Evaluating the Implementation of a Medical Student's Handoff Curriculum During the Surgery Clerkship.

INTRODUCTION: Early introduction to essential communication skills is important. We sought to determine if a handoff curriculum (HC) would improve confidence, decrease anxiety, and increase participation in clinical handoffs during the surgical clerkship. METHODS: A multi-center prospective cohort study was performed at two medical schools. Training in the intervention group (HC) consisted of a didactic lecture, video review, and practice session. Students completed a pre-clerkship knowledge test and confidence/anxiety/handoff experience questionnaire pre- and post-clerkship. RESULTS: There were no significant differences in pre-clerkship handoff experiences between institutions except having previously witnessed a verbal handoff (School A 96.4% versus School B 76.2%, P = 0.01). While there were no significant differences in post-clerkship confidence or anxiety, HC students were significantly more involved with written sign-outs (52.9% versus 18.2%, P = 0.02) and verbal handoffs (29.4% versus 4.6%, P = 0.03). CONCLUSIONS: Medical students exposed to handoff training shared similar confidence and anxiety scores compared to those that were not, however, they were more involved in handoff experiences during their surgical clerkship. Early introduction to handoff skills may encourage greater participation during subsequent clinical experiences.

Established Primary Care Provider Improves Odds of Survival to Discharge for Injured Patients.

INTRODUCTION: The average age and number of comorbidities is increasing among trauma patients. Primary care providers (PCPs) provide pre-injury diagnosis and management of comorbidities that may affect outcomes for injured patients. The role of primary care in trauma systems is currently unknown. METHODS: Observational retrospective review of an institutional trauma databank from 2013 - 2019. PCP was extracted from the electronic medical record and combined with trauma data. Case-control matching was performed to compare outcomes between patients with and without primary care based on age, injury severity score, sex, and injury mechanism. Mann-Whitney U test, chi-square test, and multivariate regression described differences between subgroups. Primary outcome was difference in mortality rate for injured patients with and without PCPs. RESULTS: Within the study period, 19,096 patients were included. 6,626 (34.7%) had a PCP recorded. Of these, 2,158 were matched in a case-control design. Patients with PCPs had a lower mortality rate (1.6%) compared to patients without PCPs (3.6%, P < 0.01). PCP retention was associated with longer length of stay overall, equivalent rates of complications (5.4% vs. 5.7%, P = 0.63), and similar numbers of ICU and ventilator days. Multivariate logistic regression controlling for case-control factors, insurance, and comorbidities conferred an odds ratio of 2.58 (95% Confidence Interval: 1.59 - 4.19, P < 0.001) for survival to discharge. CONCLUSION: Pre-injury primary care significantly improves the odds of survival to discharge for injured patients. Prospective study of this relationship may identify strategies to promote primary care within health systems.

Complicated appendicitis and considerations for interval appendectomy.

Acute appendicitis is one of the most common surgical emergencies. Of the 300,000 appendectomies performed each year, 25% are due to complicated appendicitis. This article reviews the incidence and pathophysiology of acute appendicitis, the nonoperative management of complicated appendicitis, and the rationales for and against interval appendectomy.

Relationships between study habits, burnout, and general surgery resident performance on the American Board of Surgery In-Training Examination.

BACKGROUND: The American Board of Surgery In-Training Examination (ABSITE) is used by programs to evaluate the knowledge and readiness of trainees to sit for the general surgery qualifying examination. It is often used as a tool for resident promotion and may be used by fellowship programs to evaluate candidates. Burnout has been associated with job performance and satisfaction; however, its presence and effects on surgical trainees' performance are not well studied. We sought to understand factors including burnout and study habits that may contribute to performance on the ABSITE examination. METHODS: Anonymous electronic surveys were distributed to all residents at 10 surgical residency programs (n = 326). Questions included demographics as well as study habits, career interests, residency characteristics, and burnout scores using the Oldenburg Burnout Inventory, which assesses burnout because of both exhaustion and disengagement. These surveys were then linked to the individual's 2016 ABSITE and United States Medical Licensing Examination (USMLE) step 1 and 2 scores provided by the programs to determine factors associated with successful ABSITE performance. RESULTS: In total, 48% (n = 157) of the residents completed the survey. Of those completing the survey, 48 (31%) scored in the highest ABSITE quartile (≥75th percentile) and 109 (69%) scored less than the 75th percentile. In univariate analyses, those in the highest ABSITE quartile had significantly higher USMLE step 1 and step 2 scores (P < 0.001), significantly lower burnout scores (disengagement, P < 0.01; exhaustion, P < 0.04), and held opinions that the ABSITE was important for improving their surgical knowledge (P < 0.01). They also read more frequently to prepare for the ABSITE (P < 0.001), had more disciplined study habits (P < 0.001), were more likely to study at the hospital or other public settings (e.g., library, coffee shop compared with at home; P < 0.04), and used active rather than passive study strategies (P < 0.04). Gender, marital status, having children, and debt burden had no correlation with examination success. Backward stepwise multiple regression analysis identified the following independent predictors of ABSITE scores: study location (P < 0.0001), frequency of reading (P = 0.0001), Oldenburg Burnout Inventory exhaustion (P = 0.02), and USMLE step 1 and 2 scores (P = 0.007 and 0.0001, respectively). CONCLUSIONS: Residents who perform higher on the ABSITE have a regular study schedule throughout the year, report less burnout because of exhaustion, study away from home, and have shown success in prior standardized tests. Further study is needed to determine the effects of burnout on clinical duties, career advancement, and satisfaction.

