The Surgical Clerkship in the COVID Era: A Natural Language Processing and Thematic Analysis.

INTRODUCTION: Responses to COVID-19 within medical education prompted significant changes to the surgical clerkship. We analyzed the changes in medical student end of course feedback before and after the COVID-19 outbreak. METHODS: Postclerkship surveys from 2017 to 2022 were analyzed including both Likert scale data and free text, excluding the COVID outbreak year 2019-2020. Likert scale questions were compared between pre-COVID (2017-2019) and COVID-era cohorts (2020-2022) with the Mann-Whitney U-test. Free-text comments were analyzed using both thematic analysis and natural language processing including sentiment, word and phrase frequency, and topic modeling. RESULTS: Of the 483 medical students surveyed from 2017 to 2022, 297 responded (61% response rate) to the included end of clerkship surveys. Most medical students rated the clerkship above average or excellent with no significant difference between the pre-COVID and COVID-era cohorts (70.4% Versus 64.8%, P = 0.35). Perception of grading expectations did significantly differ, 51% of pre-COVID students reported clerkship grading standards were almost always clear compared to 27.5% of COVID-era students (P = 0.01). Pre-COVID cohorts more frequently mentioned learning and feedback while COVID-era cohorts more frequently mentioned case, attending, and expectation. Natural language processing topic modeling and formal thematic analysis identified similar themes: team, time, autonomy, and expectations. CONCLUSIONS: COVID-19 presented many challenges to undergraduate medical education. Despite many changes, there was no significant difference in clerkship satisfaction ratings. Unexpectedly, the greater freedom and autonomy of asynchronous lectures and choice of cases became a highlight of the new curriculum. Future research should investigate if there are similar associations nationally with a multi-institutional study.

Longitudinal Integrated Clerkships and Undergraduate Surgical Education: A Scoping Review and Gap Analysis.

OBJECTIVE: Longitudinal integrated clerkships (LICs) are an increasingly popular approach to medical student clinical education, and the literature describing them is expanding. Despite this, there is a lack of understanding for how surgery didactics and skills are currently taught as a part of the LIC curriculum. DESIGN: We conducted a scoping literature review in July 2022 using terms related to LIC and surgical education. Abstract and full-length text screening followed. Data extraction was completed in August 2022. Articles published in English, focused on LIC students, and discussed any element of LIC curriculum surgical education was included. SETTING: Scoping literature review. PARTICIPANTS: A total of 282 studies describing LICs were identified from the scoping literature review. After applying inclusion and exclusion criteria, 37 (13%) studies describing some element of surgical education were included. RESULTS: Of these 37 studies, the majority did not delve into pertinent details related to students' surgery experience, expectations, and surgical skills accomplishments. Four studies (11%) reported on the outpatient surgical experience, such as minimum required time that students were expected to be in the clinic, and 8 studies (22%) described the inpatient and operating room exposure. Only 1 study (3%) described the surgical floor management of surgical patients, including tasks like documentation and wound care, and 3 studies (8%) reported formal assessment of surgical skills, such as suturing technique. CONCLUSIONS: Our study highlights the paucity LIC literature examining the relationship between this curricular innovation and the unique needs of medical students on a surgical clerkship. Surgeon educators should embrace the opportunity to contribute LIC curriculum development and subsequent investigation into how this modality interfaces with the learning objectives of undergraduate surgical education. A formal description of essential curriculum components for all surgical LIC programs is needed to ensure appropriate surgical education across the varied LIC models.

Surgical Residents as Clerkship Scholars May Improve Student Perception of the Surgery Clerkship.

