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Cardiopulmonary resuscitation (CPR) is widely used in response to cardiac arrest. However, little is known regarding outcomes for those who undergo multiple episodes of cardiac arrest while in the hospital.The purpose of this study was to evaluate the association of multiple cardiac events with in-hospital mortality for patients admitted to our tertiary care hospital who underwent multiple code events.We performed a retrospective cohort study on all patients who underwent cardiac arrest from 2012 to 2016. Primary outcome was survival to discharge. Secondary outcomes included post-cardiac-arrest neurologic events (PCANE), non-home discharge, and one-year mortality.There were 622 patients with an overall mortality rate of 78.0%. Patients undergoing CPR for cardiac arrest once during their admission had lower in-hospital mortality rates compared to those that had multiple (68.9% versus 91.3%, p.01). Subset analysis of those who had multiple episodes of CPR revealed that more than one event within a 24-hour period led to significantly higher in-hospital mortality rates (94.7% versus 74.4%, p.01). Other variables associated with in-hospital mortality included body mass index, female sex, malignancy, and increased down time per code. Patients that had a non-home discharge were more likely to have sustained a PCANE than those that were discharged home (31.4% versus 3.9%, p.01). A non-home discharge was associated with higher one-year mortality rates compared to a home discharge (78.4% versus 54.3%, p=.01).Multiple codes within a 24-hour period and the average time per code were associated with in-hospital mortality in cardiac arrest patients.

The Accreditation Council for Graduate Medical Education has focused its interests on resident wellbeing and the clinical work environment in recent years. Concerns regarding both duty hours as well as service obligations versus education resulted in programs nationwide receiving citations, including ours. This study aimed to evaluate the impact of those 2 factors on surgical residents' general wellbeing, hypothesizing that service obligations would be a stronger predictor.We have previously reported on the use of a "Fuel Gauge" tool developed at our institution for monitoring resident wellbeing. We performed a retrospective comparison of prospectively collected cross-sectional survey data comparing the Fuel Gauge to a bimonthly "Service Versus Education" (SVE) report. This report used similar scaling and allowed residents to provide feedback on the balance of the educational quality of their current rotation in comparison to their perception of service obligation. Pearson's correlation was then used to compare those scores with duty hour logs to determine if a relationship could be identified between the 3 measurements.Academic institution of the University of Texas Southwestern in Dallas, Texas.Active general surgery residents (n = 73).During the study period, 73 residents filled out both a Fuel Gauge assessment and a SVE assessment at least once, with 273 complete data points available for analysis. Our program's Fuel Gauge median was 4, and our program's median SVE score was 4. Fuel Gauge assessment scores demonstrated a moderate positive correlation with SVE (r = 0.65, p0.001), while only a weakly negative association with increasing hours worked (r = -0.15, p = 0.015). SVE also demonstrated a weak negative correlation with hours logged (r = -0.225, p = 0.001).While the Accreditation Council for Graduate Medical Education recognizes that multiple factors contribute to resident wellbeing issues, early efforts were focused on limiting excessive duty hours. Examining our institutional data regarding the previously understudied factor of SVE, we indeed found a stronger correlation with resident perception of low educational value rather than excessive work hours contributing to lower Fuel Gauge scores. These data, if verified, should guide program directors in identifying other institutional factors that may more strongly contribute to their own culture of resident wellness.

Mortality associated with burn injuries is declining with improved critical care. However, patients admitted with concurrent substance use have increased risk of complications and poor outcomes. The impact of alcohol and methamphetamine use on acute burn resuscitation has been described in single center studies, however, has not been studied since implementation of computerized decision support for resuscitation. Patients were evaluated based presence of alcohol, with a minimum blood alcohol level of 0.10, or positive methamphetamines on urine drug screen. Fluid volumes and urine output were examined over 48 hours. A total of 296 patients were analyzed. 37 (12.5%) were positive for methamphetamine use, 50 (16.9%) were positive for alcohol use, and 209 (70.1%) with negative for both. Patients positive for methamphetamine received a mean of 5.30 ±2.63 cc/kg/TBSA, patients positive for alcohol received a mean of 5.41 ±2.49 cc/kg/TBSA, and patients with neither received a mean of 4.33 ±1.79 cc/kg/TBSA. Patients with methamphetamine or alcohol use had significantly higher fluid requirements. In the first 6 hours patients with alcohol use had significantly higher urinary output in comparison to patients with methamphetamine use which had similar output to patients negative for both substances. This study demonstrated that patients with alcohol and methamphetamine use had statistically significantly greater fluid resuscitation requirements compared to patients without. The effects of alcohol as a diuretic align with previous literature. However, patients with methamphetamine lack the increased urinary output as a cause for their increased fluid requirements.

