Gun Violence Education in Medical School: A Call to Action.

ISSUE: Gun violence is a major public health burden, adversely affecting patients, families, and communities across the United States (U.S.) and the world. To manage the burden of injury from gun violence and identify primary, secondary, and tertiary prevention strategies, physician leaders must understand the biological and psychosocial aspects of this complex problem. However, gun violence and its complexities are not widely taught in medical schools. This Observation article details why gun violence education is not being included in medical education, offers an informed, science-based model for the disease of gun violence, and suggests methods to integrate gun violence education into medical school curricula. EVIDENCE: We surveyed the literature for articles addressing this topic and for studies on medical school education and curriculum changes. We also examined some of the resources commonly used in medical school for mention of gun violence. Finally, we conducted a query of the AAMC Curriculum Inventory to further see if gun violence is currently incorporated into participating U.S. medical schools' curricula and found that gun violence is not a topic discussed in any significant capacity at most U.S. medical schools. Only 13-18% of schools that participated in the AAMC Curriculum Inventory during the years 2015-2018 documented gun and firearm content in their curriculum. Any other disease with similar number of deaths and injuries would be considered worthy of inclusion into medical education curricula. IMPLICATIONS: Medical school curricula commonly adjust with the ebb and flow of disease. Although gun violence meets the classic definition of a disease and is a major cause of harm and death, it is not taught to medical students. We assert that gun violence should be taught and framed as a biopsychosocial disease, highlighting many opportunities for interventions across a team of health care providers and physician leaders. We strongly urge medical schools to evaluate their curricula, address this teaching gap, and train the next generation of physician leaders to address all aspects of gun violence.

Nanodrug delivery platform for glucocorticoid use in skeletal muscle injury.

Glucocorticoids are utilized for their anti-inflammatory properties in the skeletal muscle and arthritis. However, the major drawback of use of glucocorticoids is that it leads to senescence and toxicity. Therefore, based on the idea that decreasing particle size allows for increased surface area and bioavailability of the drug, in the present study, we hypothesized that nanodelivery of dexamethasone will offer increased efficacy and decreased toxicity. The dexamethasone-loaded poly(lactic-co-glycolic acid) (PLGA) nanoparticles were prepared using nanoprecipitation method. The morphological characteristics of the nanoparticles were studied under scanning electron microscope. The particle size of nanoparticles was 217.5 ± 19.99 nm with polydispersity index of 0.14 ± 0.07. The nanoparticles encapsulation efficiency was 34.57% ± 1.99% with in vitro drug release profile exhibiting a sustained release pattern over 10 days. We identified improved skeletal muscle myoblast performance with improved closure of the wound along with increased cell viability at 10 nmol/L nano-dexamethasone-PLGA. However, dexamethasone solution (1 µmol/L) was injurious to cells because the migration efficiency was decreased. In addition, the use of dexamethasone nanoparticles decreased lipopolysaccharide-induced lactate dehydrogenase release compared with dexamethasone solution. Taken together, the present study clearly demonstrates that delivery of PLGA-dexamethasone nanoparticles to the skeletal muscle cells is beneficial for treating inflammation and skeletal muscle function.

Postoperative Complications of Laparoscopic Cholecystectomy for Acute Cholecystitis: A Comparison to the ACS-NSQIP Risk Calculator and the Tokyo Guidelines.

BACKGROUND: We compared observed postoperative outcomes from laparoscopic cholecystectomy performed for acute cholecystitis (AC) to outcomes predicted by the ACS-NSQIP risk calculator.We also noted and compared any differences in observed outcomes across the different Tokyo Guidelines (TG) levels of AC severity.We hypothesized that ACS-NSQIP would accurately predict complications and length of stay (LOS) and that increased TG severity levels would correlate with more complications, increased conversion to open surgery, and longer LOS. METHODS: A review of all patients who underwent laparoscopic cholecystectomy for acute cholecystitis over eighteen months was performed. RESULTS: ACS-NSQIP predicted a complication rate of 4.6% (11% found) and LOS of 0.73 days (2.5 found), p < 0.05. Increased TG severity had LOS of 1.89, 2.75, and 5.33, respectively, p < 0.05. The complication numbers and conversion to open cholecystectomy were insignificant between the TG classes. CONCLUSION: ACS-NSQIP did not accurately predict complications or LOS. TG classifications did not show a significant difference in complications or conversion to open surgery, but positively correlated with LOS. ACS-NSQIP may not accurately predict patient outcomes and the TG, originally created with the purpose of differentiating levels of inflammation and severity, may only be useful for predicting LOS.

