Assessment of three point-of-care platelet function assays in adult trauma patients.

BACKGROUND: Antiplatelet (AP) medication use is common among trauma patients and is associated with poor outcomes. Management options for platelet dysfunction in trauma patients are controversial, expensive, and potentially harmful. Although light transmission platelet aggregometry is considered the standard test to assess platelet function, it is cumbersome and not generally available. Currently, there are no widely accepted platelet function point-of-care tests for acute trauma. STUDY DESIGN: Prospective observational study from 2014 to 2015. Baseline Multiplate aggregometry aspirin area under the platelet aggregation curve (ASPI AUC), Thrombelastography Platelet Mapping percent inhibition of arachidonic acid (TEG-PM AA), and VerifyNow Aspirin Test (ARU) were compared for ability to detect any AP medication use (aspirin or clopidogrel), platelet dysfunction, and identify patients at risk for intracranial hemorrhage (ICH) progression by calculating the area under receiver operating characteristic curves (AUC), sensitivity, specificity, and positive and negative predictive values. Adenosine diphosphate assays were similarly evaluated. RESULTS: Sixty-four patients were enrolled, 25 were taking AP medications. AP patients were older (71.6 versus 35.0 y, P < 0.001) and received more platelet transfusions, but other baseline characteristics were similar. Median ASPI AUC (22.0 versus 53.5 P < 0.001) and VerifyNow ARU (503.5 versus 629.0, P < 0.001) were lower, whereas TEG-PM AA (51.8% versus 18.3%, P < 0.001) was higher in AP patients. Multiplate ASPI AUC, TEG-PM AA percent inhibition, and VerifyNow ARU could identify AP medication use (AUC: 0.90, 0.77, and 0.90, respectively). Adenosine diphosphate assays did not correlate with AP medication use in this population. TEG-PM AA percent inhibition and VerifyNow ARU correlated well with Multiplate ASPI AUC to identify platelet dysfunction (AUC: 0.78, 0.89, respectively). ICH occurred in 29 patients; 12 of which had progression of their injury. ASPI AUC (AUC: 0.50) and VerifyNow ARU (AUC: 0.59) did not correlate, and TEG-PM AA percent inhibition (AUC: 0.66) minimally correlated with progression. CONCLUSIONS: Multiplate, TEG-PM, and VerifyNow are useful point-of-care tests which identify AP medication use and platelet dysfunction in trauma patients. Initial TEG-PM AA percent inhibition may be associated with risk for ICH progression. However, additional large, prospective studies are needed.

Weight-based enoxaparin thromboprophylaxis in young trauma patients: analysis of the CLOTT-1 registry.

Introduction: Optimal venous thromboembolism (VTE) enoxaparin prophylaxis dosing remains elusive. Weight-based (WB) dosing safely increases anti-factor Xa levels without the need for routine monitoring but it is unclear if it leads to lower VTE risk. We hypothesized that WB dosing would decrease VTE risk compared with standard fixed dosing (SFD). Methods: Patients from the prospective, observational CLOTT-1 registry receiving prophylactic enoxaparin (n=5539) were categorized as WB (0.45-0.55 mg/kg two times per day) or SFD (30 mg two times per day, 40 mg once a day). Multivariate logistic regression was used to generate a predicted probability of VTE for WB and SFD patients. Results: Of 4360 patients analyzed, 1065 (24.4%) were WB and 3295 (75.6%) were SFD. WB patients were younger, female, more severely injured, and underwent major operation or major venous repair at a higher rate than individuals in the SFD group. Obesity was more common among the SFD group. Unadjusted VTE rates were comparable (WB 3.1% vs. SFD 3.9%; p=0.221). Early prophylaxis was associated with lower VTE rate (1.4% vs. 5.0%; p=0.001) and deep vein thrombosis (0.9% vs. 4.4%; p<0.001), but not pulmonary embolism (0.7% vs. 1.4%; p=0.259). After adjustment, VTE incidence did not differ by dosing strategy (adjusted OR (aOR) 0.75, 95% CI 0.38 to 1.48); however, early administration was associated with a significant reduction in VTE (aOR 0.47, 95% CI 0.30 to 0.74). Conclusion: In young trauma patients, WB prophylaxis is not associated with reduced VTE rate when compared with SFD. The timing of the initiation of chemoprophylaxis may be more important than the dosing strategy. Further studies need to evaluate these findings across a wider age and comorbidity spectrum. Level of evidence: Level IV, therapeutic/care management.