There is a paucity of objective data about the advantages or disadvantages of handedness in surgery. Given the need for ambidexterity in laparoscopic surgery, our study aimed to identify the patterns in handedness and performance on basic laparoscopic tasks.A retrospective analysis of intern laparoscopic performance on bimanual tasks was assessed for delta time (differences in task time between the dominant and nondominant hand) between left-hand and right-hand dominant interns.Data were analyzed for 16 residents. 25% were left-handed dominant (4/16) and 75% were right-handed dominant (12/16). Of the left-handed surgeons, 75% (3/4) operated primarily with their right hand. There was a significant difference between the time to task completion in Task 2 of left-handed and right-handed residents with median (IQR) time 94 s (90.25-97) and 127 s (104.25-128.5), respectively (P value = 0.02). No significant difference was seen between left-handed and right-handed residents on Task 1 (50 s versus 49 s) and Task 3 (51 s versus 59.5 s). In all three tasks, however, left-handed dominant residents had smaller variability (IQR 4.5-8 s versus 7-24.25 s) and significantly shorter delta times.Although true ambidexterity is rare, the ability to be facile with both hands is crucial for laparoscopic surgery. Our data show that variability in performance between the dominant hand and nondominant hand was remarkably smaller for left-hand dominant residents. This remains true despite the majority learning to operate with their nondominant hand. These data demonstrate a possible advantage to being left-hand dominant and may lead to further insights into variations of skill acquisition and improved curriculum development.

The lack of guidelines for videoconferencing etiquette elucidated frustrations during the COVID-19 pandemic. The authors aimed to assess the perceptions of faculty educators and residents regarding videoconferencing etiquette.In 2021, a survey assessing perceptions regarding the formality of various meeting types and the importance of various videoconferencing etiquette practices (Likert scale of 1-5) was created and disseminated to all faculty educators and residents at a single institution. Responses of faculty versus residents were analyzed in general and by procedural and mixed/nonprocedural subspecialties.The faculty response rate was 53.5% (38/71). The resident response rate was 7.3% (115/1569). A total of 19 departments were represented. Faculty respondents reported having significantly more hours of weekly formal meetings than residents, 4 (3-10) versus 2 (1-4) h (P 0.05), and no difference in informal meeting hours, with 3 (2-6) versus 3 (1.6-5) h (P = 0.210). Faculty and residents concurred on the formality of all meeting types except for didactics, which residents regarded more frequently as informal (80.9% versus 57.9%; P 0.01). Faculty rated wearing professional attire and keeping one's video on as mattering more, and that videoconferencing from bed was more inappropriate (P 0.05). Furthermore, faculty and residents in mixed/nonprocedural specialties had more significantly discordant perceptions between them than did those in procedural specialties.The data demonstrated that faculty educators and residents have differing perceptions regarding the formality of meeting types and etiquette practices. These should be addressed to prevent future frustrations and improve engagement in ongoing virtual conferencing education.

Objective To describe the implementation of a department-wide research curriculum and infrastructure created to promote academic collaboration and productivity, particularly amongst trainees and junior investigators involved in basic, translational, clinical, quality, or education research. Design Description of UT Southwestern Medical Center's (UTSW) surgical research resources and infrastructure and the development of a didactic curriculum focused on research methods, writing skills, and optimizing academic time and effort. Setting The collaboration was initiated by UTSW Department of Surgery residents who were on dedicated research time (DRT) and grew to include trainees and faculty at all levels of the institution. Guest lecturers from institutions around the country were incorporated via virtual meeting platforms. Participants Medical students, residents, and clinical and research faculty from the Department of Surgery were invited to attend research meetings, didactics, and the guest-lecture series. Additionally, all groups were given access to shared resources and encouraged to share their own work. Results A robust set of resources including data analysis tools, manuscript and grant writing templates, funding opportunities, and a comprehensive list of surgical conferences was created and made accessible to UTSW Surgery team members. Moreover, a curriculum of lectures covering a broad variety of topics for all types of research was created and has thus far reached an audience of over 40 UTSW Surgery trainees and staff. Conclusions A comprehensive set of lectures and resources targeted toward facilitating surgical research was designed and implemented at one of the largest surgical training programs in the country. This effort represents a low-cost, feasible, and accessible way to improve academic productivity and enhance the training of surgeon-scientists and can serve as a blueprint for other institutions around the country.

