Management of Pediatric Cavum Cysts: A Scoping Review and a Single Institution Case Series.

INTRODUCTION: Pediatric cavum cysts are a rare yet complicated pathology to manage. The literature is scarce, primarily consisting of case series, and lacking a consensus regarding clear management. In this scoping review, we aimed to compile existing information in the literature regarding the management of pediatric cavum cysts across the last 10 years. We also present our management of 19 patients, the largest case series to date, highlighting knowledge gaps surrounding the management of this salient pathology. METHODS: A literature search using PubMed and SCOPUS was conducted using the following search terms: (pediatric) AND (Cavum septum pellucidum) OR (cavum vergae) OR (cavum velum interpositum) AND (management). Eligibility criteria included peer-reviewed publication published in the last 10 years, pediatric population, cavum cyst, and English language. A retrospective search was conducted for all pediatric cavum cysts between 2013 and 2023 at our institution. Clinical and radiographic characteristics as well as intervention and outcome data were collected for both the scoping review and our cases. RESULTS: 330 total articles were populated using our search. 12 articles met our inclusion criteria. 41.7% (n = 5) of the articles were case series, 33.3% (n = 4) were case reports, 8.3% (n = 1) was a technical article, 8.3% (n = 1) was a systematic review, and 8.3% (n = 1) was a case questionnaire. Resolution of symptoms was noted in all articles of our scoping review, regardless of treatment modality. The average age in our case series was 9.84 years old and average age at diagnosis was 5.53 years old. 6 patients (31.6%) were female and 13 patients (68.4%) were male. 2 out of the 19 patients (10.5%) were surgically treated. CONCLUSION: There is no clear consensus on the management of cavum cysts. A prospective, multicenter study is needed to create standardized pediatric cyst management guidelines. The current thought is that surgical intervention should be saved for those patients with obstructive hydrocephalus and signs of intracranial hypertension.

Barbary macaques show sex-related differences in body weight based on anthropogenic food exposure despite comparable female-male stable isotope ratios.

As the human-primate interface expands, many nonhuman primate (NHP) populations exploit anthropogenic foods to survive, while some populations opportunistically target them. Though anthropogenic food consumption is sometimes associated with greater reproductive output and survival in these populations, there is a dearth of research on possible health effects. We explore how differential exposure to anthropogenic foods is linked to variation in isotopic compositions (δ13C and δ15N) and body weights in Barbary macaques (Macaca sylvanus) in the Upper Rock Nature Reserve, Gibraltar. We placed monkeys into three categories based on anthropogenic food exposure. We then analyzed individuals for isotopic signatures (N = 147) and body weight measurements (N = 80). Using the lowest exposure category as the comparison, we found body weights and δ15N values, but not δ13C values, significantly differed across key categories. Within categories, we found no significant associations between sex and δ13C or δ15N values, suggesting that individuals within categories consumed similar foods regardless of sex. We found a significant interaction effect between category and sex for predicting body weights. These results suggest that sex plays a role in how anthropogenic foods are accessed and consumed regardless of exposure, which may result in differential health profiles for female and male macaques.

A Community-Engaged Approach to Understanding Suicide in a Small Rural County in Georgia: A Two-Phase Content Analysis of Individual and Focus Group Interviews.

Suicide is a significant public health problem, with disproportionate rates in rural areas. Rural communities face substantial structural and cultural barriers to suicide prevention. This study aimed to gain a deeper understanding of the need for suicide prevention and gauge the appropriateness of prevention efforts in the context of a rural Georgia county by leveraging existing community resources and knowledge. Twenty one-on-one, semi-structured interviews and two focus groups were conducted, with participants recruited via purposive snowball sampling. Data analysis included qualitative deductive and inductive content analysis from individual interviews and focus groups with community stakeholders. The findings highlight how rural contexts exacerbate drivers of death by suicide and how the substantial loss of community members to suicide contributes to the ongoing crisis and reduces available support. Access to mental health care often depended on a connection to an established public system such as schools, a military base, or Veterans Administration. There were perceived gaps in crisis and post-crisis services, with participants actively trying to address these gaps and build community support through coalition building. This study contributes knowledge to contextual drivers of suicide in rural areas beyond individual-level risk factors. Community-engaged suicide prevention research in rural areas is promising, but there is a need to develop interventions to best support coalition building and capacity development.