INTRODUCTION: The surgical clerkship is a formative experience in the medical school curriculum and can leave a lasting impression on students' perception of surgery. Given the historical negative stereotypes of surgeons, the clerkship represents an opportunity to impact students in a meaningful way. METHODS: Our institution developed a program in which research residents can serve as junior clerkship coordinators and educators; working closely with medical students on their surgery clerkship. At the end of their clerkship, students were administered a survey with Likert-scale and free text responses regarding satisfaction with the rotation, lectures, feedback, and value of the clerkship. Student survey results were compared before (2015-2016) and after (2017-2019) the implementation of the scholar program with nonparametric statistical analysis and qualitative text analysis. RESULTS: A total of 413 students responded to the survey with no significant difference in response rate by term (P = 0.88). We found no statistical difference with respect to overall course perception (92.3% versus 91.2%, P = 0.84), but a statistically significant difference was noted for the clarity of the provided written clerkship materials (80.3% versus 91.3%, P = 0.02) and usefulness of the feedback (57.5% versus 78.7%, P = 0.01). Qualitative analysis demonstrated an overall positive shift in perception of the clerkship, improvement in the course materials, and organization. CONCLUSIONS: The scholar program was overall well received by the students with improvements in certain aspects of the clerkship: organization, feedback, and course materials. This program represents a potential strategy to improve certain portions of the medical school clerkship experience.

A novel low-cost model of superficial abscess for trainee education in incision and drainage.

Background: Proficiency in ultrasound usage is quickly becoming an expectation in multiple residency programs: emergency medicine, obstetrics-gynecology, surgery, and internal medicine. There is a lack of affordable training devices for ultrasound training and identification of superficial fluid collections. We sought to develop a model for trainee education in ultrasound usage, identification of superficial fluid collection, aspiration, and incision & drainage (I&D). Materials & methods: Commercially available products were used to develop a novel, low-cost model for ultrasound-guided aspiration and I&D of an abscess. A latex balloon embedded in silicone gel construct simulated a superficial fluid collection when examined with an ultrasound probe and monitor. A 18-gauge needle on a 10-cc syringe were used for aspiration, and a 15-blade disposal scalpel with 0.25″ packing strip used for I&D. Results: Approximately six hours are required to generate 24 individual models of a superficial abscess. Following an initial investment, each model costs less than $1 USD to produce. Compared to commercially available models, this represents a significant savings. This model was utilized during the medical school academic year as a teaching aid for medical students to simulate ultrasound-guided identification, aspiration, and incision and drainage of a superficial abscess. Conclusions: We successfully produced an affordable, low-cost model of a superficial fluid collection for training in ultrasound usage, aspiration, and I&D. The model represents significant savings over commercially available alternatives and can be easily replicated for trainee education.

Revisiting Medical Student Expectations on the Surgery Clerkship.

OBJECTIVE: Medical students frequently report ambiguity of expectations in their feedback of the surgery clerkship. Herein, we aimed to gauge general surgery resident and attending expectations of students on their clerkship. DESIGN: Residents and attending surgeons were surveyed on medical student expectations for rounding and floor duties, the operating room, clinic, and professionalism. RESULTS: There were slight differences in expectations between residents and attendings, which were then utilized to facilitate a discussion to create consensus expectations for students. Early outcomes demonstrate improved understanding of expectations by medical students. CONCLUSION: Identifying differences in resident and attending expectations of medical students on their surgery clerkship can help improve the alignment of such expectations. We hope that longterm, this intervention can facilitate a better learning environment for medical students on their surgery clerkship.

Antibiotic prophylaxis for tube thoracostomy placement in trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma.

Background: Antibiotic prophylaxis is routinely administered for most operative procedures, but their utility for certain bedside procedures remains controversial. We performed a systematic review and meta-analysis and developed evidence-based recommendations on whether trauma patients receiving tube thoracostomy (TT) for traumatic hemothorax or pneumothorax should receive antibiotic prophylaxis. Methods: Published literature was searched through MEDLINE (via PubMed), Embase (via Elsevier), Cochrane Central Register of Controlled Trials (via Wiley), Web of Science and ClinicalTrials.gov databases by a professional librarian. The date ranges for our literature search were January 1900 to March 2020. A systematic review and meta-analysis of currently available evidence were performed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Results: Fourteen relevant studies were identified and analyzed. All but one were prospective, with eight being prospective randomized control studies. Antibiotic prophylaxis protocols ranged from a single dose at insertion to 48 hours post-TT removal. The pooled data showed that patients who received antibiotic prophylaxis were significantly less likely to develop empyema (OR 0.47, 95% CI 0.25 to 0.86, p=0.01). The benefit was greater in patients with penetrating injuries (penetrating OR 0.25, 95% CI 0.10 to 0.59, p=0.002, vs blunt OR 0.25, 95% CI 0.06 to 1.12, p=0.07). Administration of antibiotic prophylaxis did not significantly affect pneumonia incidence or mortality. Discussion: In adult trauma patients who require TT insertion, we conditionally recommend antibiotic prophylaxis be given at the time of insertion to reduce incidence of empyema. PROSPERO registration number: CRD42018088759.

