Timing of Surgery and Internal Medicine Clerkships and Surgery Shelf Examination Scores.

BACKGROUND: Many medical students believe that third-year clerkship rotation sequence affects their success. We hypothesized that students who completed the internal medicine clerkship before the surgery clerkship received higher surgery shelf examination scores compared with the students who did not. MATERIALS AND METHODS: Deidentified academic data including preclinical data and National Board of Medical Examiners shelf examination scores for surgery for all third-year medical students at a single institution from 2012 to 2017 were analyzed. Students who did not complete all six core clerkships during the standard third-year time frame were excluded. Data were analyzed using 2-tailed t-tests and Z-scores. RESULTS: Four hundred and twenty four students were included in the study. Average undergraduate grade point average, Medical College Admission Test scores, and United States Medical Licensing Examination Step 1 scores showed no significant differences between groups. In aggregate, average shelf examination scores of students who completed the internal medicine clerkship before the surgery clerkship were significantly higher than those of students who did not. When the average shelf examination scores for the two groups were analyzed by individual rotation slot, no significant difference was found between the two groups. CONCLUSIONS: Initially, it appeared that students who completed the internal medicine clerkship before the surgery clerkship scored higher on their surgery shelf examinations. When the data were analyzed by individual rotation slot, we found no difference between the students who had already completed the internal medicine clerkship and those who had not. Experience over the year rather than completion of the internal medicine rotation was associated with higher surgery shelf examination scores.

An AAST-MITC analysis of pancreatic trauma: Staple or sew? Resect or drain?

INTRODUCTION: Pancreatic trauma results in high morbidity and mortality, in part caused by the delay in diagnosis and subsequent organ dysfunction. Optimal operative management strategies remain unclear. We therefore sought to determine CT accuracy in diagnosing pancreatic injury and the morbidity and mortality associated with varying operative strategies. METHODS: We created a multicenter, pancreatic trauma registry from 18 Level 1 and 2 trauma centers. Adult, blunt or penetrating injured patients from 2005 to 2012 were analyzed. Sensitivity and specificity of CT scan identification of main pancreatic duct injury was calculated against operative findings. Independent predictors for mortality, adult respiratory distress syndrome (ARDS), and pancreatic fistula and/or pseudocyst were identified through multivariate regression analysis. The association between outcomes and operative management was measured. RESULTS: We identified 704 pancreatic injury patients of whom 584 (83%) underwent a pancreas-related procedure. CT grade modestly correlated with OR grade (r 0.39) missing 10 ductal injuries (9 grade III, 1 grade IV) providing 78.7% sensitivity and 61.6% specificity. Independent predictors of mortality were age, Injury Severity Score (ISS), lactate, and number of packed red blood cells transfused. Independent predictors of ARDS were ISS, Glasgow Coma Scale score, and pancreatic fistula (OR 5.2, 2.6-10.1). Among grade III injuries (n = 158, 22.4%), the risk of pancreatic fistula/pseudocyst was reduced when the end of the pancreas was stapled (OR 0.21, 95% CI 0.05-0.9) compared with sewn and was not affected by duct stitch placement. Drainage alone in grades IV (n = 25) and V (n = 24) injuries carried increased risk of pancreatic fistula/pseudocyst (OR 8.3, 95% CI 2.2-32.9). CONCLUSION: CT is insufficiently sensitive to reliably identify pancreatic duct injury. Patients with grade III injuries should have their resection site stapled instead of sewn and a duct stitch is unnecessary. Further study is needed to determine if drainage alone should be employed in grades IV and V injuries. LEVEL OF EVIDENCE: Epidemiologic/Diagnostic study, level III.

Saline versus Plasma-Lyte A in initial resuscitation of trauma patients: a randomized trial.