Bumps and Bruises in the Trauma Bay: A Level One Trauma Center's Analysis of Dedicated Skeletal X-Ray Imaging.

The Ottawa Ankle Rule and Canadian C-Spine Rule were created to guide the utility of radiographic studies. There are no guidelines to guide X-rays within trauma. Our objective was to evaluate which findings have the highest yield for determining fractures on skeletal x-ray. A retrospective study was performed on 5050 patients at a level one trauma center from January 2018 through October 2019. 2382 patients received X-Rays. Our analysis focused on five categories: limb deformity/obvious open fracture, abrasions, hematoma/contusion/sprain, laceration, and skin tear. Standard demographic and outcome variables were collected. While the cost burden on an overwhelmed system, time in the trauma bay prior to disposition and radiation exposure has not been fully evaluated, our evidence shows that X-Rays ordered for soft tissue defects are less sensitive at identifying fracture (0.0-6.9% fracture detection rate, P = 0.00) than when ordered for limb deformity or obvious fracture.

Isolated Hip Fractures in the Elderly: Best Practice Analysis of Perioperative Medical Optimization Including Effect of Comorbidities, Functional Status, and Demographics.

Isolated hip fractures (IHFs) contribute to functional decline in the elderly. Our purpose was to evaluate IHF at two level 1 trauma centers and the effect of comorbidities on length of stay (LOS), ICU admission, disposition, and mortality. A retrospective study from July 2016 through December 2020 including patients ≥65 with IHFs identified 785 patients. Prior dependent functional status yielded a longer LOS (>6 days vs <6 days, P = .01). Comorbidities were not associated with increased LOS or ICU admission. ICU admission rate was 12.75%. Patients with advanced directive had increased ICU admission (8% vs 3%). The mortality rate was 2%. Increased mortality was seen with advanced directives (17% vs 2%, P < .05) and cirrhosis/substance abuse (12% vs 2%, P < .05). Disposition included home (20%), rehabilitation (43%), and SNF (31%). Comorbidities did not affect ICU admission, LOS, or disposition; however, cirrhosis/substance abuse demonstrated increased mortality.

A Descriptive Analysis of Patients With Attempted Suicide at a Rural Level I Trauma Center.

Objectives: For patients with self-harm, suicide attempt, or suicide completion, the trauma bay is often the single point of contact. Regional differences and patterns exist for suicide that should be studied to enhance preventive strategies. Our goal was to critically evaluate the suicidal population of Southeast Georgia over a 9-year period. Methods: A retrospective review of our trauma database from January 2010 through December 2019 was conducted at a Level I Trauma Center. All ages were included. All patients arriving with attempted suicide or death due to a suicidal complication were included. Patients with deaths highly suspicious for suicide were also included. Exclusion criteria included accidental motor vehicle death, accidental generalized deaths, and accidental drowning. Age, gender, race, ethnicity, mechanism of injury (MOI), death rates, length of stay (LOS), injury severity score (ISS), home zip code, day of the week, transfer vs. from scene, location of injury, alcohol levels, and urine drug screening results were analyzed. Results: From 2010 to 2019, there were 381 total suicides with 260 survivals and 121 completions (mortality: 31.7%) at our Level I Trauma Center. The majority of suicides were performed by middle-aged White men with an average age of 40 years (SD: 17.2). This was true even if the White race was not the majority race in the patient's zip code. The majority of the time, these patients presented directly from the scene and, if the patient's suicide location was known, it usually took place at their home. Other common areas included secluded areas, such as wooded areas, and personal vehicles. Of the suicides, 11.6% were performed within the criminal justice system including jail and solitary confinement. The average LOS following admission was 7.51 days (SD: 22.1). The majority of suicides came from the metro Savannah district, which has higher unemployment and poverty rates than other parts of our study area. Gun violence was the most common MOI for suicide (75%). If suicide was attempted via a penetrating mechanism including glass, knife, or gun, there was an increased rate of death when compared to our general data (38% vs. 31%). When the gun mechanisms were analyzed as a group, there was a 57% rate of death after arrival at the hospital. Acute alcohol intoxication was present in 56.6% of patients and 80 (21%) had drugs in their system. Conclusion: Our data demonstrate epidemiologic and socioeconomic trends in Southeast Georgia. This included increased alcohol intoxication, deaths related to gun use, and in a higher incidence of suicide among White males, including geographic locations where the White race is not the majority. Suicides and suicide attempts were also more common in areas with higher unemployment rates.

