Key Issues in Surgical Residency Education: Recommendations of the Blue Ribbon II Committee Residency Education Subcommittee.

In September 2022, a summit was convened by the American Board of Surgery (ABS) to discuss competency-based reform in surgical education. A key output of that summit was the recommendation that the prior work of the Blue Ribbon I Committee convened 20 years earlier be revived. With leadership from the American College of Surgeons (ACS) and the American Surgical Association (ASA) , the Blue Ribbon Committee (BRC) II was subsequently convened. This paper describes the output of the Residency Education Subcommittee of the BRC II Committee. The Subcommittee organized its work around prioritized themes including curriculum, assessment, and transition to practice. Top recommendations, time-based action steps, potential barriers, and required resources were detailed and vetted through group discussion, broader Committee review and critique, and subsequent refinement. Primary concluding emphases included transitioning to a competency-based training model, facilitating dynamically capable curricular reform emphasizing the digital transformation of surgical care, using predictive analytic assessment strategies to optimize training effectiveness and efficiency, and creating mentorship strategies to govern the transition from training to independent practice in an outcomes-accountable fashion. It was recognized that coordinated efforts across existing organizational structures will be required, informed by dataset integration strategies that meaningfully measure educational and related patient outcomes.

Sustaining Military Surgeons and the Joint Trauma System: Current Efforts, Unique Challenges, and Proposed Strategies in an Era of Global Uncertainty.

Mini abstract US military assets have been integral to the response to global pandemics, natural disasters, civilian casualties, and combat care. Strategies are being implemented to strengthen the military health care system and curtail the erosion of relevant surgical skills and knowledge during periods of low combat intensity. However, additional challenges remain. We describe these strategies and obstacles but also explore potential solutions that may strengthen the readiness of military surgeons and combat trauma teams.

Missing in action: A bibliometric analysis of military research in the medical literature since 1950.

BACKGROUND: Top-tier general and specialty scientific journals serve as a bellwether for national research priorities. We hypothesize that military-relevant publications are underrepresented in the scientific literature and that such publications decrease significantly during peacetime. METHODS: We identified high impact journals in the fields of Medicine, Surgery and Critical Care and developed Boolean searches for military-focused topics using National Library of Medicine Subject Headings terms. A PubMed search from 1950 to 2020 returned the number of research publications in relevant journals and the rate of military-focused publications by year. Rates of military publications were compared between peacetime and wartime. Publication rate trends were modeled with a quadratic function controlling for the start of active conflict and total casualty numbers. Baseline proportions of military physicians relative to the civilian sector served to estimate expected publication rates. Comparisons were performed using Pearson's Chi Square and Mann-Whitney U test, with p < 0.05 considered a significant difference. RESULTS: From 1950 to 2020, a total of 716,340 manuscripts were published in the journals queried. Of these, military-relevant manuscripts totaled 4,052 (0.57%). We found a significant difference in the rate of publication during times of peace and times of war (0.40% vs. 0.69%, p < 0.001). Subgroup analysis found significantly reduced rates of publication in medical and critical care journals during peacetime. For each conflict, the percentage of military-focused publications peaked during periods of war but then receded below baseline levels within a median of 2.5 years (interquartile range 1.5-3.8 years) during peacetime. The proportion of military-focused publications never reached the current proportion of military physicians in the workforce. CONCLUSION: There is marked reduction in rates of publication for military-focused articles in high impact journals during peacetime. Military-focused articles are underrepresented in high-impact journals. Investigators of military-relevant topics and editors of high-impact journals should seek to close this gap.

Refocusing the Military Health System to Support Role 4 Definitive Care in future large-scale combat operations.

ABSTRACT: The last twenty years of sustained combat operations during the Global War on Terror generated significant advancements in combat casualty care. Improvements in point-of-injury, en route, and forward surgical care appropriately aligned with the survival, evacuation, and return to duty needs of the small-scale unconventional conflict. However, casualty numbers in large-scale combat operations have brought into focus the critical need for modernized casualty receiving and convalescence: Role 4 definitive care (R4DC). Historically, World War II was the most recent conflict in which the United States fought in multiple operational theaters, with hundreds of thousands of combat casualties returned to the continental United States. These numbers necessitated the establishment of a "Zone of the Interior" which integrated military and civilian healthcare networks for definitive treatment and rehabilitation of casualties. Current security threats demand refocusing and bolstering the Military Health System's definitive care capabilities to maximize its force regeneration capacity in a similar fashion. Medical force generation, medical force sustainment and readiness, and integrated casualty care capabilities are three pillars that must be developed for MHS readiness of Role 4 definitive care in future large-scale contingencies against near-peer/peer adversaries.

