Prospective, multicenter study of antimicrobial-coated, noncrosslinked, acellular porcine dermal matrix (XenMatrix™ AB Surgical Graft) for hernia repair in all centers for disease control and prevention wound classes: 24-month follow-up cohort.

Prospective, multicenter, single-arm study of antimicrobial-coated, noncrosslinked, acellular porcine dermal matrix (AC-PDM) in a cohort involving all centers for disease control and prevention wound classes in ventral/incisional midline hernia repair (VIHR). Materials and methods: Seventy-five patients (mean age 58.6±12.7 years; BMI 31.3±4.9 kg/m2) underwent ventral/incisional midline hernia repair with AC-PDM. Surgical site occurrence (SSO) was assessed in the first 45 days post-implantation. Length of stay, return to work, hernia recurrence, reoperation, quality of life, and SSO were assessed at 1, 3, 6, 12, 18, and 24 months. Results: 14.7% of patients experienced SSO requiring intervention within 45 days post-implantation, and 20.0% thereafter (>45 d post-implantation). Recurrence (5.8%), definitely device-related adverse events (4.0%), and reoperation (10.7%) were low at 24 months; all quality-of-life indicators were significantly improved compared to baseline. Conclusion: AC-PDM exhibited favourable results, including infrequent hernia recurrence and definitely device-related adverse events, with reoperation and SSO comparable to other studies, and significantly improved quality of life.

Point-of-Encounter Assessment: Using Health Belief Model Constructs to Change Grading Behaviors.

OBJECTIVE: Fourth-year medical students need feedback to improve. Even during 1-month rotations, there needs to be a formal mid-clerkship feedback session. Better feedback involves multiple surgical evaluators at multiple levels. Constructs from the Health Belief Model of behavior change were used to assess faculty and resident grading behaviors to create a more usable evaluation system. A point-of-encounter (POE) system was created. The objective of this study was to review the efficacy of a POE clinical evaluation card (CEC) system which was initiated to increase evaluator's participation in grading and formative feedback prior to mid-clerkship evaluation. DESIGN: The study was a 1-year retrospective cohort study reviewing the CECs for level of evaluator, content, and student compliance. A Likert-type scale survey regarding the usage of the clinical cards was also completed by evaluators. SETTING: Texas Tech University Health Sciences Center at El Paso, during 2 fourth-year medical student rotations, Subinternship (Sub-I), and Surgical Intensive Care Unit (SICU). PARTICIPANTS: 34 fourth-year medical students and 20 evaluators. RESULTS: Students turned in a mean of 10 cards, 75% in SICU and 65% in Sub-I turned in all 10 cards. There were significantly greater advanced residents evaluating during Sub-I vs SICU: mean evals by PGY3 were 1.9 vs 0.75 (p = .01) and mean evals by PGY5 were 1.4 vs 0.1 (p < .0001). There were significantly more faculty completing evaluations during SICU vs Sub-I: 2.5 faculty evals/student vs 1.4 faculty evals/student (p = .023). Evaluator ratings were high on a 5-point Likert-type scale, with most responses near the "strongly agree" rating of 4.7 to 4.8. CONCLUSIONS: Use of POE CECs met goals of having at least 7 CECs turned in by mid-clerkship and 10 at end-clerkships. Formative evaluations by mid-clerkship went from 0 to 7 evaluations. Evaluator surveys highlighted clarity and efficiency as reasons for using CECs.

Characteristics and Management of Blunt Renal Injury in Children.

BACKGROUND: Renal trauma in the pediatric population is predominately due to blunt mechanism of injury. Our purpose was to determine the associated injuries, features, incidence, management, and outcomes of kidney injuries resulting from blunt trauma in the pediatric population in a single level I trauma center. METHODS: This was a retrospective chart and trauma registry review of all pediatric blunt renal injuries at a regional level I trauma center that provides care to injured adults and children. The inclusion dates were January 2001-June 2014. RESULTS: Of 5790 pediatric blunt trauma admissions, 68 children sustained renal trauma (incidence: 1.2%). Only two had nephrectomies (2.9%). Five renal angiograms were performed, only one required angioembolization. Macroscopic hematuria rate was significantly higher in the high-grade injury group (47% vs. 16%; P = 0.031). Over half of the patients had other intra-abdominal injuries. The liver and spleen were the most frequently injured abdominal organs. CONCLUSION: Blunt renal trauma is uncommon in children and is typically of low American Association for the Surgery of Trauma injury grade. It is commonly associated with other intra-abdominal injuries, especially the liver and the spleen. The nephrectomy rate in pediatric trauma is lower compared to adult trauma. Most pediatric blunt renal injury can be managed conservatively by adult trauma surgeons.