Quality of ICU Discharge Summaries Produced by Pediatric Residents: The Memorial Health University Medical Center Experience.

Background: Discharging intensive care unit (ICU) patients directly home is becoming more common. High-quality ICU discharge summaries are crucial in the transition of patient care. Currently, at Memorial Health University Medical Center (MHUMC), there exists no standardized ICU discharge summary template or consistency when discharge documentation is completed. Investigators evaluated the timeliness and completeness of ICU discharge summaries at MHUMC produced by pediatric residents. Methods: A single-center retrospective chart review of pediatric patients discharged directly from a 10-bed Pediatric ICU to home was conducted. Charts were evaluated pre- and post-intervention. The intervention included the implementation of a standardized ICU discharge template, formal resident training in writing discharge summaries, and a new policy mandating documentation completion within 48 hours of patient discharge. Timeliness was based on documentation completion within 48 hours. Completeness was evaluated on the presence of the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) recommendations of specific components that should be included in all discharge summaries. Results were reported as proportions, with differences calculated using Fisher's exact and chi-square tests. Patient descriptive characteristics were recorded. Results: Thirty-nine total patients, 13 pre-intervention and 26 post-intervention were included in the study. In the pre-intervention group, 38.5% (5/13) had discharge summaries completed in less than 48 hours from patient discharge compared to 88.5% (23/26) in the post-intervention group (P=.002). Post-intervention discharge documentation was more likely than pre-intervention to contain the discharge diagnosis (100% vs. 69.2%, P=.009) and to provide follow-up care instructions for the outpatient physician (100% vs. 75%, P=.031). Conclusion: Standardizing discharge summary templates and encouraging stricter institutional policies regarding the timely completion of discharge summaries can improve the ICU discharge process. Formal resident training in medical documentation is important and should be incorporated into graduate medical education curricula.

Clinical characteristics, appropriateness of empiric antibiotic therapy, and outcome of Pseudomonas aeruginosa bacteremia across multiple community hospitals.

There is relatively little contemporary information regarding clinical characteristics of patients with Pseudomonas aeruginosa bacteremia (PAB) in the community hospital setting. This was a retrospective, observational cohort study examining the clinical characteristics of patients with PAB across several community hospitals in the USA with a focus on the appropriateness of initial empirical therapy and impact on patient outcomes. Cases of PAB occurring between 2016 and 2019 were pulled from 8 community medical centers. Patients were classified as having either positive or negative outcome at hospital discharge. Several variables including receipt of active empiric therapy (AET) and the time to receiving AET were collected. Variables with a p value of < 0.05 in univariate analyses were included in a multivariable logistic regression model. Two hundred and eleven episodes of PAB were included in the analysis. AET was given to 81.5% of patients and there was no difference in regard to outcome (p = 0.62). There was no difference in the median time to AET in patients with a positive or negative outcome (p = 0.53). After controlling for other variables, age, Pitt bacteremia score ≥ 4, and septic shock were independently associated with a negative outcome. A high proportion of patients received timely, active antimicrobial therapy for PAB and time to AET did not have a significant impact on patient outcome.

Desmopressin Administration and Impact on Hypertonic Saline Effectiveness in Intracranial Hemorrhage.