Use of a Structured Observation Tool to Promote Medical Student Engagement in Trauma Resuscitations.

OBJECTIVE: We describe a novel approach to promoting medical student learning and engagement during trauma resuscitation with implementation of a structured observation and debriefing tool. DESIGN: In the context of a multifaceted quality improvement effort in our emergency room, we implemented a structured trauma observation tool (SOT) for medical students based on ATLS trauma guidelines. The SOT reflects the American College of Surgeons and Association for Surgical Education (ACS/ASE) trauma evaluation module for medical students. Two medical students from our quality improvement working group undertook a proof-of-concept study to determine whether the SOT facilitated accurate observations of trauma resuscitations and promoted educational debriefs with precepting providers. Results were encouraging, so the tool was implemented for elective use on surgical clerkships. Clerkship students who used the SOT were given the opportunity to share its impact on their experience. Institutional Review Board approval was obtained under Pro00109569. SETTING: A large level 1 trauma center at an academic hospital in the southeastern United States. PARTICIPANTS: An interdisciplinary working group including surgeons, emergency medicine physicians, nurses, and students developed the observation tool. Two medical students from this team showed that the tool was effective at guiding observations and facilitating debriefs prior to its broader implementation on the general surgery clerkship. RESULTS: A total of 630 resuscitation tasks were observed during 15 trauma activations prior to implementation on the surgery clerkship. There was over 97% agreement between students observations and evaluating physicians self-reporting on which tasks were completed. Tasks on which there was disagreement were discussed to aid student learning. The tool was implemented for elective use on the surgery clerkship where students reported positive experiences. CONCLUSIONS: Early data suggest that this structured observation tool facilitates accurate trauma assessment observations and provides an opportunity for high-yield debriefs with the evaluating physician. This promotes student comprehension of ATLS principles. The SOT is being implemented as a pedagogic tool for students on the surgery clerkship to guide their observations, improve comprehension of decisions made in a hyperacute setting, and offer real time feedback as part of their learning in the trauma bay. The tool appears to be a valuable supplement which supports the ACS/ASE curriculum.

The Role of Surgery for Pancreatic Neuroendocrine Tumors.

Pancreatic neuroendocrine tumors (PNETs) arise from endocrine pancreatic cells and comprise 3-5% of pancreatic cancers. Surgical resection is the only potentially curative option for PNETs. Surgical candidates should be carefully selected according to tumor functionality, size, location, grade, and stage. Current guidelines state that patients with neuroendocrine carcinoma may not be surgical candidates due to aggressive tumor behavior and poor prognosis, while in cases of PNET with unresectable metastatic disease, resection may be of benefit in certain patients. The current guidelines recommend resection of any size of functional PNETs and of non-functional PNETs >2 cm. Watchful waiting is recommended for patients with non-functional PNETs <1 cm. Further evidence is needed to determine whether surgery for non-functional PNETs of 1-2 cm would be of benefit or if surgery should be individualized. This review aimed to discuss the current literature on the management of PNETs and highlight the utility of surgery in treatment.

Platelet rich plasma concentration improves biologic mesh incorporation and decreases multinucleated giant cells in a dose dependent fashion.