Chylothorax and chylous ascites: Overview, management, and nutrition.

Chyle leaks of any source or type can cause significant morbidity and mortality. Attention to the anatomy and physiology of the leak, followed by stepwise dietary and pharmacologic management, obviates the need for surgical intervention in a majority of patients. In this article, we review the importance, etiology, anatomy, diagnosis, nutrition and immunologic effects, and options for treatment of chylothorax and chylous ascites based on experience and prior literature. We propose a multidisciplinary approach to optimize these treatments including the primary surgical teams, pharmacists, and dietitians, with reoperation as a last resort to minimize the morbidity of this challenging complication.

Challenging Traditional Paradigms in Posttraumatic Pulmonary Thromboembolism.

Importance: Pulmonary clots are seen frequently on chest computed tomography performed after trauma, but recent studies suggest that pulmonary thrombosis (PT) and pulmonary embolism (PE) after trauma are independent clinical events. Objective: To assess whether posttraumatic PT represents a distinct clinical entity associated with the nature of the injury, different from the traditional venous thromboembolic paradigm of deep venous thrombosis (DVT) and PE. Design, Setting, and Participants: This prospective, observational, multicenter cohort study was conducted by the Consortium of Leaders in the Study of Traumatic Thromboembolism (CLOTT) study group. The study was conducted at 17 US level I trauma centers during a 2-year period (January 1, 2018, to December 31, 2020). Consecutive patients 18 to 40 years of age admitted for a minimum of 48 hours with at least 1 previously defined trauma-associated venous thromboembolism (VTE) risk factor were followed up until discharge or 30 days. Exposures: Investigational imaging, prophylactic measures used, and treatment of clots. Main Outcomes and Measures: The main outcomes of interest were the presence, timing, location, and treatment of any pulmonary clots, as well as the associated injury-related risk factors. Secondary outcomes included DVT. We regarded pulmonary clots with DVT as PE and those without DVT as de novo PT. Results: A total of 7880 patients (mean [SD] age, 29.1 [6.4] years; 5859 [74.4%] male) were studied, 277 with DVT (3.5%), 40 with PE (0.5%), and 117 with PT (1.5%). Shock on admission was present in only 460 patients (6.2%) who had no DVT, PT, or PE but was documented in 11 (27.5%) of those with PE and 30 (25.6%) in those with PT. Risk factors independently associated with PT but not DVT or PE included shock on admission (systolic blood pressure <90 mm Hg) (odds ratio, 2.74; 95% CI, 1.72-4.39; P < .001) and major chest injury with Abbreviated Injury Score of 3 or higher (odds ratio, 1.72; 95% CI, 1.16-2.56; P = .007). Factors associated with the presence of PT on admission included major chest injury (14 patients [50.0%] with or without major chest injury with an Abbreviated Injury Score >3; P = .04) and major venous injury (23 [82.1%] without major venous injury and 5 [17.9%] with major venous injury; P = .02). No deaths were attributed to PT or PE. Conclusions and Relevance: To our knowledge, this CLOTT study is the largest prospective investigation in the world that focuses on posttraumatic PT. The study suggests that most pulmonary clots are not embolic but rather result from inflammation, endothelial injury, and the hypercoagulable state caused by the injury itself.

Management of colonic injuries in the combat theater.