Background The coronavirus disease 2019 restrictions on in-person simulation activities necessitated modifying the traditional boot camp skills curriculum for matriculating PGY1 general surgery residents to a virtual format. This study investigated the relative effectiveness of in-person versus virtual instruction on the development of suturing and knot-tying skills. Methods In all, 55 residents participated in a validated, proficiency-based, preinternship skills curriculum, 26 in 2019 and 29 in 2020. Both groups received an introduction to the curriculum, were given time for practice and offered one-on-one tutoring by faculty by request, and completed a filmed posttest. The 2019 class received in-person instruction during a boot camp at the end of June, while the 2020 class was provided with suture kits and received instruction via Zoom throughout June. The 2 groups were compared by post-test performance, date of task proficiency, and additional coaching required. Results In 2019, 5.7% of the posttest tasks were graded as proficient versus 87% in 2020. The 2020 class outperformed the 2019 class on every metric in every task (P < .001). In 2019, faculty spent 55.5 hours with residents in one-on-one remediation, resulting in proficiency in 64% of the tasks by November. In 2020, 18 hours of one-on-one remediation resulted in proficiency in 92% of the tasks by September. Conclusion Learners who received virtual instruction with access to materials at home gained proficiency in suturing and knot-tying skills earlier and with less coaching. These data demonstrate that the virtual curriculum is effective and an improvement on the previous in-person curriculum.

Purpose Surgical trainees are exposed to less procedures with increasing need for simulation. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has become increasingly implemented for hemorrhage control, yet most courses are catered to faculty level with little data on trainees. We propose that routine training in this critical procedure will improve trainee performance over time. Methods This is a prospective, observational study at a level I trauma center involving a monthly trauma procedural program. Early in the month, trainees received hands-on REBOA training; at the end, trainees underwent standardized, class-based evaluation on a perfused trainer. Score percentages were recorded (0-100%). Endpoints included early, mid and late performance (2-12 months). Paired T-test and Pearson's coefficient were used to evaluate differences and strength of association between time between training and performance. Results 25 trainees participated with 5 and 11 repeat learners in the PGY-2 and PGY-3 classes, respectively. Median early performance score was 62.5% (IQR 56-81) for PGY-2s and 91.6% (IQR 75-100) in PGY-3s. Pearson's coefficient between time between and training and score demonstrated a weak correlation in the PGY-2s (r2 = - 0.13), but was more pronounced in the PGY-3s (r2 = - 0.44) with an inflection point at 5 months. Conclusions Routine REBOA training in trainees is associated with improvement in performance within a short period of time. Skill degradation was most pronounced in trainees who did not receive training for more than 5 months. Trainees can be successfully trained in REBOA; however, this should be done at shorter intervals to prevent skill degradation.

Background At the onset of social distancing, our general surgery residency transitioned its educational curriculum to an entirely virtual format with no gaps in conference offerings. The aim of this study is to examine the feasibility of our evolution to a virtual format and report program attitudes toward the changes. Methods On March 15, 2020, due to the coronavirus disease (COVID-19) our institution restricted mass gatherings. We immediately transitioned all lectures to a virtual platform. The cancellation of elective surgeries in April 2020 then created the need for augmented resident education opportunities. We responded by creating additional lectures and implementing a daily conference itinerary. To evaluate the success of the changes and inform the development of future curriculum, we surveyed residents and faculty regarding the changes. Classes and faculty answers were compared for perception of value of the online format. Results Pre-COVID-19, residency-wide educational offerings were concentrated to one half-day per week. Once restrictions were in place, our educational opportunities were expanded to a daily schedule and averaged 16.5 hours/week during April. Overall, 41/63 residents and 25/94 faculty completed the survey. The majority of residents reported an increased ability (56%) or similar ability (34.1%) to attend virtual conferences while 9.9% indicated a decrease. Faculty responses indicated similar effects (64% increased, 32% similar, 4% decreased). PGY-1 residents rated the changes negatively compared to other trainees and faculty. PGY-2 residents reported neutral views and all other trainees and faculty believed the changes positively affected educational value. Comments from PGY1 and 2 residents revealed they could not focus on virtual conferences as it was not “protected time” in a classroom and that they felt responsible for patient care during virtual lectures. A majority of both residents (61%) and faculty (84%) reported they would prefer to continue virtual conferences in the future. Conclusions The necessity for adapting our academic offerings during the COVID-19 era has afforded our program the opportunity to recognize the feasibility of virtual platforms and expand our educational offerings. The majority of participants report stable to improved attendance and educational value. Virtual lectures should still be considered protected time in order to maximize the experience for junior residents.

INTRODUCTION The rate of burnout among residents has reached an alarming level and negatively impacts learning, attrition, and patient care. We implemented a comprehensive Surgery Resident Wellness Program in a large academic program and aimed to assess the degree this initiative improved resident burnout based on validated burnout and well-being models utilizing voluntary surveys. Materials and Methods A voluntary survey was sent to surgical residents and included the Maslach Burnout Inventory and The Psychological General Well-Being Index. These were graded according to the respective validated scale for each test. The survey was administered prior to establishing a wellness program, and at 6 month- and 24 month-intervals following its establishment. These data were analyzed using univariate analysis based on survey data from each of the time points. RESULTS The survey had a 51% response rate. The baseline, 6-month, and 24-month mean scores for MBI personal accomplishment were 32.80, 32.91, and 35.57, emotional exhaustion was 23.48, 23.0, and 24.42, and depersonalization were 10.94, 9.54, and 11.11. Resident burnout was present in 16 of 31 (51.61%), 14 of 33 (42.42%), and 12 of 27 (44.44%) residents at each time point. The rate of change in resident burnout was –17.8% at 6 months and -13.9% at 24 months. The averaged PGWBI global scores were 66, 73, and 83 among the participants who took the survey at each time interval. CONCLUSIONS Conclusion Implementation of a structured wellness program was associated with a decrease in resident burnout and an increase in overall resident wellness.