OBJECTIVE: We sought to compare resuscitation with 0.9% NaCl versus Plasma-Lyte A, a calcium-free balanced crystalloid solution, hypothesizing that Plasma-Lyte A would better correct the base deficit 24 hours after injury. BACKGROUND: Sodium chloride (0.9%) (0.9% NaCl), though often used for resuscitation of trauma patients, may exacerbate the metabolic acidosis that occurs with injury, and this acidosis may have detrimental clinical effects. METHODS: We conducted a randomized, double-blind, parallel-group trial (NCT01270854) of adult trauma patients requiring blood transfusion, intubation, or operation within 60 minutes of arrival at the University of California Davis Medical Center. Based on a computer-generated, blocked sequence, subjects received either 0.9% NaCl or Plasma-Lyte A for resuscitation during the first 24 hours after injury. The primary outcome was mean change in base excess from 0 to 24 hours. Secondary outcomes included 24-hour arterial pH, serum electrolytes, fluid balance, resource utilization, and in-hospital mortality. RESULTS: Of 46 evaluable subjects (among 65 randomized), 43% had penetrating injuries, injury severity score was 23 ± 16, 20% had admission systolic blood pressure less than 90 mm Hg, and 78% required an operation within 60 minutes of arrival. The baseline pH was 7.27 ± 0.11 and base excess -5.9 ± 5.0 mmol/L. The mean improvement in base excess from 0 to 24 hours was significantly greater with Plasma-Lyte A than with 0.9% NaCl {7.5 ± 4.7 vs 4.4 ± 3.9 mmol/L; difference: 3.1 [95% confidence interval (CI): 0.5-5.6]}. At 24 hours, arterial pH was greater [7.41 ± 0.06 vs 7.37 ± 0.07; difference: 0.05 (95% CI: 0.01-0.09)] and serum chloride was lower [104 ± 4 vs 111 ± 8 mEq/L; difference: -7 (95% CI: -10 to -3)] with Plasma-Lyte A than with 0.9% NaCl. Volumes of study fluid administered, 24-hour urine output, measures of resource utilization, and mortality did not significantly differ between the 2 arms. CONCLUSIONS: Compared with 0.9% NaCl, resuscitation of trauma patients with Plasma-Lyte A resulted in improved acid-base status and less hyperchloremia at 24 hours postinjury. Further studies are warranted to evaluate whether resuscitation with Plasma-Lyte A improves clinical outcomes.

Stump appendicitis after childhood incidental appendectomy.

Stump appendicitis is a rare late complication of appendectomy. Most cases present months to years following surgery for acute appendicitis. Cases of stump appendicitis after incidental appendectomy are very rare. We present a case of stump appendicitis after incidental appendectomy during a procedure for duodenal obstruction as an infant.

Necrotizing soft tissue infections in the intensive care unit.

Necrotizing soft tissue infection is a severe illness that is associated with significant morbidity and mortality. It is often caused by a wide spectrum of pathogens and is most frequently polymicrobial. Care for patients with necrotizing soft tissue infection requires a team approach with expertise from critical care, surgery, reconstructive surgery, and rehabilitation specialists. The early diagnosis of necrotizing soft tissue infection is challenging, but the keys to successful management of patients with necrotizing soft tissue infection are early recognition and complete surgical debridement. Early initiation of appropriate broad-spectrum antibiotic therapy must take into consideration the potential pathogens. Critical care management components such as the initial fluid resuscitation, end-organ support, pain management, nutrition support, and wound care are all important aspects of the care of patients with necrotizing soft tissue infection. Soft tissue reconstruction should take into account both functional and cosmetic outcome.

Trauma surgery to acute care surgery: defining the paradigm shift.

BACKGROUND: Trauma surgery is gradually evolving into acute care surgery (ACS). We sought to better define this evolution by using work relative value units (wRVU) to characterize the current practices of trauma and ACS. METHODS: Fiscal year 2007-2008 data from the UHC-AAMC Faculty Practice Solutions Center database, which is comprised of coding or billing data from 85 institutions was used. We compared averages for trauma surgeons with general, oncology, and vascular surgeons. RESULTS: Trauma surgeons are distinct from other surgical specialties; only 43% of their total wRVU were procedural compared to 69% to 75% for vascular, surgical oncology, and general surgeons. The total procedures for each specialty were similar: trauma 660, general surgery 715, surgical oncology 713, vascular 835, but trauma surgeons performed more bedside procedures. Of the top 20 total wRVU generating procedures, 20% of trauma surgeon's were bedside compared to 0% of a general surgeon's. The wRVU or surgeon for cholecystectomy were comparable between trauma and general surgery (388 vs. 452); both groups perform about 75% of the cholecystectomies laparoscopically. With respect to appendectomies, wRVU or surgeon for trauma surgeons (180) exceeded general surgeons (128). Each group performed approximately 65% laparoscopically. CONCLUSIONS: Trauma surgeons are distinctly different from their colleagues, with a greater emphasis on intensive care unit "cognitive" work. The number of procedures performed by trauma surgeons is comparable to other disciplines but with more "bedside" procedures. Trauma surgeons' high appendectomy wRVUs may be a reflection of the transition to an ACS model. The characterization of trauma surgery as nonoperative and intensive care unit-based is in part substantiated but there are indications of a paradigm shift toward more operative experience with transition to an ACS model.

CD14-dependent modulation of NF-kappaB alternative splicing in the lung after burn injury.