PURPOSE: Combat injuries are more often associated with blast, penetrating, and high-energy mechanisms than civilian trauma, generating controversy about the management of combat colonic injury. Despite implementation of mandatory colostomy in World War II, recent civilian data suggest that primary repair without diversion is safe and feasible. This study describes the modern management of battle-related colonic injuries and seeks to determine whether management strategy affects early complications. METHODS: Records from the combat theater (downrange) and tertiary referral center in Germany were retrospectively reviewed from 2005 to 2006. Patient characteristics, management strategy, treatment course, and early complications were recorded. Comparison groups by management strategy were as follows: primary repair, diversion, and damage control. RESULTS: A total of 133 (97% male) patients sustained colonic injuries from penetrating (71%), blunt (5%), and blast (23%) mechanisms. Average injury severity score was 21 and length of stay in the referral center was 7.1 days. Injury distribution was 21% ascending, 21% descending, 15% transverse, 27% sigmoid, and 25% rectum. Downrange complications for primary repair, initial ostomy, and damage control groups were 14%, 15%, and 30%, respectively. On discharge from the center, 62% of patients had undergone a diversion. The complication rate was 18% overall and was unrelated to management strategy (P = .16). Multivariate analysis did not identify independent predictors of complications. CONCLUSION: Early complications were similar by mechanism, anatomic location, severity of injury, and management strategy. More diversions were performed for rectosigmoid injury. Good surgical judgment allows for low morbidity and supports primary repair in selected cases. Damage control surgery is effective in a multinational theater of operations.

Comparison of abdominal damage control surgery in combat versus civilian trauma.

BACKGROUND: The majority of individuals who perform damage control surgery in the military arena are trained in civilian venues. Therefore, it is important to compare and contrast damage control performed in civilian and military settings. In contrast to civilian trauma, which is primarily caused by blunt injury and addressed at one or two surgical facilities, combat casualties primarily sustain explosion-related injuries and undergo treatment at multiple levels of care across continents. We aimed to compare patients undergoing abdominal damage control surgery across these two very different settings. METHODS: Parallel retrospective reviews were conducted over 2 years (2005-2006) in a combat setting and at a US Level I trauma center. Patients were examined during the first 7 days after injury. RESULTS: The civilian population (CP) was older (40 vs. 23; p < 0.01) with a higher injury severity score (35 vs. 27; p < 0.02). The CP experienced greater blunt injury than the military population (MP) (83 vs. 4%; p < 0.01). Explosion-related injury was only present in the MP (64%). At baseline, the CP presented with lower systolic blood pressure (108 vs. 126) and larger base deficit (9.8 vs. 6.5; p < 0.05). The MP underwent more surgeries (3.5 vs. 2.9; p = 0.02) with similar rates of fascial closure (48.7% vs. 70.0%; p = 0.11). Complication rates were similar between the CP and the MP (43% vs. 58%, respectively; p = 0.14). CONCLUSIONS: Military and civilian trauma patients who undergo damage control surgery experience similar fascial closure rates despite differing demographics and widely disparate mechanisms of injury. The MP undergoes a greater number of procedures than the CP, but complication rates do not differ between the groups.

Transfusion of aged packed red blood cells results in decreased tissue oxygenation in critically injured trauma patients.

BACKGROUND: Blood transfusion is a common event in the treatment of injured patients. The effect of red blood cell transfusion on tissue oxygenation is unclear. The transfusion of older blood has been shown to be detrimental in retrospective studies. This study aims to study the effect of the age of the blood transfused on the tissue oxygenation using near infrared spectroscopy. METHODS: Thirty-two critically injured trauma patients for whom a blood transfusion had been ordered were recruited. Each patient had a transcutaneous probe placed on the thenar eminence. The probe was placed 1 hour before the transfusion and left in place until 4 hours after transfusion. Tissue oxygen saturation (Sto2) was recorded every 2 minutes. The Sto2 area under the curve (AUC) over time periods was calculated. A control group (n = 16), not transfused, was recruited. The transfusion group was divided into two groups by blood age. One group received blood less than 21 days old, (new blood, n = 15) and the other received blood 21 days old or greater (old blood, n = 17). The data were analyzed for significance with Kendall's W and Wilcoxon's signed rank test (p < 0.05). RESULTS: Baseline characteristics such were not significantly different between groups. The baseline AUC did not differ between groups. The old blood group demonstrated a significant decline in Sto2 comparing its baseline period to its transfusion period (p < 0.05). There was no similar decline in the control group or the new blood group. The posttransfusion period AUC for the old blood group was also lower versus baseline (p = 0.06). There was a moderate correlation between increasing age of blood and decrease in oxygenation (r = 0.5). CONCLUSIONS: There was a decrease in peripheral tissue oxygenation in patients receiving older red blood cells. There was no oxygenation decrease in patients receiving blood less than 21 days. This indicates that factors in stored blood may influence the peripheral vasculature and oxygen delivery.