We sought to measure the emotional intelligence (EI) of surgical faculty and the relationship between faculty EI and medical student (MS) evaluations of faculty.Faculty completed the Emotional Intelligence Appraisal. Aggregate, anonymous MS evaluations were collected from the Program Director's office. Parametric and nonparametric tests were used for analysis.This study was first performed in a single surgical division at 1 center which informed an expanded study including the entire General Surgery Department at a single academic institution.A pilot study was conducted in 1 surgical division which was then expanded to all clinical faculty in the Department of Surgery. All clinical faculty in the Department of Surgery were eligible for enrollment.Pilot study faculty EI scores were positively correlated with MS evaluations (r = 0.92, p0.001). The follow-up study enrolled 41 surgeons with a median age of 48 (inter-quartile range 12). The sample was mostly white (70.7%). Mean EI for the group was 76 (standard deviation ± 7.8). Total faculty EI scores were not significantly correlated with MS evaluations (r = 0.30, p = 0.06).MS evaluations of surgeon faculty were not related to EI in the larger sample. However, EI did correlate to MS evaluations in 2 surgical specialties. Further exploration into the utility of EI training in surgical departments should be conducted to determine the true value of such endeavors.

The goal of burn resuscitation is to provide the optimal amount of fluid necessary to maintain end-organ perfusion and prevent burn shock. The objective of this analysis was to examine how the Burn Navigator (BN), a clinical decision support tool in burn resuscitation, was utilized across five major burn centers in the United States, using an observational trial of 300 adult patients. Subject demographics, burn characteristics, fluid volumes, urine output, and resuscitation-related complications were examined. Two hundred eighty-five patients were eligible for analysis. There was no difference among the centers on mean age (45.5 ± 16.8 years), body mass index (29.2 ± 6.9), median injury severity score (18 [interquartile range: 9–25]), or total body surface area (TBSA) (34 [25.8–47]). Primary crystalloid infusion volumes at 24 h differed significantly in ml/kg/TBSA (range: 3.1 ± 1.2 to 4.5 ± 1.7). Total fluids, including colloid, drip medications, and enteral fluids, differed among centers in both ml/kg (range: 132.5 ± 61.4 to 201.9 ± 109.9) and ml/kg/TBSA (3.5 ± 1.0 to 5.3 ± 2.0) at 24 h. Post-hoc adjustment using pairwise comparisons resulted in a loss of significance between most of the sites. There was a total of 156 resuscitation-related complications in 92 patients. Experienced burn centers using the BN successfully titrated resuscitation to adhere to 24 h goals. With fluid volumes near the Parkland formula prediction and a low prevalence of complications, the device can be utilized effectively in experienced centers. Further study should examine device utility in other facilities and on the battlefield.

This study aimed to determine the emotional intelligence (EI) of surgical faculty and evaluate its relationship with resident evaluations of faculty behaviors.This study retrospectively collected faculty EI scores as well as general surgery resident evaluations of faculty. Parametric and nonparametric tests were used for statistical analysis.The study was conducted at the University of Texas Southwestern in the Department of Surgery in Dallas, Texas. This is an academic, tertiary care center.Surgical faculty members at a single institution in 2018 completed the Emotional Intelligence Appraisal, a 28-item, electronic assessment with possible scores ranging from zero to 100. Aggregate, anonymous resident evaluations of faculty members were collected from the program director's office. Faculty with fewer than 8 resident evaluations were excluded.In total, 59 faculty members participated (89%). The sample was mostly white (69.2%), male (63.5%), with an average of 47 ± 10 years of age, 12.2 ± 10 years in practice, and 44 ± 24 evaluations per faculty member. The group's mean EI score was 76 ± 7.7. Faculty EI scores were found to have a moderate, positive correlation with resident rotational evaluations of faculty (r(51) = 0.52, p0.001). Faculty EI scores did not significantly correlate with resident evaluations of faculty intraoperative behaviors.The results of this study suggest that a majority of our faculty are competent with regard to EI. Furthermore, faculty EI is an important factor in the clinical learning environment and correlates with resident rotational evaluations of teaching behaviors.

