Value Analysis of Central Line Simulation-Based Education.

BACKGROUND: Central line-associated bloodstream infections (CLABSIs) are preventable complications that pose a significant health risk to patients and place a financial burden on hospitals. Central line simulation-based education (SBE) efforts vary widely in the literature. The aim of this study was to perform a value analysis of published central line SBE and develop a refined method of studying central line SBE. METHODS: A database search of PubMed Central and Cumulative Index to Nursing and Allied Health Literature (CINAHL) was performed for articles mentioning "Cost and CLABSI," "Cost and Central line Associated Bloodstream Infections," and "Cost and Central Line" in their abstract and article body. Articles chosen for qualitative synthesis mentioned "simulation" in their abstract and article body and were analyzed based on the following criteria: infection rate before vs. after SBE, cost of simulation, SBE design including simulator model used, and learner analysis. RESULTS: Of 215 articles identified, 23 were analyzed, 10 (43.48%) discussed cost of central line simulation with varying criteria for cost reporting, 8 (34.8%) numerically discussed central line complication rates (7 CLABSIs and 1 pneumothorax), and only 3 (13%) discussed both (Figure). Only 1 addressed the true cost of simulation (including space rental, equipment startup costs, and faculty salary) and its longitudinal effect on CLABSIs. CONCLUSION: Current literature on central line SBE efforts lacks value propositions. Due to the lack of value-based data in the area of central line SBE, the authors propose a cost reporting standard for use by future studies reporting central line SBE costs.

Cecal perforation secondary to fungal necrotizing enterocolitis in a premature neonate.

INTRODUCTION: Necrotizing enterocolitis (NEC) remains one of the most critical gastrointestinal comorbidities associated with neonatal prematurity and low birth weight. Despite extensive research and innovations for successful management, NEC remains the leading cause of morbidity and mortality in premature infants. NEC is commonly appreciated at the level of the small bowel, but in rare instances, it is experienced at the colon. While colonic perforation is rare, cecal perforation, specifically, is seldom reported. CASE REPORT: We report the successful surgical intervention of a preterm African-American infant born at 24-weeks' gestation found to have a cecal perforation due to fungal necrotizing enterocolitis. DISCUSSION: Perforation is a major cause of morbidity in necrotizing enterocolitis, and even with extensive research in the management of necrotizing enterocolitis, mortality rates have remained unchanged; the treatment option with the most advantageous outcomes is still uncertain. CONCLUSION: To our knowledge, there are few reported cases of cecal perforation due to NEC. The pathologic report of our colonic specimen demonstrated mucosal invasion with Candida Albicans. This case report is noteworthy due to the unusual location of bowel perforation, fungal sepsis, and successful surgical outcome that is not commonly seen in neonates with intestinal candidiasis. Cecal perforation is rare in necrotizing enterocolitis but should not rule out the pathology.

Utilizing In-Hospital Fabrication to Decrease Simulation Costs.

BACKGROUND: Two restrictive factors for surgical training through simulation, are the cost of and accessibility to materials and consoles for simulation models. Commercial surgical simulation models continue to maintain high prices with a wide range of fidelity levels. We believe that by utilizing in-house fabrication, these barriers can be decreased while maintaining and even improving the functionality of surgical simulation models as well as increase their individualization and customization. METHODS: By using a combination of digital and manual fabrication techniques such as 3D printing and basic mold making methods, we were able to create models equivalent to current commercial products by utilizing the first of its kind MakerHEALTH space and collaborating with our surgical simulation staff. We then compared our research and development, start-up, materials, operational, and labor costs to buying comparable commercial models with the simulation usage rates of our institution. RESULTS: We were able to decrease the costs of a 6 model simulation sample set (appendectomy, cholecystectomy, common bile duct exploration, ventral hernia, chest tube insertion, and suture pads) at our institution from $99,646.60 to $13,817.21 for a medical student laborer, $14,500.56 for a surgical resident laborer, $15,321.08 for a simulation staff laborer, and $18,984.48 for an attending physician laborer. CONCLUSION: We describe successful approaches for the creation of cost-effective and modular simulation models with the aim of decreasing the barriers to entry and improving surgical training and skills. These techniques make it financially feasible for learners to train during larger faculty-led workshops and on an individual basis, allowing for access to simulation at any time or place.