Surgical palliative care training in general surgery residency: An educational needs assessment.

INTRODUCTION: There is increasing recognition that Surgical Palliative Care is an essential component of the holistic care of surgical patients and involves more than end-of-life care in the intensive care unit. General surgery residents are clinically exposed to patients with palliative care needs during each year of training, but few have a dedicated surgical palliative care curriculum. We undertook this educational needs assessment as the first step towards a longitudinal curriculum. METHODS: We conducted an anonymous survey of 94 general surgery residents and 115 faculty at community and university hospitals to assess their experience and comfort with surgical palliative care delivery. Residents and faculty were asked multiple choice and open-ended questions. RESULTS: There was a 55% response rate from residents and 33% response rate from faculty. The majority (77%) of respondents were junior residents (PGY1-3) and university-based faculty (66%). Approximately half of residents felt comfortable leading conversations in goals of care (58%), comfort-focused care (52%) and delivering bad news (57%), while greater than 90% of faculty agreed that chief residents needed additional training. All residents agreed they needed additional training and 85% wanted a formal curriculum. Analysis of open-ended questions suggests a deficiency in the pre-operative setting as no residents had participated in these conversations in an outpatient setting. CONCLUSION: Residents and faculty believe trainees would benefit from further education in surgical palliative care with a dedicated curriculum. The outpatient, pre-operative counseling of patients was identified as a key learning need. These data support our ongoing work to develop a surgically pertinent palliative care curriculum.

Factors influencing amount of guidance in the operating room during laparoscopic cases.

BACKGROUND: Identifying factors associated with resident autonomy may help improve training efficiency. This study evaluates resident and procedural factors associated with level of guidance needed in the operating room. METHODS: Intraoperative performance and yearly performance on Fundamentals of Laparoscopic Surgery (FLS) tasks from 74 general surgery residents were retrospectively reviewed. The effect of post-graduate year (PGY), procedure complexity, case difficulty, intraoperative performance, and FLS task performance were analyzed using a mixed-effects model. RESULTS: PGY level, procedure complexity, case difficulty, operative technique, and operative knowledge were significantly associated with level of intraoperative guidance. In PGY2-4 residents, ratings of medical knowledge and communication were also significantly associated with guidance. There was no significant association between FLS performance and level of guidance for any PGY level. CONCLUSIONS: The amount of intraoperative guidance is influenced by many factors, including resident performance and case characteristics. FLS tasks performance was not significantly associated with intraoperative guidance.

Ketamine-based total intravenous anesthesia versus isoflurane anesthesia in a swine model of hemorrhagic shock.