Trauma patients warrant upper and lower extremity venous duplex ultrasound surveillance.

BACKGROUND: Due to the high incidence of thromboembolic events (deep venous thrombosis [DVT] and pulmonary embolus [PE]) after injury, many trauma centers perform lower extremity surveillance duplex ultrasounds. We hypothesize that trauma patients are at a higher risk of upper extremity DVTs (UEDVTs) than lower extremity DVTs (LEDVTs), and therefore, all extremities should be evaluated. MATERIALS AND METHODS: A retrospective chart and trauma registry review of Intensive Care Unit trauma patients with upper and LEDVTs detected on surveillance duplex ultrasound from January 2010 to December 2014 was carried out. Variables reviewed were age, gender, injury severity score, injury mechanism, clot location, day of clot detection, presence of central venous pressure catheter, presence of inferior vena cava filter, mechanical ventilation, and fracture. RESULTS: A total of 136 patients had a DVT in a 5-year period: upper - 71 (52.2%), lower - 61 (44.9%), both upper and lower - 4 (2.9%). Overall, 75 (55.2%) patients had a UEDVT. Upper DVT vein: Brachial (62), axillary (26), subclavian (11), and internal jugular (10). Lower DVT vein: femoral (58), popliteal (14), below knee (4), and iliac (2). 10.3% had a PE: UEDVT - 5 (6.7%) and LEDVT - 9 (14.8%) P = 0.159. CONCLUSIONS: The majority of the DVTs in the study were in the upper extremities. For trauma centers that aggressively screen the lower extremities with venous duplex ultrasound, surveillance to include the upper extremities is warranted.

Cecal bascule after spinal cord injury: A case series report.

INTRODUCTION: Cecal bascule is a rare cause of intestinal obstruction associated with upward and anterior folding of the ascending colon. We report three patients who presented with spinal cord injury complicated with a cecal bascule. Diagnosis and management of cecal bascule is discussed. PRESENTATION OF CASES: Patient 1: 59-year-old male sustained a traumatic brain injury and cervical spinal cord injury after a motorcycle crash. He had abdominal distension and the diagnosis of cecal bascule was made. Cecopexy was performed. Patient 2: 51-year-old male sustained an unstable C7 vertebral fracture with a cord contusion and quadriplegia after a diving incident. After an unsuccessful medical management of the colonic distension, the patient was taken for a laparotomy and cecal bascule was found. A cecostomy and a cecopexy were performed. Patient 3: 63-year-old male was transferred after a fall. He had diffuse degenerative changes in the thoracic and lumbar spine. He was found to have a perforated cecal bascule. He had a right hemicolectomy with an ileocolic anastomosis. DISCUSSION: We suggest the possibility of spinal cord injury being a risk factor for cecal bascule. Currently, right hemicolectomy is recommended for the treatment of cecal bascule. Cecopexy is also acceptable treatment option for a case in which the patient will be undergoing an operation with an insertion of hardware. CONCLUSION: The diagnosis of cecal bascule should be considered for trauma patients with cecal distention without delay in order to prevent disastrous complications.

Case-Based Learning and its Application in Medical and Health-Care Fields: A Review of Worldwide Literature.