HJC0416 Attenuates Fibrogenesis in Activated Hepatic Stellate Cells via STAT3 and NF-κB Pathways.

BACKGROUND: Hepatic fibrosis is wound-healing response that is the result of hepatic stellate cell (HSC) activation and subsequent excess extracellular matrix deposition. HSCs can be activated by a variety of inflammatory stimuli as well as through the signal transducer and activator of transcription 3 (STAT3) pathway. HJC0416 is a novel, orally bioavailable small-molecule inhibitor of STAT3 that was developed by our team using a fragment-based drug design approach. Previously, our team has shown that HJC0416 has antifibrogenic effects in activated HSCs. Recently, increasing evidence suggests that nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) plays an important role in the activation of HSCs. In the present study, we examined the role of NF-κB inhibition of HSC activation by HJC0416. METHODS: LX-2 (human) and HSC-T6 (rat) cell lines were used. Expression levels of extracellular proteins, NF-κB and STAT3 expression and DNA binding, and inflammatory cytokine levels were determined using western blot, ELISA, and immunofluorescence assay. RESULTS: HJC0416 decreased cell viability in a dose-dependent manner in both cell lines and arrested the cell cycle at the S phase. Increased apoptosis was seen in LX-2 cells through Yo-Pro-1 and propidium iodide immunofluorescent stating. HJC0416 significantly decreased expression of fibronectin and collagen I as well as markedly decreased α-SMA and laminin. HJC0416 inhibited the STAT3 pathway by decreasing phosphorylation of STAT3, as well as signal transduction pathway activation. Notably, HJC0416 also inhibited the classic and alternative pathways of NF-κB activation. HJC0416 inhibited LPS-induced p65 nuclear translocation and DNA binding, as well as prevented phosphorylation and degradation of inhibitory protein IκBα. HJC0416 also prevented phosphorylation of serine residue 536 on p65. CONCLUSIONS: HJC0416, an inhibitor of STAT3, was found to have antifibrogenic properties in activated hepatic stellate cell lines. In addition, HJC0416 was found to inhibit the NF-κB pathway. Owing to this double effect, HJC0416 demonstrates promise for in vivo experimentation as an antifibrosis treatment.

Colectomy among Fee-for-Service Medicare Enrollees Coded as DRG 330: A Potential Platform to Allow Consumer Cost Transparency?

The use of Centers for Medicare and Medicaid Services Diagnosis Related Group (CMS-DRG) codes define hospital reimbursement for Medicare beneficiaries. Our objective was to assess all patients with comorbidities on admission who were discharged in the DRG 330 category to determine the impact of postoperative complications on Medicare costs. The 5% Medicare Database was used to evaluate patients who underwent a colectomy and were coded as CMS-DRG 330. Patients were divided into two groups: No surgical complications (NSC) and surgical complications (SC). Length of stay (LOS), complications, hospital charges, CMS reimbursement, discharge destination, and inpatient mortality were assessed. Statistical significance was set at p < 0.05. In total, 13,072 patients were identified. The SC group had higher inpatient mortality, a longer LOS (p < 0.0001) and was more likely to be discharged with post-acute care support (p = 0.0005). The use of CMS-DRG coding has the potential to provide Medicare fiscal intermediaries, beneficiaries, and providers with a more accurate understanding of the relative impact of their baseline health. The data further suggest that providers may benefit by more fully understanding the cost of preventive measures as a means of reducing total cost of care for this population.

Development of a Low-cost, High-fidelity Skin Model for Suturing.