BACKGROUND: Inhalational anesthetics can cause profound hemodynamic effects including decreases in systemic vascular resistance and cardiac inotropy. Although widely used in uncontrolled hemorrhagic shock (UHS), their consequences compared with other anesthetic regimens are not well-studied. Ketamine-based total intravenous anesthesia (TIVA) may produce less profound cardiovascular depression, and has been used during elective surgery but rarely during traumatic shock. The purpose of this study was to compare the effects of isoflurane (ISO) and TIVA regimens in a swine grade V liver injury model. We hypothesized that TIVA would result in less hypotension and dysfunctional inflammation than ISO. METHODS: Twenty swine were randomized blindly to receive either 1% to 3% ISO, or intravenous ketamine, midazolam, and buprenorphine for maintenance anesthesia. Six animals acted as controls. After sedation and intubation, randomized anesthesia was initiated and monitored by an independent animal technician. Invasive lines were placed followed by celiotomy and splenectomy. Baseline mean arterial pressure (MAP) was documented and a grade V liver injury created. After 30 minutes of UHS, animals were resuscitated with 8 mL of Ringer's lactate per milliliter blood loss at 165 mL/min. MAP and tissue oxygen saturation (StO2) were continuously recorded. The animals were sacrificed 120 minutes after injury and lung tissue was harvested. Serum cytokines (interleukin-6 [IL-6], IL-8, and tumor necrosis factor-alpha [TNF-alpha]) were quantified with enzyme-linked immunosorbent assay. Lung cytokine mRNA levels were quantified with real time reverse transcriptase polymerase chain reaction. RESULTS: Animal weight, liver injury pattern, and blood loss were similar (p > 0.1). The ISO group had a lower MAP at baseline (p = 0.02), at injury (p = 0.004), and study completion (p = 0.001). After resuscitation, MAP decreased in the ISO group but remained stable in the TIVA group. StO2 was significantly higher in the TIVA group immediately after injury (p = 0.004), but similar between groups throughout the remainder of the study. Animals who received TIVA trended toward higher levels of lactate and lower pH throughout the study, reaching significance at 30 minutes postinjury (p = 0.037 and 0.043). Inflammatory cytokine (IL-6, IL-8, and TNF-alpha) production did not differ between groups, however TNF-alpha mRNA production was significantly lower in the TIVA group (p = 0.04). CONCLUSION: Although a TIVA regimen produced less pronounced hypotension in a swine model of UHS than did ISO, end-organ perfusion with TIVA appeared to be equivalent or inferior to ISO. In circumstances of limited resources, such as those experienced by forward Army surgical teams, a ketamine-based TIVA regimen may be an option for use in UHS.

PGY-specific benchmarks improve resident performance on Fundamentals of Laparoscopic Surgery tasks.

BACKGROUND: Although expert proficiency times for Fundamentals of Laparoscopic Surgery (FLS) tasks exist, these times are not always attainable for junior residents. We hypothesize that post-graduate year (PGY)-specific benchmarks will improve resident performance of FLS tasks. METHODS: In 2014, PGY-specific benchmarks were developed for FLS tasks for PGY1-PGY4 general surgery residents by averaging completion times for each task from 2007 to 2013. Resident performance on each FLS task and overall performance was compared for PGY1-PGY4 residents in the 2007-2013 group and the 2014-2016 group, before and after implementation of PGY-specific benchmarks. RESULTS: There was a significant improvement in FLS performance in the 2014-2016 group at the PGY1 (p = 0.01), PGY2 (p < 0.01), and PGY3 (p = 0.01) levels, but no difference at the PGY4 level (p = 0.71). CONCLUSIONS: PGY-specific benchmarks may improve efficacy of laparoscopic skills training for junior residents, increasing the efficiency of skill development.

Fellowship training in extracorporeal life support: Characterization and educational needs assessment.

PURPOSE: Adult Extracorporeal Life Support (ECLS) use is rapidly increasing. The structure of fellowship ECLS education is unknown. We sought to define current ECLS education and identify curricular needs. MATERIALS AND METHODS: An anonymous survey with Likert, binary and free response questions was sent to Critical Care Program Directors (CCPDs). RESULTS: A total of 103 CCPDs responded, a response rate of 31. ECLS training was provided by 64% (66/103) of fellowships. Importantly, 50% (52/103) of CCPDs agreed or strongly agreed that fellows should be competent in ECLS and 70% (72/103) agreed or strongly agreed that ECLS will be an important part of critical care in the next 10years. Only 28% (29/103) and 37% (38/103) of CCPDs agreed or strongly agreed their fellows could independently manage veno-arterial or veno-venous ECLS, respectively. Formal ECLS education was 5h or less in 85% (88/103) of programs. Desired curricular improvements were: simulation 50% (51/103), patient volume 47% (48/103), and didactics 44% (45/103). CONCLUSIONS: CCPDs identified ECLS as a critical care skill, but believe that a minority of fellows are prepared for independent practice. Simulation, formal didactics and clinical volume are key needs. These data will guide the development of ECLS curriculum.

