Examining the Factors Influencing Applicants' Placement on One General Surgery Program's Rank Order List.

PURPOSE: Surgery residency applications include variables that determine an individual's rank on a program's match list. We performed this study to determine which residency application variables are the most impactful in creating our program's rank order list. METHODS: We completed a retrospective examination of all interviewed applicants for the 2019 match. We recorded United States Medical Licensing Examinations (USMLE) step I and II scores, class quartile rank from the Medical Student Performance Evaluation (MSPE), Alpha Omega Alpha (AOA) membership, geographic region, surgery clerkship grade, and grades on other clerkships. The MSPE and letters of recommendation were reviewed by two of the authors and assigned a score of 1 to 3, where 1 was weak and 3 was strong. The same two authors reviewed the assessments from each applicant's interview and assigned a score from 1-5, where 1 was poor and 5 was excellent. Univariate analysis was performed, and the significant variables were used to construct an adjusted multivariate model with significance measured at P < .05. RESULTS: Univariate analysis for all 92 interviewed applicants demonstrated that USMLE step 2 scores (P = .002), class quartile rank (P = .004), AOA status (P = .014), geographic location (P < .001), letters of recommendation (P < .001), and interview rating (P < .001) were significant in predicting an applicant's position on the rank list. On multivariate analysis only USMLE step 2 (P = .018) and interview (P < .001) remained significant. CONCLUSION: USMLE step 2 and an excellent interview were the most important factors in constructing our rank order list. Applicants with a demonstrated strong clinical fund of knowledge that develop a rapport with our faculty and residents receive the highest level of consideration for our program.

An Analysis of Outcomes and Management Strategies for Patients With Cholecystostomy Tubes.

BACKGROUND: Percutaneous cholecystostomy tube (PCT) drainage is an effective management strategy for acute cholecystitis in patients medically unfit for surgery. However, little is known about the fate of patients managed by PCT. We conducted this study to determine tube management outcomes for patients with acute cholecystitis managed by PCT. METHODS: The electronic record was queried to identify patients with acute cholecystitis managed by PCT from 2012-2020. Patients were divided into three groups for analysis: 1) ultimately managed by cholecystectomy, 2) eventual confirmation of distal flow of bile from the gallbladder and tube removal, and 3) tubes left in place without further management. RESULTS: A total of 179 patients with acute cholecystitis treated by PCT were included. Sixty-six patients never fully recovered from the medical insult associated with their diagnosis of acute cholecystitis and had their tubes left in situ. Sixty-four of these 66 patients (97%) died during follow-up. The remaining 113 patients recovered from their illness and presented to clinic for evaluation for tube removal and/or cholecystectomy. When distal biliary flow was confirmed, tube removal was favored (n = 70). When cystic duct outflow occlusion persisted, cholecystectomy was planned for patients who became acceptable surgical candidates (n = 43). For patients managed by cholecystectomy, 8 were approached open and 35 laparoscopically, with 12 of 35 (34.3%) converted to open and 23 (65.7%) completed laparoscopically. CONCLUSION: Our study favors PCT removal for patients who recover from their acute illness when distal bile flow from the gallbladder is confirmed. We reserve cholecystectomy for patients who recover from their illness and demonstrate persistent cystic duct outflow obstruction.

Euglycemic Diabetic Ketoacidosis in the Surgical Patient.

Postoperative euglycemic diabetic ketoacidosis (EDKA), a rare cause of acidosis, results from the metabolic derangement of diabetes and is not associated with a surgical complication requiring reoperation. Our acute care surgery service has managed several recent patients who developed postoperative EDKA. Our group was befuddled by the initial case but subsequently quickly recognized and managed the condition. The purpose of this report is to discuss the pathophysiology of EDKA, summarize 3 recent cases, and increase awareness about the condition to permit prompt recognition and treatment.

The use of ABC score in activation of massive transfusion: The yin and the yang.