Post-ICU syndrome: Rescuing the undiagnosed.

Survivors of critical illness may develop postintensive care syndrome (PICS), a spectrum of conditions that include persistent cognitive dysfunction, acquired weakness, and intrusive memories akin to post-traumatic stress disorder. Relatively few ICU survivors are routinely followed in the outpatient setting by intensivists, but are regularly evaluated by primary care physicians and physician assistants in their practices. Specific and focused education about the key features of PICS, its effect on patients as well as family members, and potential therapeutic interventions may increase recognition of PICS and reduce its effect on survivors of critical illness.

Hyperglycemia impairs cytotrophoblast function via stress signaling.

OBJECTIVE: Diabetes mellitus is a risk factor for preeclampsia. Cytotrophoblast (CTB) invasion is facilitated from the conversion of plasminogen to plasmin by urokinase plasminogen activator (uPA), regulated by plasminogen activator inhibitor 1 (PAI-1), and may be inhibited in preeclampsia. This study assessed signaling mechanisms of hyperglycemia-induced CTB dysfunction. STUDY DESIGN: Human CTBs were treated with 45, 135, 225, 495, or 945 mg/dL glucose for 48 hours. Some cells were pretreated with a p38 inhibitor (SB203580) or a peroxisome proliferator-activated receptor-gamma (PPAR-γ) ligand (rosiglitazone). Expression of uPA, PAI-1, and PPAR-γ levels and p38 mitogen-activated protein kinase phosphorylation were measured by Western blot in cell lysates. Messenger ribonucleic acid of uPA and PAI-1 was measured by quantitative polymerase chain reaction. Levels of interleukin-6, angiogenic (vascular endothelial growth factor [VEGF], placenta growth factor [PlGF]) and antiangiogenic factors (soluble fms-like tyrosine kinase-1 [sFlt-1], soluble endoglin [sEng]) were measured in the media by enzyme-linked immunosorbent assay kits. Statistical comparisons were performed using analysis of variance with a Duncan's post-hoc test. RESULTS: Both uPA and PAI-1 protein and messenger ribonucleic acid were down-regulated (P < .05) in CTBs treated with 135 mg/dL glucose or greater compared with basal (45 mg/dL). The sEng, sFlt-1, and interleukin-6 were up-regulated, whereas the VEGF and PlGF were down-regulated by 135 mg/dL glucose or greater. p38 phosphorylation and PPAR-γ were up-regulated (P < .05) in hyperglycemia-treated CTBs. The SB203580 or rosiglitazone pretreatment showed an attenuation of glucose-induced down-regulation of uPA and PAI-1. CONCLUSION: Hyperglycemia disrupts the invasive profile of CTB by decreasing uPA and PAI-1 expression; down-regulating VEGF and PlGF; and up-regulating sEng, sFlt-1, and interleukin-6. Attenuation of CTB dysfunction by SB203580 or rosiglitazone pretreatment suggests the involvement of stress signaling.

Practitioner perceptions of trauma video review.