A dual-stage approach to contaminated, high-risk ventral hernia repairs.

BACKGROUND: The Modified Hernia Grading System (MHGS) was developed to risk stratify complex ventral hernia repairs (VHRs). MHGS grade 3 patients have mesh infections, dirty or contaminated fields, and/or violation of the alimentary tract. Reported surgical site infection (SSI) rates are over 40% after single-stage VHR in contaminated fields. In an attempt to decrease the SSI rate in MHGS grade 3 patients, we developed a dual-stage VHR (DSVHR) approach. METHODS: We reviewed adult general surgery patients undergoing DSVHR between January 2010 and June 2014. All patients were MHGS grade 3. Primary end point was 30-d superficial and deep SSI. Secondary end points included other surgical site occurrences, 6-mo recurrence, and mesh excision rates. RESULTS: Fifteen patients underwent DSVHR. Mean age was 56 y, and median body mass index was 38.3 kg/m(2). Operative indication included enterocutaneous fistulas (ECF; n = 6), ECF with infected mesh (n = 2), infected mesh (n = 2), and VHR requiring bowel resection (n = 5). Thirty-one operative procedures were performed with median of 2.5 d between procedures. Fascial closure was re-established in 12 patients; five patients had underlay biologic mesh placement; seven underwent component separation with retrorectus mesh placement (synthetic [n = 2], biologic [n = 5]). The remaining patients underwent bridging repair with biologic mesh. One patient developed a recurrence after 6 mo, whereas a single patient had a recurrence of their ECF. Four (27%) patients developed a SSI, with an additional four (27%) experiencing a surgical site occurrence. There were no postoperative mesh infections. CONCLUSIONS: DSVHR in MHGS grade 3 patients is associated with a lower SSI rate than previously reported for those undergoing single-stage repairs.

Cost Effectiveness of a Fast-Track Protocol for Urgent Laparoscopic Cholecystectomies and Appendectomies.

BACKGROUND: Fast-track protocols (FTPs) are used to decrease length of stay (LOS) and hospital costs for elective outpatient procedures. Few institutions have implemented FTP for urgent procedures such as laparoscopic cholecystectomy (LC) and laparoscopic appendectomy (LA). STUDY DESIGN: This is a retrospective single-institution cohort study including all patients undergoing urgent LC or LA between July 1, 2010 and May 1, 2013. Exclusion criteria included conversion to open procedure, perforated appendicitis, or procedure related to intra-abdominal injury. Analysis included a comparison of the three study groups: (1) before (PRE) and after (POST) implementation of the fast-track protocol (FTP), (2) fast-track cohort (FT) and non-fast-track cohort (NFT), and (3) those completing the fast-track pathway (FT-C) and those who began but failed to complete the pathway (FT-F). RESULTS: There were significant reductions in LOS between all study groups compared: between PRE (n = 256) and POST (n = 472) cohorts by half a day (2.0 vs. 1.5 days, p < 0.02); between FT and NFT (0.68 vs. 1.82 days, p < 0.01); and FT-C and FT-F (0.49 vs. 1.05 days, p < 0.01). Total hospital charges were significantly reduced in FT compared with NFT ($22,347 vs. $30,868, p < 0.01) with an average savings of $8521. Total hospital charges were decreased in the FT-C compared with FT-F cohorts ($21,971 vs. $22,939, p = 0.3) with an average savings of $968. Readmissions, complications, and satisfaction were similar for all comparison groups. CONCLUSIONS: FTPs for urgent appendectomies and cholecystectomies can significantly reduce hospital costs by reducing LOS without compromising patient outcomes.

Sarcopenia and frailty in elderly trauma patients.