INTRODUCTION: Desmopressin improves hemostasis through the release of factor VIII, von Willebrand factor, and tissue plasminogen activator, and increases platelet adhesion. Neurocritical Care guidelines recommend consideration of desmopressin in antiplatelet-associated intracranial hemorrhage. Studies supporting its use have not evaluated the potential impact of desmopressin on serum sodium levels in patients receiving hypertonic saline therapy. The purpose of this study was to assess the impact of desmopressin on sodium levels and hypertonic saline effectiveness in intracranial hemorrhage. METHODS: This was a single center retrospective observational chart review. Patients were included in the desmopressin group if they were diagnosed with intracranial hemorrhage, administered desmopressin, and received hypertonic saline infusion. Patients in the hypertonic saline alone group were then matched 1:1 to the patients in the desmopressin group. The primary end point was the effect of desmopressin on reaching a sodium goal of 145-155 mEq/L. The secondary end points included intensive care unit and hospital length of stay, change in sodium, time to reach sodium goal, thrombotic events, mortality, and a composite of increased cerebral edema, hematoma expansion, midline shift, herniation, need for neurosurgical intervention, and neurologic decompensation. RESULTS: Of 112 patients screened, 25 patients met inclusion criteria for the desmopressin group, and 25 patients were matched with patients in the hypertonic saline alone group. The percentage of patients who reached goal sodium in the desmopressin group compared with hypertonic saline alone was similar (80% vs. 88%, respectively). There were no differences in the secondary end points. In the subgroup analysis, patients in the hypertonic saline group met the predefined sodium goal of 150-155 mEq/L within 48 h more often than those in the desmopressin group (82% vs. 60%, respectively, p = 0.042). CONCLUSIONS: The use of desmopressin in intracranial hemorrhage does not appear to negatively impact the ability for patients to reach goal sodium of 145-155 mEq/L. However, in patients with higher sodium goals, desmopressin may decrease hypertonic saline effectiveness.

Utility of the HScore for Predicting COVID-19 Severity.

BACKGROUND: Cytokine release syndrome is a life-threatening condition known to cause fever and multiple organ dysfunction and is suspected to be related to the severity of coronavirus disease 2019 (COVID-19). We sought to examine the utility of the HScore and non-cytokine markers of inflammation for predicting COVID-19 outcomes. We hypothesized that cytokine storm, assessed by a modified HScore, would be linked to more severe COVID-19 symptoms and higher mortality. METHODS:  A retrospective review of records from a large, private hospital system was conducted on patients with hemophagocytic lymphohistiocytosis (HLH) (2014-2019) and compared to a large cohort of COVID-19-positive patients (2020). Patients with a sufficient number of elements in their record for a modified HScore calculation (n=4663), were further subdivided into population 1 (POP1, n=67; HLH, n=493 COVID-19), which had eight HScore elements, and population 2 (POP2) with six available HScore elements (POP2, n=102; HLH, n=4561 COVID-19). RESULTS: Modified HScore predicted COVID-19 severity in POP1 and POP2 as measured by higher odds of being on a ventilator (POP2 OR: 1.46, CI: 1.42-1.5), ICU admission (POP2 OR: 1.38, CI: 1.34-1.42), a longer length of stay (p<0.0001), and higher mortality (POP2 OR: 1.34, CI: 1.31-1.39). C-reactive protein (CRP) and white blood cell (WBC) count were the most consistent non-cytokine predictors of COVID-19 severity. CONCLUSION:  Cytokine storm, evaluated using a modified HScore, appeared to play a role in the severity of COVID-19 infection, and selected non-cytokine markers of inflammation were predictive of disease severity.