Platelet rich plasma (PRP) has been shown to improve incorporation and reduce inflammation in ventral hernia repair (VHR) with acellular dermal matrix (ADM). The concentration of platelets in PRP varies in clinical studies and an ideal concentration has yet to be defined. The effects of varied concentrations of PRP on ADM incorporation and inflammatory cell infiltration in a rat model of VHR. We hypothesized that increasing concentration of PRP would lead to improved incorporation, decreased CD8+ and multinucleated giant cell (MNGC) infiltrate. Lewis rats underwent ventral hernia creation and repair 30 days later with porcine non-crosslinked ADM. PRP was applied to the mesh prior to skin closure at concentrations of 1 × 104 plt/µL (PRP-LOW), 1 × 106 plt/µL (PRP-MID), or 1 × 107 plt/µL (PRP-HIGH) and tissue harvested at 2 and 4 weeks. Cellularization, tissue deposition, and mesh thickness using hematoxylin and eosin and Masson's trichrome, and neovascularization was assessed with VVG staining, to establish the relationship of PRP concentration to metrics of incorporation. MNGC and CD8+ T-cell infiltration were quantified to establish the relationship of inflammatory cell infiltration in response to PRP concentration. Lymphocyte infiltration was assessed using immunohistochemical staining for CD8. PRP-HIGH treated had significantly greater tissue deposition at 4 weeks. PRP-MID showed increasing mesh thickness at 2 weeks. Cell infiltration was significantly higher with PRP-HIGH at both 2 and 4 weeks while PRP-LOW showed increased cell infiltration only at 4 weeks. At both time points there was a trend towards a dose dependent response in cell infiltration to PRP concentration. Neovascularization was highest with MID-plt at 2 weeks, yet no significant differences were noted compared to controls. CD8+ cell infiltrate was significantly decreased at 2 and 4 weeks in PRP-LOW and PRP-MID treated groups. PRP at all concentrations significantly decreased MNGC infiltration at 2 weeks while only PRP-HIGH and PRP-MID had significant reductions in MNGC at 4 weeks. Both MNGC and CD8+ cell infiltration demonstrated dose dependent reduction in relation to PRP concentration. Increasing platelet concentrations of PRP correlated with improved incorporation, tissue deposition, and decreased scaffold degradation. These findings were associated with a blunted foreign body response. These findings suggest PRP reduces inflammation which may be beneficial for ADM incorporation in VHR.

Massive Transfusion Protocol Predictive Modeling in the Modern Electronic Medical Record.

Objectives: Integrate a predictive model for massive transfusion protocol (MTP) activation and delivery in the electronic medical record (EMR) using prospectively gathered data; externally validate the model and assess the accuracy and precision of the model over time. Background: The Emory model for predicting MTP using only four input variables was chosen to be integrated into our hospital's EMR to provide a real time clinical decision support tool. The continuous variable output allows for periodic re-calibration of the model to optimize sensitivity and specificity. Methods: Prospectively collected data from level 1 and 2 trauma activations were used to input heart rate, systolic blood pressure, base excess (BE) and mechanism of injury into the EMR-integrated model for predicting MTP activation and delivery. MTP delivery was defined as: 6 units of packed red blood cells/6 hours (MTP1) or 10 units in 24 hours (MTP2). The probability of MTP was reported in the EMR. ROC and PR curves were constructed at 6, 12, and 20 months to assess the adequacy of the model. Results: Data from 1162 patients were included. Areas under ROC for MTP activation, MTP1 and MTP2 delivery at 6, 12, and 20 months were 0.800, 0.821, and 0.831; 0.796, 0.861, and 0.879; and 0.809, 0.875, and 0.905 (all P < 0.001). The areas under the PR curves also improved, reaching values at 20 months of 0.371, 0.339, and 0.355 for MTP activation, MTP1 delivery, and MTP2 delivery. Conclusions: A predictive model for MTP activation and delivery was integrated into our EMR using prospectively collected data to externally validate the model. The model's performance improved over time. The ability to choose the cut-points of the ROC and PR curves due to the continuous variable output of probability of MTP allows one to optimize sensitivity or specificity.

Addition of platelet-rich plasma supports immune modulation and improved mechanical integrity in Alloderm mesh for ventral hernia repair in a rat model.