BACKGROUND: Hemorrhage is the most common cause of early death in trauma patients. Massive transfusion protocols (MTPs) have been designed to accelerate the release of blood products but can result in waste if activated inappropriately. The Assessment of Blood Consumption (ABC) score has become a widely accepted score for MTP activation. In this study, we compared the use of ABC criteria to physician judgment in MTP activation. METHODS: Adult trauma patients treated at University of Louisville Trauma Center from January 2016 to December 2016 were studied. Activation via ABC score was assessed retrospectively from emergency department (ED) data. Location, timing of activation, percent of patients using more than 5 units of packed red blood cells, amount of product waste, factors associated with early activation by physicians, and mortality were analyzed. RESULTS: Three thousand four hundred twenty-one patients were included in this study. Only 33% of the patients who would have had MTP activation based on the ABC criteria used more than 5 units of blood products within 24 hours of admission compared with 65% of the patients in whom clinical judgment was used. Seventy-six percent of all MTP activations from clinical judgment would have been activated by the ABC criteria in the ED. Fifty-five percent of all MTP activations via clinical judgment were activated in the operating room and 41% in the ED. Eighty-one percent of activations that occurred in the operating room by physician judgment could have been activated earlier in the ED if the ABC criteria had been used. However, ABC score can lead to higher potential fresh frozen plasma waste (588 vs. 84 units) compared with physician judgment. CONCLUSIONS: The ABC criteria overestimate need for massive transfusion and can lead to increased product waste compared with physician judgment, but its use leads to earlier MTP activation. Criteria to trigger MT activation should rely on both clinical acumen and validated prediction tools. LEVEL OF EVIDENCE: Prognostic, level III.

Timing of venous thromboembolism chemoprophylaxis after traumatic brain injury.

OBJECTIVES: Currently no national standard exists on optimal timing to initiate VTE chemoprophylaxis after traumatic brain injury (TBI). We designed this survey to assess current practice regarding the timing of VTE chemoprophylaxis after TBI. METHODS: All the EAST members were surveyed online. Participants reported demographics, and responses to questions regarding VTE chemoprophylaxis in TBI and timing of chemoprophylaxis in 2 hypothetical clinical scenarios of TBI. RESULTS: Three hundred and ninety-one full responses were collected (response rate 30.9%). Most respondents (75%) reported the decision to initiate VTE chemoprophylaxis with a consensus between the neurosurgery and trauma/critical care services. While 76% of respondents reported experience of seeing pulmonary embolism without chemoprophylaxis, 44% witnessed progression of TBI after VTE chemoprophylaxis. Approximately 50% considered their practice of VTE chemoprophylaxis in TBI patients to be conservative. Almost 50% reported no standardized protocol in their institutions. While 1/3 of the members believed guidelines exist, another 1/3 believed no guidelines available. Responses to two clinical scenarios showed various approaches regarding the timing of VTE chemoprophylaxis. CONCLUSIONS: Currently there is a wide variability in the practice patterns regarding the timing of VTE chemoprophylaxis in TBI patients. This survey reinforces the need for further investigation to guide clinical practice.

Complications of Home Enteral Nutrition: Mechanical Complications and Access Issues in the Home Setting [Formula: see text].

Home enteral nutrition (HEN) is an essential component in the care of patients with an array of underlying etiologies resulting in the inability to meet caloric needs through volitional intake alone. Although some would include oral nutrition supplementation as HEN, for the purposes of this review, the term is limited to a patient's requiring an enteral access device for the delivery of exogenous nutrients. Complications related to such devices remain a difficult problem in the hospital setting, and these issues are often amplified when encountered in the home setting. Focused multidisciplinary teams and close follow-up are essential in optimizing outcomes for patients receiving HEN, but all healthcare providers should have foundational knowledge regarding commonly encountered complications of HEN access and the initial management of these issues.

Complications of Home Enteral Nutrition: Mechanical Complications and Access Issues in the Home Setting.

Home enteral nutrition (HEN) is an essential component in the care of patients with an array of underlying etiologies resulting in the inability to meet caloric needs through volitional intake alone. Although some would include oral nutrition supplementation as HEN, for the purposes of this review, the term is limited to a patient's requiring an enteral access device for the delivery of exogenous nutrients. Complications related to such devices remain a difficult problem in the hospital setting, and these issues are often amplified when encountered in the home setting. Focused multidisciplinary teams and close follow-up are essential in optimizing outcomes for patients receiving HEN, but all healthcare providers should have foundational knowledge regarding commonly encountered complications of HEN access and the initial management of these issues.