INTRODUCTION: Case-based learning (CBL) is a newer modality of teaching healthcare. In order to evaluate how CBL is currently used, a literature search and review was completed. METHODS: A literature search was completed using an OVID© database using PubMed as the data source, 1946-8/1/2015. Key words used were "Case-based learning" and "medical education", and 360 articles were retrieved. Of these, 70 articles were selected to review for location, human health care related fields of study, number of students, topics, delivery methods, and student level. RESULTS: All major continents had studies on CBL. Education levels were 64% undergraduate and 34% graduate. Medicine was the most frequently represented field, with articles on nursing, occupational therapy, allied health, child development and dentistry. Mean number of students per study was 214 (7-3105). The top 3 most common methods of delivery were live presentation in 49%, followed by computer or web-based in 20% followed by mixed modalities in 19%. The top 3 outcome evaluations were: survey of participants, knowledge test, and test plus survey, with practice outcomes less frequent. Selected studies were reviewed in greater detail, highlighting advantages and disadvantages of CBL, comparisons to Problem-based learning, variety of fields in healthcare, variety in student experience, curriculum implementation, and finally impact on patient care. CONCLUSIONS: CBL is a teaching tool used in a variety of medical fields using human cases to impart relevance and aid in connecting theory to practice. The impact of CBL can reach from simple knowledge gains to changing patient care outcomes.

Hepatic "BOLSA" a novel method of perihepatic wrapping for hepatic hemorrhage "BOLSA".

INTRODUCTION: Severe traumatic liver hemorrhage quickly leads to exsanguination. Perihepatic packing is frequently used in damage control surgery. This method can be unsuccessful and accompanied by complications. Vicryl mesh wraps have been described in the treatment of liver hemorrhage. In this report, we describe an enhanced technique of hepatic wrapping in a case of hepatic bleeding after liver biopsy in a coagulopathic patient. The technique is called the hepatic "BOLSA" (Bag on Liver Supporting Anti-Hemorrhage). PRESENTATION OF CASE: A 59 year old male presented in the recovery room after liver biopsy of a mass, followed by angio-embolization of the hepatic mass 9h earlier. The patient was acidotic, coagulopathic, and demonstrated intra-abdominal hypertension. Computed tomography demonstrated perihepatic fluid. The patient continued hemorrhaging despite attempts to correct coagulopathy by transfusion. Multiple operating room visits were required where a combination of packing and hemostatic agents could not stop hepatic venous parenchymal hemorrhage. Mesh wrap consisting of Vicryl and PDS suture were used to create the "BOLSA" to achieve hemostasis. DISCUSSION: Perihepatic packing compromises pulmonary excursion, elevates intra-abdominal pressure, is a risk factor for sepsis, and requires an additional trip to the operating room for removal. The use of Vicryl mesh wrap obviates these complications. Previously described mesh wraps require anchoring. The self-supporting structure of the BOLSA simplifies construction and application. CONCLUSION: The BOLSA is an effective tool in treatment of severe liver hemorrhage in coagulopathic patients. It is the modern simplification of hepatic wrapping and the solution to the side effects of perihepatic packing.

Blunt traumatic bladder rupture: a 10-year perspective.

The purpose of this study was to determine the incidence, features, and associated injuries of intraperitoneal (IP) and extraperitoneal (EP) bladder rupture (BR) resulting from blunt trauma. A retrospective study from September 2001 to August 2011 was performed for blunt traumatic BR in adults. Demographics, mean Injury Severity Score (ISS), mean length of stay (LOS), incidence, mortality, operative repair, and associated injuries were evaluated. Of 15,168 adult blunt trauma admissions over 10 years, 54 patients had BR (EP = 22, IP = 27, EP + IP = 5; incidence = 0.36%). Sixty-three per cent were male. The mean age, ISS, and LOS were 40 years, 29, and 15 days, respectively. The mortality rate was 11 per cent. Fifty-two per cent of BR was the result of a motor vehicle crash. Most BRs were diagnosed by computed tomography cystogram. Eighty per cent had pelvic fracture. Hollow viscus injury was present in 34.5 per cent of patients. Colonic injury was seen in 24 per cent and 9.3 per cent had a rectal injury. Although BR is rare in adult blunt trauma, it is associated with high ISS, LOS, and mortality. Pelvic fractures are essentially present in all patients with EP BR. Hollow viscus injuries, especially colonic and rectal injuries, are more prominent in IP BR.

Case based review questions, review sessions, and call schedule type enhance knowledge gains in a surgical clerkship.