Risk Factors and Outcomes of Late Posttraumatic Seizures in Combat-Related Traumatic Brain Injury.

INTRODUCTION: Post-traumatic seizures (PTSs) contribute to morbidity after traumatic brain injury (TBI). Early PTS are rare in combat casualties sustaining TBI, but the prevalence of late PTS is poorly described. We sought to define the prevalence and risk factors of late PTS in combat casualties with computed tomography evidence of TBI. METHODS: From 2010 to 2015, 687 combat casualties were transferred to a military treatment facility and included in the Department of Defense Trauma Registry. 71 patients with radiographic evidence of TBI were analyzed. Data collection included demographics, injury characteristics, interventions, medications, and outcomes. RESULTS: Of the 71 patients with evidence of TBI, 66 patients survived hospitalization and were followed. No patients had early PTS, and most received antiepileptic drugs (AEDs) for prophylaxis. At a median follow-up of 7.4 y, late PTS occurred in 25.8% of patients. Patients with late PTS were more severely injured (median Injury severity score 30 versus 24, P = 0.005) and required more blood products (18 units versus 2, P = 0.045). Patients with late PTS were more likely to have had a penetrating TBI (76.5% versus 38.8%, P = 0.01), multiple types of intracranial hemorrhage (94.1% versus 63.3%, P = 0.02), and cranial decompression (76.5% versus 28.6%, P = 0.001). Six-month Glasgow outcome scores were worse (3.5 versus 4.1 P = 0.001) in the late PTS population. No significant relationship was observed between administration of AEDs for early PTS prophylaxis and late PTS. CONCLUSIONS: Combat casualties with TBI suffering late PTS are more severely injured and require more blood products. Penetrating TBI, intracranial hemorrhage, and need for cranial decompression are correlated with late PTS, and associated with worse Glasgow Outcome Score. The administration of prophylactic AEDs for early PTS was not associated with a difference in rates of late PTS.

Evaluation of urological and gynecological surgeons as force multipliers for mass Casualty trauma care.

BACKGROUND: The clinical demands of mass casualty events strain even the most well-equipped trauma centers and are especially challenging in resource-limited rural, remote, or austere environments. Gynecologists and urologists care for patients with pelvic and abdominal injuries, but the extent to which they are able to serve as "force multipliers" for trauma care is unclear. This study examined the abilities of urologists and gynecologists to perform 32 trauma procedures after mentored training by expert trauma educators to inform the potential for these specialists to independently care for trauma patients. METHODS: Urological (6), gynecological surgeons (6), senior (PGY5) general surgery residents (6), and non-trauma trained general surgeons (8) completed a rigorous trauma training program (ASSET+). All participants were assessed in their trauma knowledge and surgical abilities performing 32 trauma procedures pre/post mentored training by expert trauma surgeons. Performance benchmarks were set for knowledge (80%) and independent, accurate completion of all procedural components within a realistic time window (90%). RESULTS: General surgery participants demonstrated greater trauma knowledge than gynecologists and urologists; however, none of the specialties reached the 80% benchmark. Pre-training, general surgery and urology participants outperformed gynecologists for overall procedural abilities. Post-training, only general surgeons met the 90% benchmark. Post-hoc analysis revealed no differences between the groups performing most pelvic and abdominal procedures, however knowledge associated with decision making and judgment in the provision of trauma care was significantly below the benchmark for gynecologists and urologists, even after training. CONCLUSION: For physiologically stable patients with traumatic injuries to the abdomen, pelvis or retroperitoneum, these specialists might be able to provide appropriate care; however, they would best benefit trauma patients in the capacity of highly skilled assisting surgeons to trauma specialists. These specialists should not be considered for solo resuscitative surgical care. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level III/IV.