PURPOSE: Multidisciplinary trauma team education through trauma video review (TVR) is a useful performance improvement tool, but video recording resuscitations may cause providers anxiety. We examined perceptions of educational value and anxiety associated with being reviewed in TVR. METHODS: Trauma team members were asked to complete an anonymous online survey. Educational scores (E scores) and anxiety scores (A score) were calculated from survey responses. Respondents were divided into groups by roles: trainees (T; medical students, residents, and fellows), attending surgeons (A), and nurses (N). Kruskal-Wallis test was used for statistical testing. FINDINGS: A total of 39 subjects completed the survey (T = 17, 43%; A = 8, 23%; N = 14, 35%). TVR scored high in educational value (median E score 90; IQR = 78-96) but provoked moderate anxiety (median A score 27; IQR = 20-36). No significant differences in E scores were seen between groups. A scores were not significantly different between groups N and T (20 vs 33; P = .11) or groups T and A (33 vs. 35; P = 1.0) but were significantly higher in group A than in group N (36 vs 20; P = .04). CONCLUSIONS: Despite perceptions of educational value, TVR is associated with anxiety among providers, which is different between groups. Continued assessment of perceptions regarding TVR may allow for modifications to maintain educational value while decreasing anxiety.

COMPETENCE Trial: The EVAHEART 2 continuous flow left ventricular assist device.

BACKGROUND: Continuous flow left ventricular assist devices have improved outcomes in patients with end-stage heart failure that require mechanical circulatory support. Current devices have an adverse event profile that has hindered widespread application. The EVAHEART®2 left ventricular assist device (EVA2) has design features such as large blood gaps, lower pump speeds and an inflow cannula that does not protrude into the left ventricle that may mitigate the adverse events currently seen with other continuous flow devices. METHODS: A prospective, multi-center randomized non-inferiority study, COMPETENCE Trial, is underway to assess non-inferiority of the EVA2 to the HeartMate 3 LVAS when used for the treatment of refractory advanced heart failure. The primary end-point is a composite of the individual primary outcomes: Survival to cardiac transplant or device explant for recovery; Free from disabling stroke; Free from severe Right Heart Failure after implantation of original device. Randomization is in a 2:1 (EVA2:HM3) ratio. RESULTS: The first patient was enrolled into the COMPETENCE Trial in December of 2020, and 25 subjects (16 EVA2 and 9 HM3) are currently enrolled. Enrollment of a safety cohort is projected to be completed by third quarter of 2022 at which time an interim analysis will be performed. Short-term cohort (92 EVA2 subjects) and long-term cohort is expected to be completed by the end of 2023 and 2024, respectively. CONCLUSIONS: The design features of the EVA2 such as a novel inflow cannula and large blood gaps may improve clinical outcomes but require further study. The ongoing COMPETENCE trial is designed to determine if the EVA2 is non-inferior to the HM3.

Creation of a Human Factors Board to Support Well-Being in General Surgery Residents.

PROBLEM: Demands placed on resident physicians can make it difficult to keep up with personal needs, often affecting well-being. For military pilots, confidential and nonpunitive human factors boards (HFBs) identify pilots' human factors (personal or professional problems that might interfere with the ability to perform effectively) and make recommendations for support. The authors sought to determine the feasibility of establishing an HFB for resident physicians and its utility for general surgery residents. APPROACH: Publicly available information on HFBs was reviewed and translated to the structure of a general surgery residency. An HFB consisting of a faculty member, resident representative, and neutral third party was established for the general surgery residency program (consisting of 42 residents during the study period) at Penn State Health. From January 1 to July 1, 2020, the HFB responded to human factors needs of general surgery residents. Residents could make requests for themselves or another resident. If all HFB members were in agreement that a request was reasonable, the appropriate resource was directed to the requesting resident and funding was disbursed (if applicable) by the third party. OUTCOMES: From January 1 to July 1, 2020, 14 requests were made. Of these, 3 (21%) were made for another resident and 12 (86%) were fulfilled through resources arranged by the HFB. All requests occurred between January 1 and April 1, 2020, likely because of the COVID-19 pandemic. The overall cost of the program was $932.80. NEXT STEPS: The HFB represents an adaptable tool that can meet residents' specific needs as they arise and a mechanism through which residents can receive a tangible response to human factors. Formal feedback is needed to identify areas that could be improved. This structure could be generalized to other graduate medical education programs and physicians at all levels.

Gastroschisis in one twin neonate with extracorporeal liver.