BACKGROUND: Sarcopenia describes a loss of muscle mass and resultant decrease in strength, mobility, and function that can be quantified by CT. We hypothesized that sarcopenia and related frailty characteristics are related to discharge disposition after blunt traumatic injury in the elderly. METHODS: We reviewed charts of 252 elderly blunt trauma patients who underwent abdominal CT prior to hospital admission. Data for thirteen frailty characteristics were abstracted. Sarcopenia was measured by obtaining skeletal muscle cross-sectional area (CSA) from each patient's psoas major muscle using Slice-O-Matic(®) software. Dispositions were grouped as dependent and independent based on discharge location. χ (2), Fisher's exact, and logistic regression were used to determine factors associated with discharge dependence. RESULTS: Mean age 76 years, 49 % male, median ISS 9.0 (IQR = 8.0-17.0). Discharge destination was independent in 61.5 %, dependent in 29 %, and 9.5 % of patients died. Each 1 cm(2) increase in psoas muscle CSA was associated with a 20 % decrease in dependent living (p < 0.0001). Gender, weakness, hospital complication, and cognitive impairment were also associated with disposition; ISS was not (p = 0.4754). CONCLUSIONS: Lower psoas major muscle CSA is related to discharge destination in elderly trauma patients and can be obtained from the admission CT. Lower psoas muscle CSA is related to loss of independence upon discharge in the elderly. The early availability of this variable during the hospitalization of elderly trauma patients may aid in discharge planning and the transition to dependent living.

Twelve Tips for Improving the General Surgery Resident Night Float Experience.

Restriction of resident duty hours has resulted in the implementation of night float systems in surgical and medical programs. Many papers have examined the benefits and structure of night float, but few have addressed patient safety issues, quality patient care, and the impact on the residency education system. The objective of this review is to provide practical tips to optimize the night float experience for resident training while continuing to emphasize patient care. The tips provided are based on the experiences and reflections of residents, supervising staff, group discussions, and the available literature in a hospital-based general surgery residency program. Utilizing these resources, we concluded that the night float system addresses resident work hour restrictions; however, it ultimately creates new issues. Adaptations will help achieve a balance between resident education and patient safety.

Tackling technical skills competency: a surgical skills rating tool.

BACKGROUND: The Accreditation Council for Graduate Medical Education common program requirements mandate a competency-based assignment of duties. To accomplish this, valid and reliable assessment tools must be developed to evaluate competence. This study evaluated a rating tool to assess competence in basic surgical suturing skills. METHODS: A technical skills exercise consisting of the closure of three incisions, 3 cm long, was devised in 2006. The incisions were closed with simple stitches with two-handed knots, vertical mattress stitches with instrument knots, and a running stitch with one-handed knots. Fifteen min were allotted for completion. A rating instrument with 17 competency markers worth 1 point and a global 5-point Likert scale competency score was used to evaluate the performance. Twelve first-week post graduate year 1 surgical residents completed the exercise in 2006, and 16 final-month post graduate year 1 surgical residents completed it in 2011. All tasks were scored on video review by two independent raters. Statistical analysis included descriptive statistics, t-score analysis, rank sum analysis, Cohen's kappa coefficient, and Cronbach's alpha. RESULTS: The mean total score (11.8 versus 13.9, P = 0.002) and median global competency rating (1 versus 3, P < 0.001) were lower for the first-week cohort. Cohen's kappa coefficient of inter-rater reliability was 0.77. Cronbach's alpha measure of internal consistency was 0.87. CONCLUSION: This rating form is a valuable tool to evaluate technical skill competency. Construct validity was demonstrated with improvement in total score and global rating. Excellent internal consistency and inter-rater reliability were also demonstrated. This form may be used to assess technical skill competency in an efficient skills exercise.

Comparison of outcomes with coils versus vascular plug embolization of the internal iliac artery for endovascular aortoiliac aneurysm repair.