Putting the ready in readiness: A post-hoc analysis of surgeon performance during a military MASCAL in Afghanistan.

BACKGROUND: All military surgeons must maintain trauma capabilities for expeditionary care contexts, yet most are not trauma specialists. Maintaining clinical readiness for trauma and mass casualty care is a significant challenge for military and civilian surgeons. We examined the effect of a prescribed clinical readiness program for expeditionary trauma care on the surgical performance of 12 surgeons during a 60-patient MASCAL event. METHODS: The sample included orthopaedic (4) and general surgeons (8) who cared for MASCAL victims at Hamad Karzai International Airport, Kabul, Afghanistan on 26 August 2021. One orthopaedic and two general surgeons had prior deployment experience. The prescribed program included three primary measures of clinical readiness: 1. expeditionary knowledge (exam score), 2. procedural skills competencies (performance assessment score), 3. clinical activity (operative practice profile metric). Data were attained from program records for each surgeon in the sample. Each of the 60 patient cases were reviewed and rated (performance score) by The Joint Trauma System's Performance Improvement Branch; a military-wide performance improvement organization. All scores were normalized to facilitate direct comparisons using effect size calculations between each pre-deployment measure and MASCAL surgical care. RESULTS: Pre-deployment knowledge and clinical activity measures met program benchmarks. Baseline pre-deployment procedural skills competency scores did not meet program benchmarks, however those gaps were closed through re-training, ensuring all surgeons met or exceeded the program benchmarks pre-deployment. There were very large effect sizes (Cohen's d) between all program measures and surgical care score, confirming the relationship between the program measures and MASCAL trauma care provided by the 12 surgeons. CONCLUSION: The prescribed program measures ensured all surgeons achieved pre-deployment performance benchmarks and provided high quality trauma care to our nation's servicemembers. LEVEL OF EVIDENCE: Prognostic, Level III/IV.

Derivation and Validation of Generalized Sepsis-induced Acute Respiratory Failure Phenotypes Among Critically Ill Patients: A Retrospective Study.

Background: Septic patients who develop acute respiratory failure (ARF) requiring mechanical ventilation represent a heterogenous subgroup of critically ill patients with widely variable clinical characteristics. Identifying distinct phenotypes of these patients may reveal insights about the broader heterogeneity in the clinical course of sepsis. We aimed to derive novel phenotypes of sepsis-induced ARF using observational clinical data and investigate their generalizability across multi-ICU specialties, considering multi-organ dynamics. Methods: We performed a multi-center retrospective study of ICU patients with sepsis who required mechanical ventilation for ≥24 hours. Data from two different high-volume academic hospital systems were used as a derivation set with N=3,225 medical ICU (MICU) patients and a validation set with N=848 MICU patients. For the multi-ICU validation, we utilized retrospective data from two surgical ICUs at the same hospitals (N=1,577). Clinical data from 24 hours preceding intubation was used to derive distinct phenotypes using an explainable machine learning-based clustering model interpreted by clinical experts. Results: Four distinct ARF phenotypes were identified: A (severe multi-organ dysfunction (MOD) with a high likelihood of kidney injury and heart failure), B (severe hypoxemic respiratory failure [median P/F=123]), C (mild hypoxia [median P/F=240]), and D (severe MOD with a high likelihood of hepatic injury, coagulopathy, and lactic acidosis). Patients in each phenotype showed differences in clinical course and mortality rates despite similarities in demographics and admission co-morbidities. The phenotypes were reproduced in external validation utilizing an external MICU from second hospital and SICUs from both centers. Kaplan-Meier analysis showed significant difference in 28-day mortality across the phenotypes (p<0.01) and consistent across both centers. The phenotypes demonstrated differences in treatment effects associated with high positive end-expiratory pressure (PEEP) strategy. Conclusion: The phenotypes demonstrated unique patterns of organ injury and differences in clinical outcomes, which may help inform future research and clinical trial design for tailored management strategies.

The influence of microbial colonization on inflammatory versus pro-healing trajectories in combat extremity wounds.