Institutional review of the implementation and use of a Clostridium difficile infection bundle and probiotics in adult trauma patients.

BACKGROUND: Clostridium difficile infection (CDI) is a common cause of healthcare associated infections contributing to morbidity and mortality. Our objective was to evaluate the impact of the implementation of a CDI bundle along with probiotic utilization. METHODS: A retrospective review of trauma admissions from 2008 to 2014 was performed. The CDI bundle was implemented in stages from 2009 through 2014 with probiotics initiated in 2010. The bundle included changes in cleaning practices, education, screening, and contact precautions. RESULTS: 4632 (49%) patients received antibiotics with 21% receiving probiotics. Probiotic use was associated with increased age, male sex, more severely injured, and antibiotic use. CDI incidence decreased from 11.2 to 4.8 per 1000 admissions, p = .03. Among patients who received antibiotics CDI incidence decreased from 2.2% to 0.7%, p = .01. CONCLUSIONS: We report the largest series of a CDI bundle implementation including probiotics. During the period of adoption of these interventions, the incidence of CDI decreased significantly.

Early analysis of laparoscopic common bile duct exploration simulation.

BACKGROUND: We developed a laparoscopic common bile duct exploration (LCBDE) simulation course for resident surgeons (RS) and practicing surgeons (PS). We hypothesized that course completion would provide LCBDE procedural skills and increase procedure utilization. METHODS: RS and PS were prospectively enrolled. Pre- and post-course ability were assessed with written examinations and LCBDE simulations. PS completed pre-course, post-course, and 1-year follow-up surveys (5-point Likert-type scale). RESULTS: 17 RS and 8 PS were enrolled. Median written test scores improved (70.0%-80.0%, p < 0.001) and median LCBDE simulation times (seconds) improved (585-314, p = 0.001) among all participants. Comparing RS and PS, median written assessment scores pre-course (70% vs 72.5%, p = 0.953) and post-course (77.5% vs 80.0%, p = 0.198) were not significantly different. Simulation completion times (seconds) improved similarly from pre-course (608.0 vs 521.5, p = 0.885) to post-course (314.0 vs 373.0, p = 0.287) between groups. PS comfort with LCBDE improved (2-4, p = 0.03). All PS reported LCBDE utilization 1 year post-course. CONCLUSIONS: The LCBDE course is appropriate for RS and PS. PS also reported increased comfort with LCBDE and procedure utilization.

Optimizing physician skill development for medical students: The four-part assessment.

BACKGROUND: Medical student performance has been poorly correlated with residency performance and warrants further investigation. We propose a novel surgical assessment tool to determine correlations with clinical aptitude. METHODS: Retrospective review of medical student assessments from 2013 to 2015. Faculty rating of student performance was evaluated by: 1) case presentation, 2) problem definition, 3) question response and 4) use of literature and correlated to final exam assessment. A Likert scale interrater reliability was evaluated. RESULTS: Sixty student presentations were scored (4.8 assessors/presentation). A student's case presentation, problem definition, and question response was correlated with performance (r = 0.49 to 0.61, p ≤ 0.003). Moderate correlations for either question response or use of literature was demonstrated (0.3 and 0.26, p < 0.05). CONCLUSION: Our four-part assessment tool identified correlations with course and examination grades for medical students. As surgical education evolves, validated performance and reliable testing measures are required.

Teaching communication and supporting autonomy with a team-based operative simulator.

BACKGROUND: Changing residency structure emphasizes the need for formal instruction on team leadership and intraoperative teaching skills. A high fidelity, multi-learner surgical simulation may offer opportunities for senior learners (SLs) to learn these skills while teaching technical skills to junior learners (JLs). METHODS: We designed and optimized a low-cost inguinal hernia model that paired JLs and SLs as an operative team. This was tested in 3 pilot simulations. Participants' feedback was analyzed using qualitative methods. RESULTS: JL feedback to SLs included the themes "guiding and instructing" and "allowing autonomy." Senior Learner feedback to JLs focused on "mechanics," "knowledge," and "perspective/flow." Both groups focused on "communication" and "professionalism." CONCLUSIONS: A multi-learner simulation can successfully meet the technical learning needs of JLs and the teaching and communication learning needs of SLs. This model of resident-driven simulation may illustrate future opportunities for operative simulation.