We report a rare case of gastroschisis with extracorporeal liver suspected on late first trimester ultrasound and confirmed with second trimester ultrasound and magnetic resonance imaging in one fetus in a twin pregnancy. Liver herniation is common in omphalocele, a membrane-covered abdominal wall defect associated with other congenital anomalies. However, it is highly uncommon in gastroschisis, an uncovered abdominal wall defect aside of the cord insertion. Presence of liver herniation complicates prenatal differentiation between omphalocele and gastroschisis. The twins were born at 31 weeks' gestation due to preterm labor. The baby was treated with a silo device, followed by biologic mesh and a wound vac with instillation of fluid to prevent desiccation. Ultimately, the baby died of sepsis, with multiorgan failure and polymicrobial infection.

Adult Trauma Patients with Autism Spectrum Disorder: A Case-Control Study to Evaluate Disparities After Injury.

BACKGROUND: Adult trauma patients with autism spectrum disorder (ASD) may have distinct care needs that have not been previously described. We hypothesized that due to differences in clinical care and disposition issues, injured adults with ASD would have increased lengths of stay, higher mortality, and increased rates of complications compared to adults without ASD. METHODS: The Pennsylvania Trauma Outcomes Study database was queried from 2010-2018 for trauma patients with ASD. Case-control matching was performed for two controls per ASD patient accounting for age, gender, injury mechanism, and injury severity score. Primary outcomes included length of stay, mortality, and complication rate. Univariate analysis compared presentation and clinical care between the two groups. Multivariate regression and Kaplan-Meier curves modeled length of stay. Significance was defined as p < 0.05. RESULTS: A total of 185 patients with ASD were matched to 370 controls. Age (mean +/- standard deviation) was 33.4 +/- 16.5 years. Gender was 81.1% male. Mechanisms were 88.1% blunt, 5.9% penetrating, and 5.9% burns. Significant clinical differences identified in patients with ASD vs. case-controls included presenting verbal GCS (median [IQR]) (5 [2] vs. 5 [0], p < 0.01), proportion of patients intubated at presentation (20.0% vs. 13.0%, p = 0.031), and hospital length of stay (4 [6] days vs. 3 [4] days, p = 0.002). Adult patients with ASD were less likely to be discharged home and more often discharged to a skilled nursing facility (p < 0.01). There were no differences in mortality, rates of complications, imaging, or operations. Multivariate regression analysis controlling for demographic and clinical differences revealed the diagnosis of ASD independently contributed 3.13 days (95% Confidence Interval: 1.85 to 4.41 days) to injured adults' length of stay. Kaplan-Meier curves showed injured patients with ASD were less likely to be discharged than case-controls starting from time of admission (log rank test, p < 0.001). CONCLUSIONS: This statewide analysis suggests injured patients with ASD have increased lengths of stay without other clinical or outcome differences. Given significant differences in discharge destination, these findings support early involvement of a multidisciplinary care collaborative. Further research is needed to identify factors that contribute to disparities in care for adults with ASD.

Pain management in trauma patients affected by the opioid epidemic: A narrative review.

Acute and chronic pain in trauma patients remains a challenging entity, particularly in the setting of the escalating opioid epidemic. It has been reported that chronic opioid use increases the likelihood of hospital admissions as a result of traumatic injuries. Furthermore, patients admitted with traumatic injuries have a greater than average risk of developing opioid use disorder after discharge. Practitioners providing care to these patients will encounter the issue of balancing analgesic goals and acute opioid withdrawal with the challenge of reducing postdischarge persistent opioid use. Additionally, the practitioner is faced with the worrisome prospect that inadequate treatment of acute pain may lead to the development of chronic pain and overtreatment may result in opioid dependence. It is therefore imperative to understand and execute alternative nonopioid strategies to maximize the benefits and reduce the risks of analgesic regimens in this patient population. This narrative review will analyze the current literature on pain management in trauma patients and highlight the application of the multimodal approach in potentially reducing the risks of both short- and long-term opioid use. LEVEL OF EVIDENCE: Narrative review, moderate to High.

A novel method of optimizing patient- and family-centered care in the ICU.