The Annual Institutional Review-Key Performance Measures and Processes.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) requires sponsoring institutions to demonstrate effective oversight through an annual institutional review (AIR). The ACGME only requires 3 elements to be reported, and it is up to the discretion of the designated institutional official (DIO) whether other supporting information should be included. This leads to uncertainty and inconsistency for DIOs as they decide what to report. OBJECTIVE: We surveyed DIOs in an effort to provide national data on key performance indicators and other relevant components of the AIR process. METHODS: In July 2019, we conducted a national survey of 847 DIOs. The survey had 16 questions that explored basic institutional demographics, timelines, and processes for the AIR and key performance indicators. Written answers were grouped by similar responses, and we performed descriptive statistics on all variables to assess distributions of responses. We also explored associations between variables using cross-tabulation and chi-square statistics. RESULTS: A total of 267 DIOs responded to the survey (32% response rate). There were 7 institutional performance measures that achieved over 50% consensus. These reviews required the majority of DIOs (62%, 167 of 267) 5 to 20 hours to complete. Less than one-third of sponsoring institutions reported diversity data. The majority of DIOs (68%, 182 of 267) felt the AIR process added substantial value. CONCLUSIONS: This survey reports key performance measures and processes included by DIOs in the AIR. Our results show a wide range of institutional responses though consensus was achieved on 7 key performance measures.

Obesity, Race, and COVID-19 Mortality: Results from a Large Cohort Early in the Pandemic.

Background: Obesity has increased progressively in the United States and is a known risk factor for several diseases such as type 2 diabetes, coronary artery disease, stroke and hypertension. Amid the current pandemic, concerns have been raised about obesity as a risk factor for COVID-19 positive patients. The primary goal of this study was to explore the association between obesity and hospital mortality in COVID-19 patients. Our secondary objective was to explore the relationship between obesity and race on hospital mortality in COVID-19 patients. Methods: This was a cross-sectional, retrospective analysis using data from 186 hospitals from across the United States and the United Kingdom during the first quarter of 2020. Extraction provided data from 25,894 patients who were tested for COVID-19, of whom 2,977 were positive. Patients were stratified into standard WHO categories for BMI and by race. Results: Bivariate analysis revealed significant relationships between mortality and sex (p<0.001) When BMI was analyzed as a continuous variable, multivariate analysis revealed a significant influence of BMI on mortality (odds ratio=1.291, p<0.05). Conclusion: COVID-19 mortality was significantly related to BMI, age and select co-morbidities, but race/ethnicity was not a predictor of mortality when controlling for other variables.

Utilization of Patient-Controlled Analgesia Reduces Length of Stay of Sickle Cell Crisis Hospitalizations.

Background: Sickle cell crisis hospitalizations are emotionally and financially burdensome to patients and healthcare systems, and processes to decrease the frequency or length of stay of these crises should be examined. Methods: This is a multicenter retrospective hospital record review of sickle cell crisis hospitalizations as defined by ICD-10 codes (D57.1-4), from January 2016 through December 2019, examining inpatient medication administration records and length of stay among admitted adults aged 18-65 years. Patient controlled analgesia orders using morphine, hydromorphone, fentanyl and/or merperidine at any point of an admission (n=188) were compared to admissions without any patient-controlled analgesia orders (n=2,159). The primary end point was hospital length of stay in days. A secondary analysis examining patients with or without greater than four admissions was also conducted. Results: The 1,675 patients who met criteria comprised 2,347 sickle cell hospitalizations during the four years examined. Of those admissions, 188 had at least one patient-controlled analgesic documented in their chart and had an average length of stay of 4.54 days (SD 3.34). The 2,159 admissions without any patient-controlled analgesia had an average length of stay of 5.74 days (SD 4.64). The difference of 1.2 days between the groups was statistically significant (p≤0.0001) using a Wilcoxon signed-rank test. Conclusion: Among patients with sickle cell crises who required inpatient hospitalizations, the use of patient-controlled analgesia demonstrated a statistically significant reduction of 1.2 days in their total length of stay. These findings support potentially changing hospital protocols to increase patient-controlled analgesia utilization.

A bioinspired Separated Flow wing provides turbulence resilience and aerodynamic efficiency for miniature drones.