A night float week in a surgical clerkship improves student team cohesion.

BACKGROUND: We hypothesize that night float rotations in the third-year surgical clerkship improve student learning and perceptions of team cohesion. METHODS: A 1-week night float (NF) system was implemented during the 2013 to 2014 academic year for students. Each student completed 1 week of NF with the Trauma/Emergency General Surgery service. The Perceived Cohesion Scale survey was prospectively administered and National Board of Medical Examiners academic performance retrospectively reviewed. RESULTS: We surveyed 70 medical students, 37 traditional call and 33 NF students, with 91% response rate. Perception of team cohesion increased significantly, without perceived loss of educational benefit. Examination scores increased significantly comparing pre- and postintervention groups, with this trend continuing in the following academic year. CONCLUSIONS: A week-long student NF experience significantly improved perception of team cohesion and standardized examination results. A dedicated period of NF during the surgical clerkship may improve its overall educational value.

Long-Term Nutrition: A Clinician's Guide to Successful Long-Term Enteral Access in Adults [Formula: see text].

Long-term nutrition support requires long-term enteral access. To ensure the success of long-term enteral access, many factors need to be taken into consideration. This article represents a guide to placing and maintaining access in patients requiring long-term nutrition and addresses many of the common questions regarding long-term enteral access, such as indications, types of access, feeding after access placed, and recognition and treatment of potential complications. This guide will help the clinician establish and maintain access to maximize nutrition in patients requiring long-term nutrition.

Long-Term Nutrition: A Clinician's Guide to Successful Long-Term Enteral Access in Adults.

Long-term nutrition support requires long-term enteral access. To ensure the success of long-term enteral access, many factors need to be taken into consideration. This article represents a guide to placing and maintaining access in patients requiring long-term nutrition and addresses many of the common questions regarding long-term enteral access, such as indications, types of access, feeding after access placed, and recognition and treatment of potential complications. This guide will help the clinician establish and maintain access to maximize nutrition in patients requiring long-term nutrition.

A Disease-Specific Hybrid Rotation Increases Opportunities for Deliberate Practice.

IMPORTANCE: Incorporating deliberate practice (DP) into residency curricula may optimize education. DP includes educationally protected time, continuous expert feedback, and a focus on a limited number of technical skills. It is strongly associated with mastery level learning. OBJECTIVE: Determine if a multidisciplinary breast rotation (MDB) increases DP opportunities. DESIGN: Beginning in 2010, interns completed the 4-week MDB. Three days a week were spent in surgery and surgical clinic. Half-days were in breast radiology, pathology, medical oncology, and didactics. The MDB was retrospectively compared with a traditional community rotation (TCR) and a university surgical oncology service (USOS) using rotation feedback and resident operative volume. Data are presented as mean ± standard deviation. SETTING: Oregon Health and Science University in Portland, Oregon; an academic tertiary care general surgery residency program. PARTICIPANTS: General surgery residents at Oregon Health and Science University participating in either the MDB, TCR or USOS. RESULTS: A total of 31 interns rated the opportunity to perform procedures significantly higher for MDB than TCR or USOS (4.6 ± 0.6 vs 4.2 ± 0.9 and 4.1 ± 1.0, p < 0.05). MDB was rated higher than TCR on quality of faculty teaching and educational materials (4.5 ± 0.7 vs 4.1 ± 0.9 and 4.0 ± 1.2 vs 3.5 ± 1.0, p < 0.05). Interns operated more on the MDB than on the USOS and were more focused on breast resections, lymph node dissections, and port placements than on the traditional surgical rotation or USOS. CONCLUSIONS: The MDB incorporates multidisciplinary care into a unique, disease-specific, and educationally focused rotation. It is highly rated and affords a greater opportunity for DP than either the USOS or TCR. DP is strongly associated with mastery learning and this novel rotation structure could maximize intern education in the era of limited work hours.