INTRODUCTION: Medical students in surgical clerkships must gain surgical knowledge while doing clinical rotations. We developed a self-learning program, which is case based, the Case Review Question (CRQ) system. Our hypothesis was that students who used CRQs would score higher on the summative test, Surgery NBME (National Board of Medical Examiners). METHODS: The setting is a surgical clerkship in a Liaison Council for Medical Education (LCME) approved Medical School, with summative examination using the NBME shelf examination in Surgery. Each CRQ document is a series of 20 to 25 questions based on cases. The cases are a paragraph, with pertinent medical facts and extra facts as distracters. The students are encouraged to use these questions to guide study. Students must come to a review session to hear the answers and a discussion. We review the NBME Surgery shelf examination scores taken before and after this program was initiated, along with changes in rotation group size, call schedule type, and other changes. RESULTS: CRQs, review sessions, and call schedule changes improved scores. NBME examination average rose from 77.12 to 82.01 (p = 0.004) after the CRQ program was initiated. Call schedule revision improved scores: intermittent call NBME score was 80.98, whereas night float schedule mean NBME was 84.66 (p < 0.001). During night float call, the CRQ program was already in effect, so that there is no non-CRQ program comparison group. Students scored higher in the second semester, throughout the study. First semester students scored a mean of 79.11, whereas second semester students scored 84.195 (p < 0.001). By the end of the study, there were no failures on the NBME examination, even in the first semester. The factors of presence of the CRQ program, review sessions, call schedule type, and which semester were all significant in a correlation matrix against NBME scores and in a regression analysis (p < 0.001). CONCLUSIONS: The CRQ program of case-based self-study was associated with higher scores on the NBME shelf examination, as a summative test of medical knowledge in surgery.

Injuries sustained after falls from bridges across the United States-Mexico border at El Paso.

OBJECTIVE: To compare demographics and motivations for falls from bridges at the United States-Mexico border and in El Paso County, Texas, and to analyze injuries and injury patterns to support intentionality and to provide treatment recommendations. METHODS: A retrospective observational review was conducted of hospital admissions to a trauma center after falls from bridges from 1995 to 2009. Statistical methods used were chi-square testing, T-test for means comparison, univariate correlations, and regression analysis. RESULTS: Of the 97 evaluated patients, 81.4% fell from U.S.-Mexico border bridges, including one patient who fell from a railway bridge; 74.7% of those falling from border bridges had a non-U.S. address, contrasting with 22.2% of those who fell within the United States. Falls over the border were associated with more immigration-related motivations and fewer suicide attempts. Injuries included lower extremities in 76 (78.4%) and thoracolumbar spine in 27 (27.8%) patients; 16 patients with a thoracolumbar spine fracture (59.3%) also had a lower extremity injury. Mean hospital length of stay was 7.2 days. Mean injury severity score was 8.45 (range 1-43). Age, injury severity score, and pelvic fracture increased the hospital length of stay. CONCLUSIONS: Patients fell while emigrating-immigrating based on residence and motivating factors. A dyad of lower extremity and thoracolumbar spine injuries coincided in 59.3% of those with a thoracolumbar spine injury; thoracolumbar spine imaging of patients evaluated after falls from bridges is recommended. Proposed prevention strategies include posting signs on bridges and installing catch-net safety barriers.

Injuries sustained after falls from bridges across the United State - Mexico border at El Paso / Traumatismos por caídas desde puentes que atraviesan la frontera entre México y los Estados Unidos en El Paso