A combination of improved body armor, medical transportation, and treatment has led to the increased survival of warfighters from combat extremity injuries predominantly caused by blasts in modern conflicts. Despite advances, a high rate of complications such as wound infections, wound failure, amputations, and a decreased quality of life exist. To study the molecular underpinnings of wound failure, wound tissue biopsies from combat extremity injuries had RNA extracted and sequenced. Wounds were classified by colonization (colonized vs. non-colonized) and outcome (healed vs. failed) status. Differences in gene expression were investigated between timepoints at a gene level, and longitudinally by multi-gene networks, inferred proportions of immune cells, and expression of healing-related functions. Differences between wound outcomes in colonized wounds were more apparent than in non-colonized wounds. Colonized/healed wounds appeared able to mount an adaptive immune response to infection and progress beyond the inflammatory stage of healing, while colonized/failed wounds did not. Although, both colonized and non-colonized failed wounds showed increasing inferred immune and inflammatory programs, non-colonized/failed wounds progressed beyond the inflammatory stage, suggesting different mechanisms of failure dependent on colonization status. Overall, these data reveal gene expression profile differences in healing wounds that may be utilized to improve clinical treatment paradigms.

Developing the Ready Military Medical Force: military-specific training in Graduate Medical Education.

Introduction: Graduate Medical Education plays a critical role in training the next generation of military physicians, ensuring they are ready to uphold the dual professional requirements inherent to being both a military officer and a military physician. This involves executing the operational duties as a commissioned leader while also providing exceptional medical care in austere environments and in harm's way. The purpose of this study is to review prior efforts at developing and implementing military unique curricula (MUC) in residency training programs. Methods: We performed a literature search in PubMed (MEDLINE), Embase, Web of Science, and the Defense Technical Information Center through August 8, 2023, including terms "graduate medical education" and "military." We included articles if they specifically addressed military curricula in residency with terms including "residency and operational" or "readiness training", "military program", or "military curriculum". Results: We identified 1455 articles based on title and abstract initially and fully reviewed 111. We determined that 64 articles met our inclusion criteria by describing the history or context of MUC, surveys supporting MUC, or military programs or curricula incorporated into residency training or military-specific residency programs. Conclusion: We found that although there have been multiple attempts at establishing MUC across training programs, it is difficult to create a uniform curriculum that can be implemented to train residents to a single standard across services and specialties.

ClotCatcher: a novel natural language model to accurately adjudicate venous thromboembolism from radiology reports.

INTRODUCTION: Accurate identification of venous thromboembolism (VTE) is critical to develop replicable epidemiological studies and rigorous predictions models. Traditionally, VTE studies have relied on international classification of diseases (ICD) codes which are inaccurate - leading to misclassification bias. Here, we developed ClotCatcher, a novel deep learning model that uses natural language processing to detect VTE from radiology reports. METHODS: Radiology reports to detect VTE were obtained from patients admitted to Emory University Hospital (EUH) and Grady Memorial Hospital (GMH). Data augmentation was performed using the Google PEGASUS paraphraser. This data was then used to fine-tune ClotCatcher, a novel deep learning model. ClotCatcher was validated on both the EUH dataset alone and GMH dataset alone. RESULTS: The dataset contained 1358 studies from EUH and 915 studies from GMH (n = 2273). The dataset contained 1506 ultrasound studies with 528 (35.1%) studies positive for VTE, and 767 CT studies with 91 (11.9%) positive for VTE. When validated on the EUH dataset, ClotCatcher performed best (AUC = 0.980) when trained on both EUH and GMH dataset without paraphrasing. When validated on the GMH dataset, ClotCatcher performed best (AUC = 0.995) when trained on both EUH and GMH dataset with paraphrasing. CONCLUSION: ClotCatcher, a novel deep learning model with data augmentation rapidly and accurately adjudicated the presence of VTE from radiology reports. Applying ClotCatcher to large databases would allow for rapid and accurate adjudication of incident VTE. This would reduce misclassification bias and form the foundation for future studies to estimate individual risk for patient to develop incident VTE.

Targeted metagenomic assessment reflects critical colonization in battlefield injuries.

