many subspecialists are reticent to participate in trauma care. This has resulted in a gap in the provision of emergency surgical care. The Acute Care Surgery (ACS) fellowship, incorporating trauma, critical care, and emergency general surgery, was developed to address this need. One of the most important aspects in establishing these ACS fellowships is that they do not detract from the existing general surgery residents' experience. METHODS: The operative case logs for residents and fellows were compared for the number of resident cases during the 3 years before the ACS fellowship and during the 3 years after the fellowship was established. Surveys were distributed to the general surgery residents addressing the impact of the fellows from the resident's perspective at the end of the 2011 to 2012 academic year. RESULTS: There was no significant change in the number of total cases; total chief resident cases; and trauma, thoracic, or vascular procedures done per graduate. A decrease in the number of liver cases performed by the residents was noted but includes the increase in resident complement as well as the fellowship. ACS fellow cases increased from 172 cases in the first year to 221 cases in the second year and 295 in the third year. The survey showed that the residents had a very positive response to having the fellow as a teacher and did not feel like their operative experience was compromised with the addition of the ACS fellowship. CONCLUSION: The ACS fellow did not compromise general surgery resident experience and was regarded as an asset to the resident's education. An ACS fellowship can be beneficial to residents and fellows. LEVEL OF EVIDENCE: Care management study, level IV.