OBJECTIVE: To compare the safety and efficacy of coil embolization (COIL) to Amplatzer vascular plug embolization (PLUG) to achieve internal iliac artery (IIA) occlusion prior to endovascular aortiliac aneurysm repair (EVAR). METHODS: Data from consecutive patients who underwent IIA embolization prior to EVAR over a 6-year period (2004-2010) were retrospectively reviewed. Patient demographics, treatment modalities, and outcomes were compared. RESULTS: From January 1, 2004 to December 31, 2010, a total of 53 patients underwent percutaneous embolization of 57 IIAs prior to EVAR. Twenty-nine IIAs underwent COIL and 28 IIAs underwent PLUG embolization. Patient demographics and risk factors were similar between the two groups. Patients underwent repair for aneurysmal dilation of the infrarenal aorta in conjunction with the common or internal iliac arteries (n = 35, 62%) or isolated iliac artery aneurysms (n = 19, 38%). A significantly greater number of embolization devices were used in the COIL group (5.8 ± 3.8 vs 1.1 ± 0.4; P < .0001). Patients undergoing PLUG embolization demonstrated significantly shorter procedure times (118.4 ± 64.7 minutes vs 72.6 ± 22.4 minutes; P = .008) and fluoroscopy times (32.6 ± 14.6 vs 14.4 ± 8.6 minutes; P = .002). However, radiation dose between the groups did not differ (COIL: 470,192.7 ± 190,606.6 vs PLUG: 300,972.2 ± 191,815.7 mGycm(2); P = .10). Overall periprocedural morbidity did not differ between the groups (COIL: 11% vs PLUG: 6%; P = 1.0), and there were no perioperative mortalities or severe complications. Nontarget embolization occurred in two COIL and no PLUG cases (COIL: 6.9% vs PLUG: 0%; P = .49). Patient-reported buttock claudication at 1 month was 17.2% for COIL and 39.3% for PLUG patients (P = .08). At last follow-up, persistent buttock claudication was reported in 13.8% of COIL and in 14.3% of PLUG embolizations (P = 1.0). There was no significant difference in charges for the embolization material, operating room, or overall hospital charges (COIL: 44,720 ± 19,153 vs 37,367 ± 10,915; P = .22). Lastly, zero endoleaks in the COIL group and three in the PLUG group (P = .40) were detected on the most recent follow-up computed tomography imaging. No endoleak was related to the site of IIA embolization. CONCLUSIONS: COIL and PLUG embolization both provide effective IIA embolization with low complication rates when used for EVAR. Buttock claudication did occur in approximately one-third of patients but resolved in half of those affected. PLUG embolization took significantly less time to perform and required decreased fluoroscopy times. Based on outcomes and cost-analysis, COIL and PLUG embolization are equivalent methods to achieve IIA occlusion during EVAR.

Bowel Ischemia Score Predicts Early Operation in Patients With Adhesive Small Bowel Obstruction.

BACKGROUND: Nonoperative management of adhesive small bowel obstruction (SBO) is successful in up to 80% of patients. Current recommendations advocate for computed tomography (CT) scan in all patients with SBO to supplement surgical decision-making. The hypothesis of this study was that cumulative findings on CT would predict the need for operative intervention in the setting of SBO. METHODS: This is an analysis of a retrospectively and prospectively collected adhesive SBO database over a 6-year period. A Bowel Ischemia Score (BIS) was developed based on the Eastern Association for the Surgery of Trauma guidelines of CT findings suggestive of bowel ischemia. One point was assigned for each of the six variables. Early operation was defined as surgery within 6 hours of CT scan. RESULTS: Of the 275 patients in the database, 249 (90.5%) underwent CT scan. The operative rate was 28.3% with a median time from CT to operation of 21 hours (Interquartile range 5.2-59.2 hours). Most patients (166/217, 76.4%) with a BIS of 0 or 1 were successfully managed nonoperatively, whereas the majority of those with a BIS of 3 required operative intervention (5/6, 83.3%). The discrimination (area under the receiver operating characteristic curve) of BIS for early surgery, any operative intervention, and small bowel resection were 0.83, 0.72, and 0.61, respectively. CONCLUSION: The cumulative signs of bowel ischemia on CT scan represented by BIS, rather than the presence or absence of any one finding, correlate with the need for early operative intervention.

Trauma surgeon-performed peripheral arterial repairs are associated with equivalent outcomes when compared with vascular surgeons.