IMPORTANCE: Microbial contamination in combat wounds can lead to opportunistic infections and adverse outcomes. However, current microbiological detection has a limited ability to capture microbial functional genes. This work describes the application of targeted metagenomic sequencing to profile wound bioburden and capture relevant wound-associated signatures for clinical utility. Ultimately, the ability to detect such signatures will help guide clinical decisions regarding wound care and management and aid in the prediction of wound outcomes.

Use of Levetiracetam for Post-Traumatic Seizure Prophylaxis in Combat-Related Traumatic Brain Injury.

INTRODUCTION: Post-traumatic seizure (PTS) prophylaxis is recommended in patients with traumatic brain injury (TBI) at high risk for PTSs, but consensus on the optimal pharmacologic therapy has not yet been established. Levetiracetam is frequently used for seizure prophylaxis in combat-related TBI, but its efficacy and safety in this patient population has not yet been described. METHODS: A retrospective cohort of 687 consecutive casualties transferred to the CONUS from October 2010 to December 2015 was analyzed. Seventy-one patients with combat-related injuries and radiographic evidence of skull fractures or intracranial hemorrhage were included. Data collection included demographics and injury characteristics including initial Glasgow Coma Scale, computed tomography findings, interventions, and 6-month Glasgow Outcome Score. RESULTS: All patients in this cohort were male, with an average age of 25 (median 24; Interquartile range (IQR) 4.5) and an average Injury Severity Score of 28 (median 27; IQR 15). The most common mechanism of injury was explosive blast (76%). Penetrating TBI was common (51%). Most patients (88.7%) were administered seizure prophylaxis. Of these, the majority (61/63) received levetiracetam, and the additional two were administered phenytoin. The remaining 11.3% of patients were deemed not to require seizure prophylaxis. The incidence of seizures while on prophylaxis was low (2.8%) and occurred in patients who suffered transcranial gunshot wounds and ultimately died. No serious adverse effects were attributed to levetiracetam. CONCLUSIONS: Levetiracetam appears to be a safe and effective medication for PTS prophylaxis in combat casualties. The rate of PTSs in combat-related TBI on appropriate prophylaxis is low.

A random forest model using flow cytometry data identifies pulmonary infection after thoracic injury.

BACKGROUND: Thoracic injury can cause impairment of lung function leading to respiratory complications such as pneumonia (PNA). There is increasing evidence that central memory T cells of the adaptive immune system play a key role in pulmonary immunity. We sought to explore whether assessment of cell phenotypes using flow cytometry (FCM) could be used to identify pulmonary infection after thoracic trauma. METHODS: We prospectively studied trauma patients with thoracic injuries who survived >48 hours at a Level 1 trauma center from 2014 to 2020. Clinical and FCM data from serum samples collected within 24 hours of admission were considered as potential variables. Random forest and logistic regression models were developed to estimate the risk of hospital-acquired and ventilator-associated PNA. Variables were selected using backwards elimination, and models were internally validated with leave-one-out. RESULTS: Seventy patients with thoracic injuries were included (median age, 35 years [interquartile range (IQR), 25.25-51 years]; 62.9% [44 of 70] male, 61.4% [42 of 70] blunt trauma). The most common injuries included rib fractures (52 of 70 [74.3%]) and pulmonary contusions (26 of 70 [37%]). The incidence of PNA was 14 of 70 (20%). Median Injury Severity Score was similar for patients with and without PNA (30.5 [IQR, 22.6-39.3] vs. 26.5 [IQR, 21.6-33.3]). The final random forest model selected three variables (Acute Physiology and Chronic Health Evaluation score, highest pulse rate in first 24 hours, and frequency of CD4 + central memory cells) that identified PNA with an area under the curve of 0.93, sensitivity of 0.91, and specificity of 0.88. A logistic regression with the same features had an area under the curve of 0.86, sensitivity of 0.76, and specificity of 0.85. CONCLUSION: Clinical and FCM data have diagnostic utility in the early identification of patients at risk of nosocomial PNA following thoracic injury. Signs of physiologic stress and lower frequency of central memory cells appear to be associated with higher rates of PNA after thoracic trauma. LEVEL OF EVIDENCE: Diagnostic Test/Criteria; Level IV.

Central role for neurally dysregulated IL-17A in dynamic networks of systemic and local inflammation in combat casualties.

