Applying Expectancy Theory to residency training: proposing opportunities to understand resident motivation and enhance residency training.

Medical resident education in the United States has been a matter of national priority for decades, exemplified initially through the Liaison Committee for Graduate Medical Education and then superseded by the Accreditation Council for Graduate Medical Education. A recent Special Report in the New England Journal of Medicine, however, has described resident educational programs to date as prescriptive, noting an absence of innovation in education. Current aims of contemporary medical resident education are thus being directed at ensuring quality in learning as well as in patient care. Achievement and work-motivation theories attempt to explain people's choice, performance, and persistence in tasks. Expectancy Theory as one such theory was reviewed in detail, appearing particularly applicable to surgical residency training. Correlations between Expectancy Theory as a work-motivation theory and residency education were explored. Understanding achievement and work-motivation theories affords an opportunity to gain insight into resident motivation in training. The application of Expectancy Theory in particular provides an innovative perspective into residency education. Afforded are opportunities to promote the development of programmatic methods facilitating surgical resident motivation in education.

Acute Small-Bowel Obstruction From Intestinal Anisakiasis After the Ingestion of Raw Clams; Documenting a New Method of Marine-to-Human Parasitic Transmission.

Enteric anisakiasis is a known parasitic infection. To date, human infection has been reported as resulting from the inadvertent ingestion of the anisakis larvae when eating raw/undercooked fish, squid, or eel. We present a first reported case of intestinal obstruction caused by anisakiasis, after the ingestion of raw clams.

Assessing a safe interval for subsequent negative pressure wound therapy change after initial placement in acute, contaminated wounds.

BACKGROUND: Negative pressure wound therapy (NPWT) is empirically expanding across the globe. Yet published data with NPWT in acute, contaminated wounds is limited, and several concerns arise regarding contemporary acute wound care NPWT practice. Specifically, there are no evidence-based time intervals specifying when NPWT should be changed after initial placement in such cases; therefore, NPWT was studied in acute, contaminated wounds. METHODS: The authors retrospectively reviewed 86 consecutive patients, and a total of 97 contaminated wounds. All wounds were class IV, based on Centers for Disease Control and Prevention (CDC) criteria. All patients were managed with NPWT. Patient and wound-specific variables were analyzed. Outcome endpoints included durability of wound closure and death. RESULTS: Mean time of subsequent NPWT after initial placement was 2.9 days, median time 3 days, mode 2 days, and standard deviation (SD) 1.24 days. Durability of wound closure was 73/79 (92%). Deaths were noted in 6/86 (7%) of patients. No deaths appeared related to NPWT. CONCLUSIONS: Based on the findings in this study, analyzing NPWT in the largest known patient cohort of this type, a time interval of 1.7 days to 4.1 days (mean time 2.9 days, SD 1.24), between initial and subsequent placement of NPWT in acute, contaminated wounds is safe and effective.

Negative pressure wound therapy in acute, contaminated wounds: documenting its safety and efficacy to support current global practice.

Negative pressure wound therapy (NPWT) is in widespread use and its role in wound care is expanding worldwide. It is estimated that 300 million acute wounds are treated globally each year. Currently, sporadic data exist to support NPWT in acutely contaminated wounds. Despite lack of data, use of negative pressure wound therapy in such cases is increasing across the globe. We retrospectively reviewed 86 consecutive patients, totalling 97 contaminated wounds. All wounds were Class IV based on US Center for Disease Control criteria. Sepsis criteria were present in 78/86 (91%) of patients. All patients were managed with NPWT. Wound type, degree of tissue destruction, presence of infection, wound dimension, timing of initial NPWT, type and timing of wound closure and patient comorbidities were recorded. Outcome endpoints included durability of wound closure and death. Wound location was 41/97 (42%) in the torso; 56/97 (58%) at the extremities. Tissue necrosis was present in 84/97 (87%) of wounds. Infection was present in 86/97 (89%) of wounds. Average wound size was 619 cm(2) when square surface area measured; 786 cm(3) when volume measurements taken. Mean time to wound closure was 17 days, median 10 days and mode 6 days. Durability of wound closure 73/79 (92%). Deaths were noted in 6/86 (7%) of patients. No deaths appeared related to NPWT. Contemporary NPWT related acute wound care is expanding empirically, in quantity and scope across the globe. However, several areas of concern are known regarding this contemporary use of NPWT in acute wounds. Thus, it is important to assess the safety and efficacy of such expanded empiric NPWT practice. Based on our findings with NPWT in the largest known patient cohort of this type, NPWT appears safe and effective in managing acute, contaminated wounds including patients meeting sepsis criteria. These findings provide evidence-based support for current worldwide empiric NPWT-related acute wound care.

Phlegmonous gastritis and group A streptococcal toxic shock syndrome in a patient following functional endoscopic sinus surgery.

BACKGROUND: Phlegmonous gastritis is a rare and often fatal condition that can affect healthy individuals in 50% of cases. The condition has been described in accounts dating back to the pre-antibiotic era, during which time mortality was nearly 100%. Over the past century, case reports average about one per year. The etiology remains unclear, although Streptococcus species is isolated frequently. The optimum treatment has not been delineated clearly but likely involves a combination of antibiotics with or without surgical resection. METHODS: A case report was presented and the pertinent literature was reviewed. CASE REPORT: A 45-year-old man with a history of recent paranasal sinus surgery presented with acute abdominal pain and criteria consistent with toxic shock syndrome. Computed tomography scan showed diffuse thickening of the gastric wall and free intraperitoneal fluid. Exploratory laparotomy revealed a thickened stomach wall with outer fibrinous exudate and murky peritoneal fluid, which grew Streptococcus pyogenes. Intraoperative esophagogastroduodenoscopy revealed thickened gastric folds with a "cobblestone" appearance and no evidence of perforation. He was treated with antibiotics intravenously and sustained a difficult intensive care unit course complicated by ventilator-dependent respiratory failure, renal failure, and coagulopathy, but survived without major disability. CONCLUSIONS: This is an unusual case presentation of a rare but potentially lethal condition, whose optimal treatment is unclear. Phlegmonous gastritis should be considered when isolated gastric wall thickening is encountered in the clinical setting of toxic shock syndrome.