Nuclear factor kappa-B (NF-kappaB), a key downstream player of the LPS signaling pathway, has been shown to undergo alternative splicing in in vitro studies. In this study, we examined the effect of injury and the role of CD14 on NF-kappaB alternative splicing using a murine burn model. CD14 knockout and respective wild-type mice were sacrificed after 18% total body surface area burn. RT-PCR and subsequent sequencing analysis revealed that injury induced multiple novel splicing variants of relA, relB, and NF-kappaB2 in the lungs of CD14 knockout but not wild-type mice. These novel variants resulted either from exon skipping, alternative usage of splicing signals, or intron retention. All but one variant resulted in a frameshift leading to premature termination of translation. These splicing variants encoded for proteins that lacked the domains essential for NF-kappaB transcription factor functions. Two NF-kappaB2 variants acquired only minor changes in their C-terminus that might affect their post-translational cleavage into active isoforms. These results suggest that alternative splicing may be one of the mechanisms by which NF-kappaB activity in the lungs can be regulated after injury. Furthermore, the CD14-mediated LPS signaling pathway may play a role in the regulation of NF-kappaB alternative splicing in the lungs after injury.

Impact of tight glycemic control in severely burned children.

BACKGROUND: Control of hyperglycemia has been shown to decrease mortality in critically ill adults, but the benefits of strict glucose control have not been established in children. Since January 2002, our pediatric burn center has adopted a policy of 'intensive' insulin therapy to achieve blood glucose levels 90 to 120 mg/dL. The purpose of this study was to examine the impact of this practice on patient outcomes. METHODS: We reviewed the records of children with > or =30% total body surface area (TBSA) burn injury admitted to our regional pediatric burn center from July 1, 2000 to June 31, 2003. Patients were grouped into 'conventional insulin therapy' for the 2000 to 2001 period (n = 31) and into 'intensive insulin therapy' for the 2002 to 2003 period (n = 33). The efficacy of glucose control, infection rates, and patient survival were compared for the two therapies. RESULTS: The demographic characteristics and injury severity were similar between the conventional and intensive insulin therapy groups. Children receiving intensive insulin therapy had glucose levels of 90 to 120 mg/dL more consistently than those in the conventional insulin therapy group. There was a significant decrease in urinary tract infections among intensive insulin therapy patients. TBSA burn, percent full-thickness burn, and Pediatric Risk of Mortality scores were negatively related to survival; intensive insulin therapy was positively associated with survival. CONCLUSION: Intensive insulin therapy to maintain normoglycemia in severely burned children can be safely and effectively implemented in the burn unit. This therapy seems to lower infection rates and improve survival. Intensive insulin therapy should be considered for children with severe burn injuries.

Downregulation of NF-kappaB activity associated with alteration in proliferative response in the spleen after burn injury.

Alterations in proliferation status and cellular composition of immune organs are among key events in the modulation of immune function after burn injury. Nuclear factor (NF)-kappaB is a transcription factor that plays a pivotal role in the response to injury as well as immune cell differentiation and proliferation. In this study, we investigated the effects of burn injury on the activity of NF-kappaB and its association with cellular proliferation in the spleen. Western analysis of whole spleen tissues of mice after 18% burn injury revealed a marked reduction in nuclear NF-kappaB rel A protein expression 3 to 21 days after injury when there was an increase in proliferative activity in the red pulp of the spleen after injury as indicated by an increase in proliferating cell nuclear antigen (PCNA). In the splenic B cells, however, the down-regulation of NF-kappaB rel A was associated with decreased PCNA expression as well as IkappaBalpha and phosphorylated IkappaBalpha. In contrast, no significant change in NF-kappaB rel A or PCNA expression was observed for splenic T cells. These data suggest that there is a differential regulation of NF-kappaB and proliferative activity in the splenic cell subsets after burn injury. Furthermore, the regulation of NF-kappaB may be linked to the proliferative changes seen in the spleen after burn injury.

Late cardiac reoperation after cardiac transplantation.

BACKGROUND: The intermediate and long-term results of cardiac transplantation continue to improve. Subsequent cardiac procedures may be required to extend patient survival and protect graft function. METHODS: The medical records of all adult and pediatric cardiac transplant recipients who underwent a subsequent cardiac procedure at our institution were reviewed. RESULTS: Three hundred sixty patients have undergone primary orthotopic transplantation in our institution. Seventeen patients (12 adults, 5 children) underwent a subsequent procedure requiring cardiopulmonary bypass including cardiac retransplantation (10), coronary artery bypass grafting (3), ascending aortic replacement (2), tricuspid valve repair (1), and myotomy and myomectomy (1 patient). Mean interval from time of transplantation to second procedure was 8.3 years. There was one perioperative death. Two patients, both retransplants, died late postoperatively at 22 and 84 months, respectively. Overall mean follow-up in the late survivors is 26.6 months. All survivors are currently asymptomatic and doing well. CONCLUSIONS: A variety of subsequent cardiac procedures, in addition to retransplantation, can be performed safely in carefully selected cardiac transplant recipients. The intermediate term results are gratifying in terms of survival and freedom from symptoms.