BACKGROUND: Civilian extremity trauma with vascular injury carries a significant risk of morbidity, limb loss, and mortality. We aim to describe the trends in extremity vascular injury repair and compare outcomes between trauma and vascular surgeons. METHODS: We performed a single-center retrospective review of patients 18 years or older with extremity vascular injury requiring surgical intervention between January 2009 and December 2019. Demographics, injury characteristics, operative course, and hospital course were analyzed. Descriptive statistics were used to examine management trends, and outcomes were compared for arterial repairs. Multivariate regression was used to evaluate surgeon specialty as a predictor of complications, readmission, vascular outcomes, and mortality. RESULTS: A total of 231 patients met our inclusion criteria; 80% were male with a median age of 29 years. The femoral vessels were most commonly injured (39.4%), followed by the popliteal vessels (26.8%). Trauma surgeons performed the majority of femoral artery repairs (82%), while vascular surgeons repaired the majority of popliteal artery injuries (84%). Both had a similar share of brachial artery repairs (36% vs. 39%, respectively). There were no differences in complications, readmission, vascular outcomes, and mortality. Median time from arrival to operating room was significantly shorter for trauma surgeons. There was a significant downward trend between 2009 and 2017 in the proportion of total and femoral vascular procedures performed by trauma surgeons. On multivariate regression, surgical specialty was not a significant predictor of need for vascular reintervention, prophylactic or delayed fasciotomies, postoperative complications, or readmissions. CONCLUSION: Traumas surgeons arrived quicker to the operating and had no difference in short-term clinical outcomes of brachial and femoral artery repairs compared with patients treated by vascular surgeons. Over the last decade, there has been a significant decline in the number of open vascular repairs done by trauma surgeons. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level IV.

A multidisciplinary course on injury prevention and control for medical students.

PURPOSE: Medical student education has begun to embrace integration across specialties in order to improve understanding of diseases. The Medical College of Wisconsin's Trauma and Injury Control course was developed to expose students to the science, principles, and practice of injury prevention and control, with emphasis on collaboration among disciplines. This paper describes the development, implementation, and evaluation of that course. METHODS: This retrospective study evaluated learner satisfaction and knowledge gained during a fourth-year selective from March 2007 to 2009. The educational experience provided unique activities developed through an interprofessional approach. Student assessment included oral presentations, small-group discussions, and participation in activities. Students evaluated the quality of the experience using written narrative evaluations. Two independent, blinded raters analyzed student narratives using the constant comparative method associated with grounded theory. RESULTS: Thirty-seven students completed the course and provided comments. Evaluations demonstrated high satisfaction. Five themes emerged as strengths and outcomes: (1) recognition of injury as preventable, (2) variety of interactive educational experiences, (3) understanding physician's role in injury policy, (4) opportunity to see the system of injury care, (5) recognition of injury as a disease. Criticisms of the course related to problems with coordination. CONCLUSION: Horizontal integration of the teaching of injury is feasible and should be promoted as a valued instructional technique.

Intraabdominal vascular injury: are we getting any better?

BACKGROUND: Intraabdominal vascular injury (IAVI) as a result of penetrating and blunt trauma carries a high mortality rate. This study was performed to compare current mortality rates with a previously reported historic control. METHODS: The experience at our institution from 1970 to 1981 was previously reported with an overall mortality rate of 32% in 112 patients with penetrating IAVI. In a retrospective analysis, this historic cohort was compared with 248 patients with penetrating and blunt IAVI during a 138-month interval ending in June 2007. RESULTS: Overall mortality rate was 28.6%. The most commonly injured arteries were the iliac artery, aorta, and superior mesenteric artery. The most commonly injured veins were the inferior vena cava, iliac vein, and portal vein. Injury to the aorta, IVC, and portal vein had the highest mortality rates of 67.8%, 42.1%, and 66.6%, respectively. One hundred forty-four patients with one vessel injured had a mortality rate of 18.7%, whereas those with more than one vessel injured had a mortality rate of 48.7% (p < 0.001). A total of 46% of 117 patients in shock died compared with 9.6% of 104 patients not in shock (p < 0.001). Patients with a base deficit of less than -15 had a mortality rate of 72%, whereas those with a base deficit of 0 to -15 (p < 0.001) had a mortality rate of 18.9%. There was no difference in the overall mortality rate for penetrating trauma compared with the previous study. CONCLUSIONS: Although over 20 years have passed, no significant changes have occurred in the mortality associated with IAVI. Patients presenting in shock with IAVI continue to have a high mortality rate.

