The Impact of an Intern's Clinical Guidebook on Easing the Transition of New Interns Into the United States Healthcare System.

This study explores the efficacy of an intern's clinical guidebook in facilitating the transition of categorical internal medicine interns into the United States healthcare system. New interns, particularly foreign medical graduates, face multifaceted challenges during their initial year of residency. The research, conducted at Ascension Saint Joseph Hospital in Chicago, employed a quasi-experimental pre-post design involving 20 interns. Participants were provided with an intern's clinical guidebook, and their knowledge was assessed through pre and post exams. Results demonstrated a statistically significant improvement in overall knowledge, with mean scores increasing from 65% to 77.37%. Subgroup analysis revealed similar improvements among both male and female interns. Data confidentiality and ethical considerations were prioritized, with participant data anonymized and stored securely. Despite limitations, this study highlights the guidebook's potential to enhance intern education and improve the quality of care provided during the crucial transition period. Further research is recommended to validate and extend these findings.

Evolution of Pain Control for Adult Pectus Excavatum Repair.

BACKGROUND: Pain control after minimally invasive repair of pectus excavatum (MIRPE) can be challenging, especially in adult patients undergoing surgical repair. This study reviewed different analgesic modalities used over ≥10 years after pectus repair. METHODS: A retrospective analysis was performed of adult patients (≥18 years) who underwent uncomplicated primary MIRPE at a single institution from October 2010 to December 2021. Patients were classified by analgesic modality used: epidural, elastomeric continuous infusion subcutaneous catheters (SC-Caths), and intercostal nerve cryoablation. Comparisons among the 3 groups were performed. RESULTS: In total, 729 patients were included (mean age, 30.9 ±10.3 years; 67% male; mean Haller index, 4.9 ±3.0). Patients in the cryoablation group required significantly lower doses of morphine equivalents (P < .001) and had overall the shortest hospital stay (mean, 1.9 ±1.5 days; P < .001) with <17% staying >2 days (vs epidural at 94% and SC-Cath at 48%; P < .001). The cryoablation group had a lower incidence of ileus and constipation (P < .001) but a higher incidence of pleural effusion requiring thoracentesis (P = .024). Mean pain scores among groups were minor (<3), and differences were insignificant. CONCLUSIONS: The use of cryoablation in conjunction with enhanced recovery pathways provided significant benefit to our patients undergoing MIRPE compared with previous analgesic modalities. These benefits included a decrease in length of hospital stay, a reduction of in-hospital opioid use, and a lower incidence of opioid-related complications associated with constipation and ileus. Further studies to assess additional potential benefits with long-term follow-up after discharge are warranted.

Risk Factors and Techniques for Safe Pectus Bar Removal in Adults After Modified Nuss Repair.

BACKGROUND: The Nuss repair involves implants designed for removal after 2 to 3 years. Although rare, significant complications can occur with bar removal, and the incidence of these complications may be higher in adults. This study was performed to review complications and risk factors associated with bar removal and discuss strategies to improve operative safety. METHODS: A retrospective study was performed including all patients after pectus excavatum repair who underwent Nuss implant removal at Mayo Clinic Arizona (Phoenix, AZ) from 2013 to 2022. RESULTS: In total, 1555 bars were removed (683 patients; 71% men; median age, 34 years[(range, 15-71 years]). Of the removals, 12.45% of patients had bars placed at outside institutions. Major complications were rare, with bleeding most common (2.05%), followed by pneumothorax (0.88%), infection (0.59%), and effusions (0.44%). Most major bleeding (85.71%) occurred from the bar track during removal and was controlled by packing the track. One patient required subsequent hematoma evacuation and transfusion. Bleeding secondary to lung injury was also successfully controlled with packing. Bar removal in 1 patient with significantly displaced bars required sternotomy and cardiopulmonary bypass as a result of aortic injury. Risk factors identified for bleeding included sternal erosion (P < .001), bar migration (P < .001), higher number of bars (P = .037), and revision of a previous pectus repair (P = 0.001). Bar migration was additionally associated with major complications (P < .001). Older age, although a risk factor for overall complications (P = 0.001), was not a risk factor for bleeding. CONCLUSIONS: Bar removal can be safely performed in most patients; however, significant complications, including bleeding, may occur. Identifying potential risk factors and being prepared for rescue maneuvers are critical to prevent catastrophic outcomes.

Cardiopulmonary Outcomes After the Nuss Procedure in Pectus Excavatum.

Background Pectus excavatum is the most common chest wall deformity. There is still controversy about cardiopulmonary limitations of this disease and benefits of surgical repair. This study evaluates the impact of pectus excavatum on the cardiopulmonary function of adult patients before and after a modified minimally invasive repair. Methods and Results In this retrospective cohort study, an electronic database was used to identify consecutive adult (aged ≥18 years) patients who underwent cardiopulmonary exercise testing before and after primary pectus excavatum repair at Mayo Clinic Arizona from 2011 to 2020. In total, 392 patients underwent preoperative cardiopulmonary exercise testing; abnormal oxygen consumption results were present in 68% of patients. Among them, 130 patients (68% men, mean age, 32.4±10.0 years) had post-repair evaluations. Post-repair tests were performed immediately before bar removal with a mean time between repair and post-repair testing of 3.4±0.7 years (range, 2.5-7.0). A significant improvement in cardiopulmonary outcomes (P<0.001 for all the comparisons) was seen in the post-repair evaluations, including an increase in maximum, and predicted rate of oxygen consumption, oxygen pulse, oxygen consumption at anaerobic threshold, and maximal ventilation. In a subanalysis of 39 patients who also underwent intraoperative transesophageal echocardiography at repair and at bar removal, a significant increase in right ventricle stroke volume was found (P<0.001). Conclusions Consistent improvements in cardiopulmonary function were seen for pectus excavatum adult patients undergoing surgery. These results strongly support the existence of adverse cardiopulmonary consequences from this disease as well as the benefits of surgical repair.

Sex Differences in Objective Measures of Adult Patients Presenting for Pectus Excavatum Repair.

BACKGROUND: Women have a reported incidence of pectus deformities four to five times less than men. Sex differences have not been well studied. METHODS: A retrospective review was performed of adult patients (aged 18 years or more) who underwent a pectus excavatum repair at Mayo Clinic in Arizona (January 1, 2010, to December 31, 2019). RESULTS: In total, 776 adults underwent pectus repair, with 30% being women. Women presented older (mean age 35 vs 32 years, P = .007) and more symptomatic. Despite this, women performed better on cardiopulmonary exercise testing (higher maximum oxygen consumption and oxygen pulse). Women had more severe deformities (Haller index 5.9 vs 4.3, P < .001). However, in 609 patients undergoing attempted primary minimally invasive pectus repair, intraoperative fractures/osteotomies occurred equally between men and women, with the majority occurring in patients 30 years of age or more (11.5% for age 30 or more, 1.7% for age less than 30; total 7%). Women were also less likely to require three bars for repair (12% vs 42%, P < .001). Hospital length of stay and postoperative complication rates were not significantly different. Postoperatively, women reported a greater daily intensity of pain, but only on the initial postoperative day did they use significantly more opioids than men. Cardiopulmonary exercise testing of 142 patients undergoing baseline and postoperative evaluation at bar removal showed equal and significant benefits in both sexes. CONCLUSIONS: Women presented for pectus excavatum repair at an older age and with greater symptoms and more severe symptoms. Despite this, women required fewer bars, and there were no significant differences in length of stay or complications. Cardiopulmonary benefits of repair were significant and equal for both women and men.