To establish expert consensus regarding the domains and topics for senior surgery residents (PGY-4) to make critical decisions and assume senior-level responsibilities, and to develop the formative American College of Surgeons Senior Resident Readiness Assessment (ACS SRRA) Program.The American College of Surgeons (ACS) education leadership team conducted a focus group with surgical experts to identify the content for an assessment tool to evaluate senior residents' readiness for their increased levels of responsibility. After the focus group, national experts were recruited to develop consensus on the topics through three rounds of surveys using Delphi methodology. The Delphi participants rated topics using Likert-type scales and their comments were incorporated into subsequent rounds. Consensus was defined as ≥ 80% agreement with internal-consistency reliability (Cronbach's alpha) ≥ 0.8. In a stepwise fashion, topics that did not achieve consensus for inclusion were removed from subsequent survey rounds.The surveys were administered via an online questionnaire.Twelve program directors and assistant program directors made up the focus group. The 39 Delphi participants represented seven different surgical subspecialties and were from diverse practice settings. The median length of experience in general surgery resident education was 20 years (IQR 14.3-30.0) with 64% of the experts being either current or past general surgery residency program directors.The response rate was 100% and Cronbach's alpha was ≥ 0.9 for each round. The Delphi participants contributed a large number of comments. Of the 201 topics that were evaluated initially, 120 topics in 25 core clinical areas were included to create the final domains of ACS SRRA.National consensus on the domain of the ACS SRRA has been achieved via the modified Delphi method among expert surgeon educators. ACS SRRA will identify clinical topics and areas in which each senior resident needs improvement and provide data to residents and residency programs to develop individualized learning plans. This would help in preparing the senior residents to assume their responsibilities and support their readiness for future fellowship training or surgical practice.

Introduction Burn care continues to focus on providing enough fluid resuscitation to perfuse end organs with the least amount of fluid necessary in order to prevent complications related to excess fluid. In this observational trial of 5 ABA-verified burn centers that utilized the Burn Navigator (BN), a clinical decision support tool, we sought to examine resuscitation-related complications that occurred in the first 48 hours after burn injury. Since minimal literature exists regarding the incidence of resuscitation-related complications in the acute phase after burn injury, we aimed to present our data for future comparison. Methods An observational study of adult patients undergoing burn resuscitation utilizing the BN was conducted. Data were gathered hourly for the first 48 hours for patients on fluid infusion rates, laboratory data, critical care elements to include ventilator settings and clinically relevant outcomes. Morbidities were classified based on each burn center’s definition as related to over or under-resuscitation and variables associated with these outcomes were extracted from the data set. Results Three hundred patients were enrolled into the study, and 156 resuscitation-related complications were documented in 92 patients in the first 48 hours after admission. Compartment syndromes (abdominal, extremity, ocular) accounted for 62 (40%) of the complications. ARDS occurred in 9 patients. ARDS patients were the most severely injured, reflected by highest Baux score. None of the ARDS patients had an inhalation injury. The under-resuscitation morbidities of shock and acute kidney injury accounted for 81 (52%) of the complications. Patients experiencing shock received greater than the Parkland formula in the first 24 hours after injury. Most patients with AKI continued to make adequate urine during their resuscitation period, with 59% making an average of >30 ml/hr over the first 24 hours. Nearly half of patients with AKI were placed on renal replacement therapy in the first 48 hours. Seventeen patients (18.5%) experienced both a compartment syndrome and either AKI or shock. Conclusions This large observational study demonstrates variables associated with different complications across 5 major burn centers and shows that complications associated with over- and under-resuscitation can occur within the same patient during resuscitation after burn injury. Additional comparative studies are needed to better understand the cause of these complications, to determine the incidence of these complications in a larger population and criteria used to define each complication.

In 2014, the ABS introduced the Flexible Endoscopy Curriculum (FEC). The FEC did not alter the minimum defined category case volumes for endoscopy; however, it did introduce specific cognitive and technical milestones for endoscopy training. It also mandated that residents pass the Fundamentals of Endoscopic Skills (FES) exam to qualify for board certification. Although significant research has been published regarding residents’ success on the FES exam, very little is known regarding how the FEC has changed the way general surgery programs train their residents in surgical endoscopy. The aim of this study was to quantify changes in flexible endoscopy education at a large academic program in the 4 years since the FEC was published. We classified the impact of FEC into four categories: (a) case volume or distribution, (b) clinical rotations, (c) required didactics or simulation exercises, and (d) FES pass rates. For category (a), we reviewed current and historical case logs for all categorical residents from 2013 to 2018. Mann–Whitney U tests were used to compare endoscopy volumes for each PGY level in 2013–2014 to the respective PGY level in 2017–2018 with p

Background Pre-internship boot camps have become popular platforms to rapidly teach skills to surgical interns. This study aimed to analyze psychomotor skill retention four months after completing a boot camp program. Methods Surgical interns (n = 20) took a baseline pre-test and then trained to proficiency (based on time and errors) for 5 knot tying, 4 simple suturing, and 2 running suturing tasks during a three-day boot camp. Three months later, all interns took a retention test. Results Proficiency scores significantly improved on all task types from pre-test to post test and significantly regressed on all task types from post-test to retention test. Normalized scores decreased as the tasks became more complex (knot tying = 93.5, simple suturing = 89.1, running suturing = 85.2, p = 0.05). Conclusions Boot camp style training can rapidly teach fundamental surgical skills to novices; however, skills regress significantly over time with a greater degree of regression seen on more complex skills.