Perforated appendicitis: Short duration antibiotics are noninferior to traditional long duration antibiotics.

BACKGROUND: Appendicitis usually manifests as either uncomplicated or complicated disease. Uncomplicated appendicitis is generally treated with an appendectomy without further antibiotic therapy. In contrast, complicated appendicitis can be treated in a myriad of ways. Nonoperative treatment has been proven to be effective but has variable failure rates. Operative management typically involves resection with postoperative antibiotics. The duration of antibiotic therapy is a topic of interest. Past studies have shown that a shorter duration of antibiotics (3-5 days) are equally as effective in treating intra-abdominal contamination. In the fall 2015, our practice pattern for antibiotic duration for acute complicated appendicitis changed to reflect this finding. The purpose of this study is to retrospectively review this change in practice. HYPOTHESIS: The aim of this study was to determine if a shorter duration of antibiotics for acute complicated appendicitis is as effective as a traditional longer duration of antibiotics with a historical cohort. We also aim to determine if the duration of stay improved with the shorter duration of antibiotics. METHODS: Appendicitis cases documented after September 2015 until the present were identified. Study inclusion criteria included patients aged ≥18 and patients undergoing an appendectomy (open or laparoscopic). Exclusion criteria included patients age <18, appendicitis cases not undergoing an operation, pregnant, or immunocompromised patients. Patient demographics, operation performed, pathology reports, antibiotic duration, duration of stay, infectious and postoperative complications, and 30-day readmission rates were collected through chart review. A sample of our treatment group prior to September 2015 was also obtained in a similar technique. RESULTS: The durations of stay between cohorts were not different; both were about 6.1 days. The duration of antibiotics was less in the post-2015 group (5.5 days vs 4.1 days, P = .005). The 30-day readmission rate was significantly less in the post-2015 group (16% vs 2%; P < .017). Neither in hospital infectious complications nor types of complications were statistically significantly different between groups. CONCLUSION: This study shows that adherence to short duration antibiotic treatment appears to be effective in decreasing the 30-day readmission rate without increasing in hospital infectious complications. Short duration of antibiotics did not, however, decrease the duration of hospital stay.

Implementation of an adhesive small bowel obstruction protocol using low-osmolar water soluble contrast and the impact on patient outcomes.

BACKGROUND: Small bowel obstruction (SBO) is a common condition leading to numerous hospital admissions and operations. Standardized care of adhesive SBO patients has not been widely implemented in hospital systems. METHODS: A prospective cohort of SBO patients was compared to a historical cohort of SBO patients after implementation of a SBO protocol using evidence-based guidelines and Omnipaque, a low-osmolar water soluble contrast. Patients without a history of abdominal surgery were excluded and data was collected through chart review. RESULTS: Univariate analyses demonstrated a decrease in both LOS by 1.35 days and in the proportion of patients receiving surgery (37% vs 25%; p < 0.05). There was a decrease in time to surgery, rate of SBR, and rate of complications, yet an increase in readmission, although these findings were not statistically significant. CONCLUSIONS: Utilizing an evidence-based SBO protocol can lead to shorter LOS and may result in fewer operations for adhesive SBO patients.

Enteric Fistula Treatment and Management: Results of an Institutional Inpatient Treatment Protocol.