BACKGROUND: Patient- and family-centered care permeates critical care where there are often multiple teams involved in management. A method of facilitating information sharing to support shared decision making is essential in appropriately rendering care.This study sought to determine whether incorporating family members on rounds in the intensive care unit (ICU) improves patient and family knowledge and whether doing so improves team time management and satisfaction with the process. METHODS: A nonrandomized comparative before-and-after trial of incorporating family members on rounds (July to December 2009 vs January to July 2010) in a single quarternary center's surgical ICU assessed (1) family members' knowledge, (2) nurse's and physician's satisfaction with the intervention, (3) frequency and timing of family meetings, and (4) physician's workflow. RESULTS: Intensive care unit demographics and use were similar between time frames. Presurvey (n = 412 family members; 49 nurses) and postsurvey (n = 427 family members; 47 nurses) were coupled with presurvey (n = 5) and postsurvey (n = 6) physicians' informal feedback. Family knowledge of the clinical course and plans increased from 146 (35.4%) of 412 to 374 (87.6%) of 427 (p < 0.0001). Nurses were nearly uniformly satisfied with planned family interaction on rounds (presurvey: 9/49 [18.4%] vs postsurvey: 46/47 [97.9%]; p < 0.0001). Family meetings per week outside of rounds substantially decreased from a mean of 5.3 ± 2.7 to 0.3 ± 0.9; p < 0.001). Goals of therapy including end-of-life care became an element frequently discussed on rounds with families (presurvey: 9.4% ± 4.7% vs postsurvey: 82.5% ± 14.8%; p < 0.0001). One intensivist was dissatisfied with the process. CONCLUSION: Incorporating family members on rounds in the ICU improves communication and satisfaction and shifts the team's time away from family communication events outside of rounds, condensing most of those activities within the rounding structure. Critical care nurses and intensivists were principally satisfied with the process. LEVEL OF EVIDENCE: Therapeutic, level III.

Medical School Surgical Boot Camps: A Systematic Review.

PURPOSE: Many medical schools have begun to offer surgical boot camps to senior medical students. The aim of the present study is to systematically review the literature and evidence surrounding medical school surgical boot camps to direct future research into the effectiveness of boot camps. METHODS: A systematic review was conducted, searching MEDLINE, EMBASE, PsycINFO, CINAHL, and ERIC. The review was conducted according to the PICOTS structure, with an intervention of a surgical boot camp for senior medical students entering surgical residencies. RESULTS: The search resulted in 5351 database hits, from which we identified 10 published studies that met the inclusion criteria. Two reviews were identified that met the PICOTS criteria but were excluded from data synthesis. Boot camps increase the confidence and competence of medical students entering their surgical internships. There is no objective assessment of the effect of boot camps on the clinical performance of interns. CONCLUSIONS: Despite the success of medical school surgical boot camps, no objective data exist to show that boot camps translate into improved performance during internship.

Handoffs in the Intensive Care Unit.

Operating room (OR) to intensive care unit (ICU) handoffs are complex and known to be associated with adverse events and patient harm. The authors hypothesized that handoff quality diminishes during nights/weekends and that bedside handoff practices are similar between ICUs of the same health system. Bedside OR-to-ICU handoffs were directly observed in 2 surgical ICUs with different patient volumes. Handoff quality measures were compared within the ICUs on weekdays versus nights/weekends as well as between the high- and moderate-volume ICUs. In the high-volume ICU, transmitter delivery scores were significantly better during off hours, while other measures were not different. High-volume ICU scores were consistently better than those in the moderate-volume ICU. Bedside handoff practices are not worse during off hours and may be better in ICUs used to a higher patient volume. Specific handoff protocols merit evaluation and training to ensure consistent practices in different ICU models and at different times.

Attitudes of bariatric surgeons concerning adolescent bariatric surgery (ABS).

BACKGROUND: As the number of adolescents with clinically severe obesity has grown, so too have the number of adolescents seeking bariatric surgery. METHODS: The membership of the ASBS was contacted by e-mail with a 14-question survey to ascertain plans for development of adolescent bariatric surgery (ABS) programs. Results were tabulated and expressed as a percentage of total respondents. RESULTS: Of the 92 respondents, most (84%) performed >50 adult bariatric procedures per year. Over half (53%) had performed ABS. Nearly half (45%) had performed <10 ABS cases within the last year, and 70% were planning ABS in the upcoming year. 42% reported that they have already or were in the process of developing an adolescent bariatric treatment program with pediatric specialists in their community. The vast majority (84%) of respondents was willing to participate in a multi-center collection of outcomes data, and 65% reported having dedicated personnel for clinical data collection. CONCLUSIONS: There is increasing interest in developing ABS programs. Despite the perceived need for such services, information is lacking in the adolescent age group to guide decisions regarding optimal patient selection, choice of operation, and postoperative management. Rigorous evaluation of the outcomes of this intervention with detailed prospective data collection is needed to support decision-making regarding use of bariatric surgery for adolescents with morbid obesity.