OBJECTIVE Social distancing restrictions due to COVID-19 challenged our ability to educate incoming surgery interns who depend on early simulation training for basic skill acquisition. This study aimed to create a proficiency-based laparoscopic skills curriculum using remote learning. DESIGN Content experts designed 5 surgical tasks to address hand-eye coordination, depth perception, and precision cutting. A scoring formula was used to measure performance: cutoff time - completion time - (K × errors) = score; the constant K was determined for each task. As a benchmark for proficiency, a fellowship-trained laparoscopic surgeon performed 3 consecutive repetitions of each task; proficiency was defined as the surgeon's mean score minus 2 standard deviations. To train remotely, PGY1 surgery residents (n = 29) were each issued a donated portable laparoscopic training box, task explanations, and score sheets. Remote training included submitting a pre-test video, self-training to proficiency, and submitting a post-test video. Construct validity (expert vs. trainee pre-tests) and skill acquisition (trainee pre-tests vs. post-tests) were compared using a Wilcoxon test (median [IQR] reported). SETTING The University of Texas Southwestern Medical Center in Dallas, Texas PARTICIPANTS Surgery interns RESULTS Expert and trainee pre-test performance was significantly different for all tasks, supporting construct validity. One trainee was proficient at pre-test. After 1 month of self-training, 7 additional residents achieved proficiency on all 5 tasks after 2-18 repetitions; trainee post-test scores were significantly improved versus pre-test on all tasks (p = 0.01). CONCLUSIONS This proficiency-based curriculum demonstrated construct validity, was feasible as a remote teaching option, and resulted in significant skill acquisition. The remote format, including video-based performance assessment, facilitates effective at-home learning and may allow additional innovations such as video-based coaching for more advanced curricula.

Introduction: COVID-19 altered the landscape of medical education, disrupting the general surgery residency application process. Decreased access to clinical rotations, limited access to in-person mentors, and lack of in-person interviews, highlighted the need for mentorship programs. We examined the impact of virtual mentoring following the implementation of a novel program for trainees entering the field of general surgery. Methods: We designed an exclusively online virtual mentoring program that focused on an individualized, tailored approach in five domains: requesting letters of support, personal statement composition, resume editing, interview skills, and residency program ranking. Immediately following completion of the program, a nineteen-question electronic survey was administered. Results: 18 out of 19 participants completed the survey. Following the completion of the program participants were more confident in all five domains targeted by the program when responding to survey stems (5-point Likert scale (5-strongly agree)). Utility of the program, likelihood to recommend, and likelihood to participate again in virtual mentoring were all positive 5 [4-5]. Respondents reported less concern about the impact of COVID-19 on the application cycle. Trainees reported that virtual mentoring is likely to play an increasingly important role in training programs 5[4-5]. Participants also reported an increased confidence in the match, with a pre-program median of 67 [50 - 65] and post-program median of 84 [75-91] (0.004). Conclusion: Virtual mentoring tailored for medical students entering the match is well received and increases participant confidence. This data should be used as a framework to expand and develop virtual mentoring programs.

Objective The Public Service Loan Forgiveness (PSLF) program is an option to trainees to help alleviate federal education debt. The prevalence of PSLF utilization and how this may impact career decisions of trainees is unknown. The purpose of this study was to understand the prevalence, impact, and understanding of PSLF participation on trainees. Design IRB-approved anonymous survey asking study subjects to report demographics, financial status, and reliance on PSLF. In addition, study subjects were asked to report their participation in PSLF, the possible impact of PSLF participation on career decisions, and to identify the qualifications needed to complete PSLF. Setting Online anonymous survey. Participants The survey was offered to all physician trainees in all specialties at the University of Texas, Southwestern, University of Wisconsin, Madison, and University of Michigan, Ann Arbor. Results There were 934 respondents, yielding a 37.6% response rate. A total of 416/934 (44.5%) respondents were actively or planning on participating in the PSLF program with 175/934 (18.7%) belonging to a surgical specialty. Those belonging to a surgical specialty were more likely to be PSLF participants compared to medical specialties (53.1% versus 42.6%, p = 0.01). For those participating in PSLF, 82/416 (19.7%) stated this participation impacted career decisions. A total of 275/934 (29.4%) respondents obtained and 437/934 (46.8%) wanted to receive formal training/lectures in regards to the PSLF program. Of those actively or planning on participating in the PSLF program, only 58/416 (13.9%) were able to correctly identify all of the qualifications/criteria to complete the program. Conclusions A large proportion of trainees rely on the PSLF program for education loan forgiveness with approximately 20% reporting participation impacted career decisions. Additionally, the majority may not fully understand PSLF criteria. Programs should strongly consider providing a formal education regarding PSLF to their trainees.