INTRODUCTION: Enterocutaneous fistulae (ECF) are abnormal communications between the gastrointestinal tract and skin that may occur following an abdominal operation and result in significant morbidity and even mortality. Standardized care of patients with ECF has not been implemented at the majority of tertiary hospitals. We sought to evaluate the benefits of a multidisciplinary team utilizing an evidence-based clinical treatment protocol for inpatient management of ECF. METHODS: We performed an Institutional Review Board-approved retrospective analysis of outcomes after the implementation of an evidence-based clinical treatment protocol for patients admitted with ECF to the acute care surgical service at a large academic medical facility. Patients managed prior to the established protocol were considered part of the pre-protocol cohort (pre) while patients managed following implementation were included in the postprotocol cohort (post). A review of all eligible patients' hospital and clinic medical records was performed. RESULTS: In the pre cohort (n = 6), the average length of stay was 37 days, ranging from 16-67 days, with a 16% spontaneous closure rate and 60% requiring operative management for closure. A single patient was not offered surgery due to significant comorbidities. The post cohort (n = 13) demonstrated an average length of stay of just 16 days, ranging from 4 to 28 days, with an 84% spontaneous closure rate and 16% requiring operative closure. CONCLUSION: Utilization of a standardized treatment approach results in high spontaneous closure rates with a decreased hospital length of stay.

Observing pneumothoraces: The 35-millimeter rule is safe for both blunt and penetrating chest trauma.

BACKGROUND: As more pneumothoraxes (PTX) are being identified on chest computed tomography (CT), the empiric trigger for tube thoracostomy (TT) versus observation remains unclear. We hypothesized that PTX measuring 35 mm or less on chest CT can be safely observed in both penetrating and blunt trauma mechanisms. METHODS: A retrospective review was conducted of all patients diagnosed with PTX by chest CT between January 2011 and December 2016. Patients were excluded if they had an associated hemothorax, an immediate TT (TT placed before the initial chest CT), or if they were on mechanical ventilation. Size of PTX was quantified by measuring the radial distance between the parietal and visceral pleura/mediastinum in a line perpendicular to the chest wall on axial imaging of the largest air pocket. Based on previous work, a cutoff of 35 mm on the initial CT was used to dichotomize the groups. Failure of observation was defined as the need for a delayed TT during the first week. A univariate analysis was performed to identify predictors of failure in both groups, and multivariate analysis was constructed to assess the independent impact of PTX measurement on the failure of observation while controlling for demographics and chest injuries. RESULTS: Of the 1,767 chest trauma patients screened, 832 (47%) had PTX, and of those meeting inclusion criteria, 257 (89.0%) were successfully observed until discharge. Of those successfully observed, 247 (96%) patients had a measurement of 35 mm or less. The positive predictive value for 35 mm as a cutoff was 90.8% to predict successful observation. In the univariant analyses, rib fractures (p = 0.048), Glasgow Coma Scale (p = 0.012), and size of the PTX (≤35 mm or >35 mm) (P < 0.0001) were associated with failed observation. In multivariate analysis, PTX measuring 35 mm or less was an independent predictor of successful observation (odds ratio, 0.142; 95% confidence interval, 0.047-0.428)] for the combined blunt and penetrating trauma patients. CONCLUSION: A 35-mm cutoff is safe as a general guide with only 9% of stable patients failing initial observation regardless of mechanism. LEVEL OF EVIDENCE: Therapeutic, level III.

Clinical significance of computed tomography contrast extravasation in blunt trauma patients with a pelvic fracture.

INTRODUCTION: Blunt pelvic fractures can be associated with major pelvic bleeding. The significance of contrast extravasation (CE) on computed tomography (CT) is debated. We sought to update our experience with CE on CT scan for the years 2009-2014 to determine the accuracy of CE in predicting the need for angioembolization. METHODS: This is a retrospective review of the trauma registry and our electronic medical record from a Level I trauma center. Patients seen from July 1, 2009, to September 7, 2014, with blunt pelvic fractures and contrast-enhanced CT were included. Standard demographic, clinical, and injury data were obtained. Patient records were queried for CE, performance of angiography, and angioembolization. Positive patients were those where CE was associated with active bleeding requiring angioembolization. All other patients were considered negative. RESULTS: There were 497 patients during the study time period with blunt pelvic fracture meeting inclusion criteria, and 75 patients (15%) had CE. Of those patients with CE, 30 patients (40%) underwent angiography, and 17 patients (23%) required angioembolization. The sensitivity, specificity, positive predictive value, and negative predictive value of CE on CT were 100%, 87.9%, 22.7%, and 100%, respectively. Two patients without CE underwent angiography but did not undergo embolization. Patients with CE had higher mortality (13 vs. 6%, p < 0.05) despite not having higher ISS scores. CONCLUSIONS: This study reinforces that CE on CT pelvis with blunt trauma is common, but many patients will not require angioembolization. The negative predictive value of 100% should be reassuring to trauma surgeons such that if a modern CT scanner is used, and there is no CE seen on CT, then the pelvis will not be a source of hemorrhagic shock. All of these findings are likely due to both increased comfort with observing CEs and the increased sensitivity of modern CT scanners. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.