The recurrence of ventral hernias continues to be a problem faced by surgeons, in spite of efforts toward implementing novel repair techniques and utilizing different materials to promote healing. Cadaveric acellular dermal matrices (Alloderm) have shown some promise in numerous surgical subspecialties, but these meshes still suffer from subsequent failure and necessitation of re-intervention. Here, it is demonstrated that the addition of platelet rich plasma to Alloderm meshes temporally modulates both the innate and cytotoxic inflammatory responses to the implanted material. This results in decreased inflammatory cytokine production at early time points, decreased matrix metalloproteinase expression, and decreased CD8+ T cell infiltration. Collectively, these immune effects result in a healing phenotype that is free from mesh thinning and characterized by increased material stiffness.

Thromboelastography and rotational thromboelastometry in bleeding patients with coagulopathy: Practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Assessment of the immediate need for specific blood product transfusions in acutely bleeding patients is challenging. Clinical assessment and commonly used coagulation tests are inaccurate and time-consuming. The goal of this practice management guideline was to evaluate the role of the viscoelasticity tests, which are thromboelastography (TEG) and rotational thromboelastometry (ROTEM), in the management of acutely bleeding trauma, surgical, and critically ill patients. METHODS: Systematic review and meta-analyses of manuscripts comparing TEG/ROTEM with non-TEG/ROTEM-guided blood products transfusions strategies were performed. The Grading of Recommendations Assessment, Development and Evaluation methodology was applied to assess the level of evidence and create recommendations for TEG/ROTEM-guided blood product transfusions in adult trauma, surgical, and critically ill patients. RESULTS: Using TEG/ROTEM-guided blood transfusions in acutely bleeding trauma, surgical, and critically ill patients was associated with a tendency to fewer blood product transfusions in all populations. Thromboelastography/ROTEM-guided transfusions were associated with a reduced number of additional invasive hemostatic interventions (angioembolic, endoscopic, or surgical) in surgical patients. Thromboelastography/ROTEM-guided transfusions were associated with a reduction in mortality in trauma patients. CONCLUSION: In patients with ongoing hemorrhage and concern for coagulopathy, we conditionally recommend using TEG/ROTEM-guided transfusions, compared with traditional coagulation parameters, to guide blood component transfusions in each of the following three groups: adult trauma patients, adult surgical patients, and adult patients with critical illness. LEVEL OF EVIDENCE: Systematic Review/Meta-Analysis, level III.

Outcomes of Acute Kidney Injury in Patients With Severe ARDS Due to Influenza A(H1N1) pdm09 Virus.

BACKGROUND: The incidence and long-term outcomes of acute kidney injury in patients with severe acute respiratory distress syndrome (ARDS) due to influenza A(H1N1) pdm09 virus (pH1N1) have not been examined. OBJECTIVE: To assess long-term renal recovery in patients with acute kidney injury and severe ARDS due to pH1N1. METHODS: A retrospective observational cohort study of adults with severe pH1N1-associated ARDS admitted to a tertiary referral center. Baseline characteristics, acute kidney injury stage, continuous renal replacement therapy (CRRT), intermittent hemodialysis, extracorporeal membrane oxygenation, survival, and renal recovery (defined as dialysis independence) were evaluated. RESULTS: Fifty-seven patients, most with stage 3 acute kidney injury, were included. The 53% mortality rate among the 38 patients requiring CRRT was significantly higher than the 0% mortality rate among the 19 patients not requiring CRRT or intermittent hemodialysis. Increased duration of CRRT was not significantly associated with decreased survival. Fifteen CRRT patients required transition to intermittent hemodialysis. Of the CRRT patients who survived, 94% experienced renal recovery. Extracorporeal membrane oxygenation was instituted in 17 patients; 15 of these patients required CRRT. CONCLUSIONS: Acute kidney injury is common in patients with severe ARDS caused by pH1N1 infection. CRRT is a significant risk factor for increased mortality, but most patients who survived experienced full renal recovery.