Dynamic Network Analysis (DyNA) and Dynamic Hypergraphs (DyHyp) were used to define protein-level inflammatory networks at the local (wound effluent) and systemic circulation (serum) levels from 140 active-duty, injured service members (59 with TBI and 81 non-TBI). Interleukin (IL)-17A was the only biomarker elevated significantly in both serum and effluent in TBI vs. non-TBI casualties, and the mediator with the most DyNA connections in TBI wounds. DyNA combining serum and effluent data to define cross-compartment correlations suggested that IL-17A bridges local and systemic circulation at late time points. DyHyp suggested that systemic IL-17A upregulation in TBI patients was associated with tumor necrosis factor-α, while IL-17A downregulation in non-TBI patients was associated with interferon-γ. Correlation analysis suggested differential upregulation of pathogenic Th17 cells, non-pathogenic Th17 cells, and memory/effector T cells. This was associated with reduced procalcitonin in both effluent and serum of TBI patients, in support of an antibacterial effect of Th17 cells in TBI patients. Dysregulation of Th17 responses following TBI may drive cross-compartment inflammation following combat injury, counteracting wound infection at the cost of elevated systemic inflammation.

Development, refinement, and characterization of a nonhuman primate critical care environment.

BACKGROUND: Systemic inflammatory response remains a poorly understood cause of morbidity and mortality after traumatic injury. Recent nonhuman primate (NHP) trauma models have been used to characterize the systemic response to trauma, but none have incorporated a critical care phase without the use of general anesthesia. We describe the development of a prolonged critical care environment with sedation and ventilation support, and also report corresponding NHP biologic and inflammatory markers. METHODS: Eight adult male rhesus macaques underwent ventilation with sedation for 48-96 hours in a critical care setting. Three of these NHPs underwent "sham" procedures as part of trauma control model development. Blood counts, chemistries, coagulation studies, and cytokines/chemokines were collected throughout the study, and histopathologic analysis was conducted at necropsy. RESULTS: Eight NHPs were intentionally survived and extubated. Three NHPs were euthanized at 72-96 hours without extubation. Transaminitis occurred over the duration of ventilation, but renal function, acid-base status, and hematologic profile remained stable. Chemokine and cytokine analysis were notable for baseline fold-change for Il-6 and Il-1ra (9.7 and 42.7, respectively) that subsequently downtrended throughout the experiment unless clinical respiratory compromise was observed. CONCLUSIONS: A NHP critical care environment with ventilation support is feasible but requires robust resources. The inflammatory profile of NHPs is not profoundly altered by sedation and mechanical ventilation. NHPs are susceptible to the pulmonary effects of short-term ventilation and demonstrate a similar bioprofile response to ventilator-induced pulmonary pathology. This work has implications for further development of a prolonged care NHP model.

Evidence-based Surgical Competency Outcomes from the Clinical Readiness Program.

OBJECTIVES: 1) Evaluate the value and strength of a competency framework for identifying and measuring performance requirements for expeditionary surgeons; 2) Verify psychometric integrity of assessment instrumentation for measuring domain knowledge and skills; 3) Identify gaps in knowledge and skills capabilities using assessment strategies; 4) Examine shared variance between knowledge and skills outcomes, and the volume and diversity of routine surgical practice. BACKGROUND: Expeditionary military surgeons provide care for patients with injuries that extend beyond the care requirements of their routine surgical practice. The readiness of these surgeons to independently provide accurate care in expeditionary contexts is important for casualty care in military and civilian situations. Identifying and closing performance gap areas are essential for assuring readiness. METHODS: We implemented evidence-based processes for identifying and measuring the essential performance competencies for expeditionary surgeons. All assessment instrumentation was rigorously examined for psychometric integrity. Performance outcomes were directly measured for expeditionary surgical knowledge and skills and gap areas were identified. Knowledge and skills assessment outcomes were compared, and also compared to the volume and diversity of routine surgical practice to determine shared variance. RESULTS: Outcomes confirmed the integrity of assessment instrumentation and identified significant performance gaps for knowledge and skills in the domain. CONCLUSIONS: Identification of domain competencies and performance benchmarks, combined with best-practices in assessment instrumentation, provided a rigorous and defensible framework for quantifying domain competencies. By identifying and implementing strategies for closing performance gap areas, we provide a positive process for assuring surgical competency and clinical readiness.