Evaluating handoffs in the context of a communication framework.

BACKGROUND: The implementation of mandated restrictions in resident duty hours has led to increased handoffs for patient care and thus more opportunities for errors during transitions of care. Much of the current handoff literature is empiric, with experts recommending the study of handoffs within an established framework. METHODS: A prospective, single-institution study was conducted evaluating the process of handoffs for the care of surgical patients in the context of a published communication framework. Evaluation tools for the source, receiver, and observer were developed to identify factors impacting the handoff process, and inter-rater correlations were assessed. Data analysis was generated with Pearson/Spearman correlations and multivariate linear regressions. Rater consistency was assessed with intraclass correlations. RESULTS: A total of 126 handoffs were observed. Evaluations were completed by 1 observer (N = 126), 2 observers (N = 23), 2 receivers (N = 39), 1 receiver (N = 82), and 1 source (N = 78). An average (±standard deviation) service handoff included 9.2 (±4.6) patients, lasted 9.1 (±5.4) minutes, and had 4.7 (±3.4) distractions recorded by the observer. The source and receiver(s) recognized distractions in >67% of handoffs, with the most common internal and external distractions being fatigue (60% of handoffs) and extraneous staff entering/exiting the room (31%), respectively. Teams with more patients spent less time per individual patient handoff (r = -0.298; P = .001). Statistically significant intraclass correlations (P ≤ .05) were moderate between observers (r ≥ 0.4) but not receivers (r < 0.4). Intraclass correlation values between different types of raters were inconsistent (P > .05). The quality of the handoff process was affected negatively by presence of active electronic devices (ß = -0.565; P = .005), number of teaching discussions (ß = -0.417; P = .048), and a sense of hierarchy between source and receiver (ß = -0.309; P = .002). CONCLUSION: Studying the handoff process within an established framework highlights factors that impair communication. Internal and external distractions are common during handoffs and along with the working relationship between the source and receiver impact the quality of the handoff process. This information allows further study and targeted interventions of the handoff process to improve overall effectiveness and patient safety of the handoff.

The Surgical Learning and Instructional Portfolio (SLIP) as a self-assessment educational tool demonstrating practice-based learning.

PURPOSE: Time constraints on the teaching and evaluation of residents continue to alter the way in which medical knowledge must be imparted and assessed. Lifelong learning is a component of the practice-based learning competency. A portfolio is one way to assess practice-based learning, but its use is unfamiliar to most surgical programs. The authors describe the evolution of the Surgical Learning and Instructional Portfolio (SLIP) into a worthwhile educational tool. METHODS: In March 2001, the authors began a program to encourage residents to develop a case-based portfolio to document their experience and demonstrate acquisition of knowledge in caring for a variety of surgical diseases. The monthly case topic was chosen by the resident and reported using a template: case history, supporting diagnostic studies, differential diagnosis, final diagnosis with ICD-9 coding, management options, treatment used, 3 lessons learned, embellishment of 1 lesson, and 2 articles supporting the experience. Initially, cases were submitted to the program coordinator and reviewed every 6 months with a faculty advisor to provide feedback. RESULTS: After the first 18 months of this program, resident compliance was less than 50%, satisfaction was low, and formal review did not occur. In July 2004, a single faculty member became responsible for evaluating and providing feedback on the monthly SLIPs. The assignments were handled electronically with feedback delivered within the month via e-mail. SLIP quality as measured by resident compliance and satisfaction improved. CONCLUSION: These SLIPs have matured into a valuable educational tool satisfying multiple ACGME competencies. This portfolio system required direct faculty feedback to become successful.