Small-scale drones have enough sensing and computing power to find use across a growing number of applications. However, flying in the low-Reynolds number regime remains challenging. High sensitivity to atmospheric turbulence compromises vehicle stability and control, and low aerodynamic efficiency limits flight duration. Conventional wing designs have thus far failed to address these two deficiencies simultaneously. Here, we draw inspiration from nature's small flyers to design a wing with lift generation robust to gusts and freestream turbulence without sacrificing aerodynamic efficiency. This performance is achieved by forcing flow separation at the airfoil leading edge. Water and wind tunnel measurements are used to demonstrate the working principle and aerodynamic performance of the wing, showing a substantial reduction in the sensitivity of lift force production to freestream turbulence, as compared with the performance of an Eppler E423 low-Reynolds number wing. The minimum cruise power of a custom-built 104-gram fixed-wing drone equipped with the Separated Flow wing was measured in the wind tunnel indicating an upper limit for the flight time of 170 minutes, which is about four times higher than comparable existing fixed-wing drones. In addition, we present scaling guidelines and outline future design and manufacturing challenges.

Robotic vs. open surgical management of ureteroenteric anastomotic strictures: technical modifications to enhance success.

Development of ureteroanastamotic strictures (UAS) after urinary diversion is not uncommon, but is challenging to treat. Poor outcomes are likely with endoscopic and radiologic management, and definitive surgical treatment can cause significant morbidity. The comparative advantages of an operative approach have not yet been fully described in the literature. We retrospectively reviewed the prospectively maintained Tulane University Department of Urology quality assurance database of 12 patients who underwent operative UAS repair between 2012 and 2018. Data were reviewed for operative approach, demographics, baseline disease characteristics, operative variables, and perioperative and pathological outcomes. Of the 12 patients analyzed, 5 underwent open repair (OR) (2 bilateral, 2 right, 1 left) and 7 underwent robotic repair (RR) (3 right, 4 left). One robotic case required conversion to open due to significant intestinal and peri-ureteral adhesions. The median ages were 59 years in OR and 60 years in RR. Two patients in each group had failed previous endoscopic repair. Median time from cystectomy to treatment of enteroanastamotic stricture was 13 months for OR and 10 months for RR (p = 0.25). Median estimated blood loss was 80 mL in both OR and RR (p = 1.0), median operative time was 260 min in OR and 255 min in RR (p = 0.13), and median hospital stay was 8 and 4 days, respectively (p = 0.06). There were two intra-operative and one post-operative complication in the OR group, one of whom required further surgical intervention, and no complications in the robotic cohort. A minimally invasive, robotic approach offers a non-inferior alternative to OR with similar outcomes for appropriately selected patients with UAS. High success rates combined with minimal morbidity may provide definitive therapy at an earlier stage of the stricture state.

Care coordination for complex cancer survivors in an integrated safety-net system: a study protocol.

BACKGROUND: The growing numbers of cancer survivors challenge delivery of high-quality survivorship care by healthcare systems. Innovative ways to improve care coordination for patients with cancer and multiple chronic conditions ("complex cancer survivors") are needed to achieve better care outcomes, improve patient experience of care, and lower cost. Our study, Project CONNECT, will adapt and implement three evidence-based care coordination strategies, shown to be effective for primary care conditions, among complex cancer survivors. Specifically, the purpose of this study is to: 1) Implement a system-level EHR-driven intervention for 500 complex cancer survivors at Parkland; 2) Test effectiveness of the strategies on system- and patient-level outcomes measured before and after implementation; and 3) Elucidate system and patient factors that facilitate or hinder implementation and result in differences in experiences of care coordination between complex patients with and without cancer. METHODS: Project CONNECT is a quasi-experimental implementation study among 500 breast and colorectal cancer survivors with at least one of the following chronic conditions: diabetes, hypertension, chronic lung disease, chronic kidney disease, or heart disease. We will implement three evidence-based care coordination strategies in a large, county integrated safety-net health system: 1) an EHR-driven registry to facilitate patient transitions between primary and oncology care; 2) co-locating a nurse practitioner trained in care coordination within a complex care team; 3) and enhancing teamwork through coaching. Segmented regression analysis will evaluate change in system-level (i.e. composite care quality score) and patient-level outcomes (i.e. self-reported care coordination). To evaluate implementation, we will merge quantitative findings with structured observations and physician and patient interviews. DISCUSSION: This study will result in an evaluation toolkit identifying key model elements, barriers, and facilitators that can be used to guide care coordination interventions in other safety-net settings. Because Parkland is a vanguard of safety-net healthcare nationally, findings will be widely applicable as other safety-nets move toward increased integration, enhanced EHR capability, and experience with growing patient diversity. Our proposal recognizes the complexity of interventions and scaffolds evidence-based strategies together to meet the needs of complex patients, systems of care, and service integration. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02943265 . Registered 24 October 2016.