Introduction The goal of burn resuscitation is to provide the least amount of fluid necessary to maintain end-organ perfusion and prevent burn shock. The objective of this analysis was to examine how the Burn Navigator (BN), a clinical decision support tool in burn resuscitation, was utilized across 5 major burn centers in the United States. Methods A non-interventional, observational trial of 300 adult patients with embedded prospective and retrospective components was undertaken to examine the effectiveness of the BN in burn resuscitation. 5 ABA-verified burn centers enrolled patients. Data examining patient demographics, burn characteristics, fluid volumes, and resuscitation-related complications were examined. Statistical analysis compared the 5 sites in terms of these variables. Results A total of 285 patients were eligible for analysis. There was no difference among the centers in terms of average age (45.5 + 16.8 years), BMI (29.2 + 6.9), ISS (21.2 + 12.8), or median TBSA (34 [25.8, 47]). Primary crystalloid infusion volumes at 24 hours differed significantly when measured in ml/kg/TBSA (median 3.7 [2.9, 8.8], range 1.3 to 12.3). Similarly, total fluids, which includes colloid adjuncts, drip medications and enteral fluids, differed between groups when measured in both ml/kg (median 149.8 [106.5, 224.1], range 38.4 to 536.2) and ml/kg/TBSA (4.2 [3.3, 5.5], 1.7 to 15.3) at 24 hours. Post-hoc adjustment for pairwise comparisons resulted in a loss of significance between most of the sites. There was a total of 156 resuscitation-related complications reported across the 5 sites with an average incidence of 44.4 % incidence. Conclusions The Burn Navigator appeared to standardize fluid resuscitations across 5 major US burn centers. With primary fluid volumes near the Parkland formula, the device can be utilized effectively in burn centers, and further study should exam the utility of this device in facilities that do not commonly treat burn injuries, as well as the battlefield.

Case details A 51-year-old man presented with rapid onset encephalopathy and respiratory failure after a suspected intravascular envenomation from a North American pit viper. The patient received antivenom and was transferred to a tertiary care facility where he had cardiovascular collapse and persistent coagulopathy requiring 28 vials of Crotalidae polyvalent immune Fab antivenom for initial control and six vials for maintenance. The patient's coagulopathy was monitored using “traditional” measures (platelets, fibrinogen, and prothrombin time/international normalized ratio) and rotational thromboelastometry (ROTEM®). The patient also subsequently developed intestinal necrosis requiring exploratory laparotomy with ileum and colonic resections, and anuric renal failure requiring continuous renal replacement therapy. After coordinated multidisciplinary management, he was discharged to an acute inpatient rehabilitation on hospital day 25 and has since made a full recovery. Discussion In the setting of a severe intravascular pit viper envenomation, thromboelastometry correlated well with “traditional” measures. During recovery, ROTEM® demonstrated measurable improvements in the extrinsic coagulation pathway while the INR remained between 1.5 and 1.6. Patient's intestinal necrosis may have resulted from microvascular thrombosis due to Crotalinae venom. The patient's ultimate recovery necessitated a coordinated multidisciplinary effort. ROTEM® abnormalities after North American pit viper envenomation may be more sensitive than “traditional” measures and may have prognostic value to determine the severity of envenomation, but further research to define its utility is required.

Background The goal of this article is to examine the role of simulation in documenting resident nontechnical competencies outlined by the general surgery milestones, and compare those assessments to faculty ratings. Methods Trainees completed a multiphasic simulation scenario to assess ability to obtain informed consent, lead a preoperative time out, crisis management, communication, and delivering bad news. Assessments from this scenario were compared with ratings of these same competencies collected from clinical rotations. Results Twenty-six PGY1 trainees participated in the training program. Results revealed no significant correlations between simulation performance and faculty rotation ratings for any of the 5 competencies. With the exception of communication in the operating room, faculty reported an overall inability to reliably observe these competencies 26% to 41% of the time. Conclusions This work suggests that traditional end-of-rotation evaluations may not be the most feasible and valid method to evaluate resident nontechnical skills for milestone assessment. Simulation-based assessments should be considered to fill this gap.