Objective. To compare demographics and motivations for falls from bridges at the UnitedStates–Mexico border and in El Paso County, Texas, and to analyze injuries and injury patternsto support intentionality and to provide treatment recommendations.Methods. A retrospective observational review was conducted of hospital admissions to atrauma center after falls from bridges from 1995 to 2009. Statistical methods used were chisquaretesting, T-test for means comparison, univariate correlations, and regression analysis.Results. Of the 97 evaluated patients, 81.4% fell from U.S.–Mexico border bridges, includingone patient who fell from a railway bridge; 74.7% of those falling from border bridges hada non–U.S. address, contrasting with 22.2% of those who fell within the United States. Fallsover the border were associated with more immigration-related motivations and fewer suicideattempts. Injuries included lower extremities in 76 (78.4%) and thoracolumbar spine in 27(27.8%) patients; 16 patients with a thoracolumbar spine fracture (59.3%) also had a lowerextremity injury. Mean hospital length of stay was 7.2 days. Mean injury severity score was8.45 (range 1–43). Age, injury severity score, and pelvic fracture increased the hospital lengthof stay.Conclusions. Patients fell while emigrating–immigrating based on residence and motivatingfactors. A dyad of lower extremity and thoracolumbar spine injuries coincided in 59.3% ofthose with a thoracolumbar spine injury; thoracolumbar spine imaging of patients evaluatedafter falls from bridges is recommended. Proposed prevention strategies include posting signson bridges and installing catch-net safety barriers.

Objetivo. Comparar la información demográfica y las motivaciones relacionadascon las caídas desde puentes que atraviesan la frontera entre México y los EstadosUnidos en el condado de El Paso, Texas; analizar las lesiones y los patrones de lesionesque avalan la intencionalidad; y proporcionar recomendaciones terapéuticas.Métodos. Se llevó a cabo un examen retrospectivo observacional de las internacionesen un centro traumatológico debidas a caídas desde puentes que tuvieron lugarentre 1995 y el 2009. Los métodos estadísticos usados fueron la prueba de ji al cuadrado,la prueba T de comparación de medias, correlaciones de una sola variable y elanálisis de regresión.Resultados. De los 97 pacientes evaluados, 81,4% cayeron desde puentes ubicadosen la frontera México–Estados Unidos, incluido un paciente que cayó desde unpuente ferroviario; 74,7% de las personas que cayeron desde puentes fronterizostenían un domicilio no residente, en comparación con 22,2% en las personas que cayerondesde puentes ubicados en el interior de los Estados Unidos. Las caídas desdelos puentes fronterizos estaban asociadas con más motivaciones relacionadas con lainmigración y con menos intentos de suicidio. Las lesiones afectaban las extremidadesinferiores en 76 pacientes (78,4%) y la columna vertebral toracolumbar en 27 (27,8%);16 pacientes con fractura de la columna toracolumbar (59,3%) también presentabanlesión de las extremidades inferiores. La duración media de la hospitalización fue 7,2días. La puntuación media de gravedad de la lesión fue 8,45 (rango 1 a 43). Una mayoredad, una puntuación alta en la escala de gravedad de la lesión y la fractura pelvianaaumentaron la duración de la hospitalización.Conclusiones. Los pacientes cayeron durante un intento de emigración o inmigraciónrelacionado con la residencia y otros factores motivadores. En 59,3% de lospacientes con lesión de la columna vertebral toracolumbar esta coexistía con lesiónde las extremidades inferiores; al evaluar a pacientes con lesiones por caídas desdepuentes se recomienda efectuar estudios de imágenes de la columna vertebral toracolumbar.Las estrategias de prevención propuestas comprenden la colocación deseñales en los puentes y la instalación de redes de seguridad.

The association between Chance fractures and intra-abdominal injuries revisited: a multicenter review.

The association between Chance fractures and intra-abdominal injuries is reported to be as high as 89 per cent. Because prior studies were small series or case reports, we conducted a multicenter review to learn the true association between Chance fractures and intra-abdominal injuries as well as diagnostic trends. Trauma registry data, medical records, and radiology reports from 7 trauma centers were used to characterize 79 trauma patients with Chance fractures. Initial methods of abdominal assessment were computed tomography (CT) scan (79%), clinical examination (16%), and diagnostic peritoneal lavage (DPL) (5%). Twenty-six (33%) patients had intraabdominal injuries of which hollow viscus injuries predominated (22%). Twenty patients (25%) underwent laparotomy. The presence of an abdominal wall contusion and automobile restraint use were highly predictive of intra-abdominal injury and the need for laparotomy. The association between a Chance fracture and intra-abdominal injury is not as high as previously reported. CT scan has become the primary modality to assess the abdominal cavity of patients with Chance fractures, whereas the role of DPL has diminished.