Barriers and Facilitators to Expanding Roles of Medical Assistants in Patient-Centered Medical Homes (PCMHs).

BACKGROUND: Many primary care practices participating in patient-centered medical home (PCMH) transformation initiatives are expanding the work roles of their medical assistants (MAs). Little is known about attitudes of MAs or barriers and facilitators to these role changes. METHODS: Secondary data analysis of qualitative cross-case comparison study of 15 New Jersey primary care practices participating in a PCMH project during 2012 to 2013. Observation field notes and in-depth and key informant interviews (with physicians, office managers, staff and care coordinators) were iteratively analyzed using grounded theory. RESULTS: MA roles and responsibilities changed from a mostly reactive role, completing tasks dependent on physician orders during the patient visit and facilitating patient flow through the office, to a more proactive one, conducting previsit planning, engaging in the overall care for patients, and assisting with population management. MAs differed in their attitudes about increased responsibilities, with some welcoming the opportunity to take on expanded roles, others resenting their increased responsibilities, and some expressing insufficient understanding regarding why new tasks and procedures were being implemented. Major barriers to MA role shifts included 1) insufficient understanding of the PCMH concept, 2) lack of time for added responsibilities, 3) additional workload without additional compensation, 4) disparate levels of medical knowledge and training, 5) reluctance of clinicians to delegate tasks, 6) uncertainty in making new workflow changes routine, 7) staff turnover, and 8) change fatigue. MAs were more positive about their role shifts when they 1) understood how their responsibilities fit within broader PCMH practice transformation goals; 2) received formal training in new tasks; 3) had detailed protocols and standing orders; 4) initiated role changes with small, achievable goals; 5) had open communication with clinicians and practice leaders; and 5) received additional compensation or paths to career advancement. CONCLUSIONS: Practice leaders need to be conscious of obstacles when they increase expectations of MAs, and they must be willing to invest time and resources into developing their MA workforce. An environment that allows open dialog with MAs and rewards and compensation that recognizes their increased efforts will help make expansion of MA roles occur more smoothly and efficiently.

Can fatigue affect acquisition of new surgical skills? A prospective trial of pre- and post-call general surgery residents using the da Vinci surgical skills simulator.

OBJECTIVE: To study the effects of fatigue on general surgery residents' performance on the da Vinci Skills Simulator (dVSS). METHODS: 15 General Surgery residents from various postgraduate training years (PGY2, PGY3, PGY4, and PGY5) performed 5 simulation tasks on the dVSS as recommended by the Robotic Training Network (RTN). The General Surgery residents had no prior experience with the dVSS. Participants were assigned to either the Pre-call group or Post-call group based on call schedule. As a measure of subjective fatigue, residents were given the Epworth Sleepiness Scale (ESS) prior to their dVSS testing. The dVSS MScore™ software recorded various metrics (Objective Structured Assessment of Technical Skills, OSATS) that were used to evaluate the performance of each resident to compare the robotic simulation proficiency between the Pre-call and Post-call groups. RESULTS: Six general surgery residents were stratified into the Pre-call group and nine into the Post-call group. These residents were also stratified into Fatigued (10) or Nonfatigued (5) groups, as determined by their reported ESS scores. A statistically significant difference was found between the Pre-call and Post-call reported sleep hours (p = 0.036). There was no statistically significant difference between the Pre-call and Post-call groups or between the Fatigued and Nonfatigued groups in time to complete exercise, number of attempts, and high MScore™ score. CONCLUSION: Despite variation in fatigue levels, there was no effect on the acquisition of robotic simulator skills.