BACKGROUND: In a survey of students at our institution, suturing was the most desired workshop for simulation; however, cost, quality, and availability of skin pads is often prohibitive for suturing workshops. In-hospital fabrication may be utilized to manufacture noncommercial, high-fidelity, and low-cost simulation models. We describe the production, value, and face validation of our simulated skin model. MATERIALS AND METHODS: Using an in-hospital fabrication laboratory, we have developed a model for skin and subcutaneous tissue. Our model uses a variety of commercially available materials to simulate the epidermis, dermis, subcutaneous fat, fascia, and muscle. A cost analysis was performed by comparing it with other commonly used commercial skin models. Expert surgeons assessed the material characteristics, durability, and overall quality of our model in comparison with other commercial models. RESULTS: The materials cost of our novel skin pad model was 30.9% of the mean cost of five different commonly used foam and silicone-based commercial skin models. This low-cost model is more durable than the commercial models, does not require skin pad holders, and is of higher fidelity than the commercial products. In addition to skin closure, our model may be used to simulate fascial closure or fasciotomy. CONCLUSIONS: Model creation using in-hospital workspaces is an effective strategy to decrease cost while improving quality of surgical simulation. Our methods for creation of an inexpensive and high-fidelity skin pad may be purposed for several soft tissue models.

Personality Testing May Identify Applicants Who Will Become Successful in General Surgery Residency.

BACKGROUND: Identification of successful general surgical residents remains a challenging endeavor for program directors with a national attrition of approximately 20% per year. The Big 5 personality traits and the Grit Scale have been extensively studied in many industries, and certain traits are associated with professional or academic success. However, their utility in surgery resident selection is unknown. METHODS: We performed a retrospective review of all categorical surgery residents (n = 34) at the University of Texas Medical Branch from 2015 to 2017. Current residents were classified into low performing (n = 12) or non-low performing (n = 22) based on residency performance and standardized test scores. Groups were assessed for differences in both conventional metrics used for selection and Big 5 and grit scores using bivariate analysis and Pearson's correlation coefficient. Personality testing was administered to recent resident applicants (n = 81). Applicants were ranked using conventional application information. We then examined the applicants' personalities and their rank position with personality characteristics of non-low-performing residents to determine if there was any correlation. RESULTS: The Big 5 personality test identified significantly higher extroversion, conscientiousness, and emotional stability scores in those residents classified as non-low performers. There was no significant difference in conventional metrics or in grit scores between non-low performers and low performers. Our final rank does not correlate well with personality traits of non-low performers. CONCLUSIONS: The Big 5 test may prove to be a useful adjunct to the traditional residency application in identifying applicants who may become successful in general surgery residency.

Reduced Postburn Hypertrophic Scarring and Improved Physical Recovery With Yearlong Administration of Oxandrolone and Propranolol.

BACKGROUND: Massive burns induce a hypermetabolic response that leads to total body wasting and impaired physical and psychosocial recovery. The administration of propranolol or oxandrolone positively affects postburn metabolism and growth. The combined administration of oxandrolone and propranolol (OxProp) for 1 year restores growth in children with large burns. Here, we investigated whether the combined administration of OxProp for 1 year would reduce scarring and improve quality of life compared with control. STUDY DESIGN: Children with large burns (n = 480) were enrolled into this institutional review board-approved study; patients were randomized to control (n = 226) or administration of OxProp (n = 126) for 1 year postburn. Assessments were conducted at discharge and 6, 12, and 24 months postburn. Scar biopsies were obtained for histology. Physical scar assessments and patient reported outcome measures of physical and psychosocial function were obtained. RESULTS: Reductions in cellularity, vascular structures, inflammation, and abnormal collagen (P < 0.05) occurred in OxProp-treated scars. With OxProp, scar severity was attenuated and pliability increased (both P < 0.05). Analyses of patient-reported outcomes showed improved general and emotional health within the OxProp-treated group (P < 0.05). CONCLUSIONS: Here, we have shown improvements in objective and subjective measures of scarring and an increase in overall patient-reported physical function. The combined administration of OxProp for up to a year after burn injury should be considered for the reduction of postburn scarring and improvement of long-term psychosocial outcomes in children with massive burns.