Multidimensional machine learning models predicting outcomes after trauma.

BACKGROUND: An emerging body of literature supports the role of individualized prognostic tools to guide the management of patients after trauma. The aim of this study was to develop advanced modeling tools from multidimensional data sources, including immunological analytes and clinical and administrative data, to predict outcomes in trauma patients. METHODS: This was a prospective study of trauma patients at Level 1 centers from 2015 to 2019. Clinical, flow cytometry, and serum cytokine data were collected within 48 hours of admission. Sparse logistic regression models were developed, jointly selecting predictors and estimating the risk of ventilator-associated pneumonia, acute kidney injury, complicated disposition (death, rehabilitation, or nursing facility), and return to the operating room. Model parameters (regularization controlling model sparsity) and performance estimation were obtained via nested leave-one-out cross-validation. RESULTS: A total of 179 patients were included. The incidences of ventilator-associated pneumonia, acute kidney injury, complicated disposition, and return to the operating room were 17.7%, 28.8%, 22.5%, and 12.3%, respectively. Regarding extensive resource use, 30.7% of patients had prolonged intensive care unit stay, 73.2% had prolonged length of stay, and 23.5% had need for prolonged ventilatory support. The models were developed and cross-validated for ventilator-associated pneumonia, acute kidney injury, complicated dispositions, and return to the operating room, yielding predictive areas under the curve from 0.70 to 0.91. Each model derived its optimal predictive value by combining clinical, administrative, and immunological analyte data. CONCLUSION: Clinical, immunological, and administrative data can be combined to predict post-traumatic outcomes and resource use. Multidimensional machine learning modeling can identify trauma patients with complicated clinical trajectories and high resource needs.

Virtual reality and haptic interfaces for civilian and military open trauma surgery training: A systematic review.

OBJECTIVE: Virtual (VR), augmented (AR), mixed reality (MR) and haptic interfaces make additional avenues available for surgeon assessment, guidance and training. We evaluated applications for open trauma and emergency surgery to address the question: Have new computer-supported interface developments occurred that could improve trauma training for civilian and military surgeons performing open, emergency, non-laparoscopic surgery? DESIGN: Systematic literature review. SETTING AND PARTICIPANTS: Faculty, University of Maryland School of Medicine, Baltimore., Maryland; Womack Army Medical Center, Fort Bragg, North Carolina; Temple University, Philadelphia, Pennsylvania; Uniformed Services University of Health Sciences, and Walter Reed National Military Medical Center, Bethesda, Maryland. METHODS: Structured literature searches identified studies using terms for virtual, augmented, mixed reality and haptics, as well as specific procedures in trauma training courses. Reporting bias was assessed. Study quality was evaluated by the Kirkpatrick's Level of evidence and the Machine Learning to Asses Surgical Expertise (MLASE) score. RESULTS: Of 422 papers identified, 14 met inclusion criteria, included 282 enrolled subjects, 20% were surgeons, the remainder students, medics and non-surgeon physicians. Study design was poor and sample sizes were low. No data analyses were beyond descriptive and the highest outcome types were procedural success, subjective self-reports, except three studies used validated metrics. Among the 14 studies, Kirkpatrick's level of evidence was level zero in five studies, level 1 in 8 and level 2 in one. Only one study had MLASE Score greater than 9/20. There was a high risk of bias in 6 studies, uncertain bias in 5 studies and low risk of bias in 3 studies. CONCLUSIONS: There was inadequate evidence that VR,MR,AR or haptic interfaces can facilitate training for open trauma surgery or replace cadavers. Because of limited testing in surgeons, deficient study and technology design, risk of reporting bias, no current well-designed studies of computer-supported technologies have shown benefit for open trauma, emergency surgery nor has their use shown improved patient outcomes. Larger more rigorously designed studies and evaluations by experienced surgeons are required for a greater variety of procedures and skills. COMPETENCIES: Medical Knowledge, Practice Based Learning and Improvement, Patient Care, Systems-Based Practice.