Natural Compound Oridonin Inhibits Endotoxin-Induced Inflammatory Response of Activated Hepatic Stellate Cells.

Hepatic stellate cells (HSCs) play an important role in hepatic fibrogenesis and inflammatory modulation. Endotoxin is dramatically increased in portal venous blood after serious injury and can contribute to liver damage. However, the mechanism underlying endotoxin's effects on HSCs remains largely unknown. Oridonin is a bioactive diterpenoid isolated from Rabdosia rubescens that exhibits anti-inflammatory properties in different tissues. In the present study, we determined the effects of oridonin on endotoxin-induced inflammatory response and signaling pathways in vitro. The production of proinflammatory cytokines in activated human HSCs line LX-2 was measured by ELISA and Western blots. Immunofluorescence and nuclear fractionation assay were used to determine NF-κB activity. Oridonin treatment significantly inhibited LPS-induced proinflammatory cytokines IL-1ß, IL-6, and MCP-1 production as well as cell adhesion molecules ICAM-1 and VCAM-1. Additionally, oridonin blocked LPS-induced NF-κB p65 nuclear translocation and DNA binding activity. Oridonin prevented LPS-stimulated NF-κB regulator IKKα/ß and IκBα phosphorylation and IκBα degradation. Combined treatment of oridonin and an Hsp70 substrate binding inhibitor synergistically suppressed LPS-stimulated proinflammatory cytokines and NF-κB pathway activation. Therefore, oridonin inhibits LPS-stimulated proinflammatory mediators through IKK/IκBα/NF-κB pathway. Oridonin could be a promising agent for a hepatic anti-inflammatory.

Cervical spine immobilization may be of value following firearm injury to the head and neck.

BACKGROUND: Penetrating injuries to the head and neck may not be able to cause unstable fractures without concomitant spinal cord injury, rendering prehospital spinal immobilization (PHSI) ineffectual, and possibly harmful. However, this premise is based on reports including predominantly chest and abdominal injuries, which are unlikely to cause cervical spine (CS) injuries. METHODS: We performed a retrospective review of all patients presenting with a penetrating wound to the head or neck over a 4-year period at an urban, level 1 trauma center to determine if there was a benefit of PHSI. RESULTS: One hundred seventy-two patients were identified, of which 16 (9.3%) died prior to CS evaluation. Of 156 surviving patients, mechanism was gunshot wound (GSW) in 36 (28%) and stab wound (SW) in 120 (72%). Fifty-eight patients had PHSI placed (37%), and GSW patients' odds of having PHSI were greater than SW patients (OR 2.3; CI 1.08-4.9). Eight of 156 surviving patients eventually died (5.1%), and the odds of mortality were greater among those that had PHSI than those without (OR 5.54; CI 1.08-28.4). Six (3.8%; 5 GSW, 1 SW) patients had a CS fracture. Two GSW patients (5.6%) had unstable CS fractures with a normal neurological exam at initial evaluation. CONCLUSIONS: Of patients with a GSW to the head or neck that survived to be evaluated, 5.6% had unstable fractures without an initial neurologic deficit. PHSI may be appropriate in this population. Further studies are warranted prior to a determination that PHSI is unnecessary in penetrating head and neck injuries.

Aneurysmal Rupture of a Mesodiverticular Band to a Meckel's Diverticulum.

Aneurysmal rupture of a mesodiverticular band has not previously been reported in the clinical literature. We are reporting a case of hemoperitoneum in a 51-year-old male after an aneurysmal rupture of a mesodiverticular band. This case demonstrates that in rare instances, a rupture of the mesodiverticular band leading to Meckel's diverticulum can lead to significant hemoperitoneum. This is usually caused by a traumatic injury but in our case was apparently caused by an aneurysm of the mesodiverticular artery. Patients with known Meckel's diverticula should be aware of the possibility of rupture, as should clinicians treating those with a history of this usually benign congenital abnormality. Rapid surgical intervention is necessary to repair the source of bleeding, as massive blood loss was encountered in this case.