Background Team mental models represent the shared understanding of team members within their relevant environment. Thus, team mental models should have a substantial impact on a team's ability to engage in purposeful and coordinated action. We sought to examine the impact of shared team mental models on team performance and to investigate if team mental models increase over time as teams continue to work together. Methods New surgery interns were assigned randomly to 1 of 10 teams. Each team participated in one unique simulation every day for 5 days, each followed by video-based debriefing with a facilitator. Participants also completed independently a concept similarity tool validated previously in nonmedical team literature to assess team mental models. All performances were video recorded and evaluated with a scenario-specific team performance tool by a single, blinded junior surgeon under an institutional review board–approved protocol. Changes in performance and team mental models over time were assessed with paired samples t tests. Regression analysis was used to examine the extent to which team mental models predicted team performance. Results Thirty interns (age 27; 77% men) participated in the training program. Percentage of items achieved (x¯ ± SD) on the performance evaluation was 39 ± 20, 51 ± 14, 22 ± 17, 63 ± 14, and 77 ± 25 for Days 1–5, respectively. Team mental models were 30 ± 5, 28 ± 6, 27 ± 8, 26 ± 7, and 25 ± 6 for Days 1–5 respectively, such that larger values corresponded to greater differences in team mental models. Paired sample t tests indicated that both average performance and team mental models similarity improved from the first to last day (P

County hospital systems are local public healthcare entities that play a crucial role in modern healthcare. They provide medical and public health services to underserved populations, serve as training centers for physicians, nurses, and others, and offer research opportunities with the potential to elevate medical science as a whole [1]. Our experience at Parkland Health and Hospital System (PHHS) in Dallas, Texas, informs this chapter. We have seen that county systems function in a particular manner and building a surgical practice in this context presents several unique challenges and opportunities. Nevertheless, many of the strategies critical to success in a county system are the same strategies relevant to succeeding in a private or university setting. These universal keys to success include knowing and understanding the setting in which you practice, integrating research with clinical practice, avoiding reinvention of the wheel or major overlap with established programs, and cultivating constructive relationships with administrators and other faculty in order to optimize delivery of care.

Background Establishing proficiency in specific trauma procedures during surgical residency has been limited to annual courses with limited data on its effect on the delivery of health care and patient outcomes. There is a wide variety of training on content and complexity with recent studies looking at time to imaging or secondary survey. In this study, we implement monthly case-based simulation after initial training on a variety of bedside trauma procedures. The overall goal is to evaluate the effect of simulation on time to specific interventions. Methods This is a prospective, observational study between July 2018 and February 2019 at a single-institution, Level I trauma center with a large surgical residency program. A trauma simulation program was implemented in November 2018 to train and evaluate surgical residents from post-graduate year 1 through 5. All rotating residents participated in an initial course on basic trauma procedures, such as percutaneous sheath placement, tube thoracostomy, and resuscitative thoracotomy followed by an end-of-month simulation. All Level I activations from preintervention starting in July to October 2018 (preintervention) and October 2018 through February 2019 (postintervention) were reviewed; monitored variables included age, sex, mechanism of injury, blunt or penetrating, and time to intervention in the trauma bay. Median times to intervention were recorded with interquartile ranges (IQR). Pearson's coefficient was used to measure the strength of the relationship between simulation and time to patient intervention. Results Median time to most interventions improved over time but with more consistent improvement after the implementation of formal simulation and procedural training in November 2018. Median pretraining time for resuscitative thoracotomy was 14 minutes (IQR, 8-32 minutes); posttraining median time was 3 minutes (IQR, 2.7-8 minutes, p = 0.02). Median pretraining time to tube thoracostomy was 13 minutes (IQR, 5.5-19 minutes); posttraining time was 6 minutes (IQR, 4-31 minutes, p = 0.04). Pearson's coefficient (r) measured strength of correlation and was highest for tube thoracostomy followed by resuscitative thoracotomy and percutaneous sheath access with r values of 0.46, 0.35, and 0.24, respectively. Conclusion High-complexity, routine procedural training, and trauma simulation are associated with decreased time to interventions within a short period of time. Routine implementation of a training program emphasizing efficient, effective approaches to bedside procedures is necessary to train our residents in these high-acuity, low-frequency situations. Future investigations are warranted in the effect of simulation on short-term and long-term patient outcomes. Level of evidence Therapeutic, level III.

Outcomes of appendectomy stratified by type of complicated appendicitis (CA) features are poorly researched, and the evidence to guide operative versus nonoperative management for CA is lacking. This study aimed to determine laparoscopic-to-open conversion risk, postoperative abscess risk, unplanned readmission risk, and length of hospital stay (LOS) associated with appendectomy in patients with perforated appendicitis without abscess (PA) and perforated appendicitis with abscess (PAWA) compared with a control cohort of nonperforated appendicitis (NPA).The 2016-2017 National Surgical Quality Improvement Program Appendectomy-targeted database identified 12,537 (76.1%) patients with NPA, 2142 (13.0%) patients with PA, and 1799 (10.9%) patients with PAWA. Chi-squared analysis and analysis of variance were used to compare categorical and continuous variables. Binary logistic and linear regression models were used to compare risk-adjusted outcomes.Compared with NPA, PA and PAWA had higher rates of conversion (0.8% versus 4.9% and 6.5%, respectively; P 0.001), postoperative abscess requiring intervention (0.6% versus 4.8% and 7.0%, respectively; P 0.001), readmission (2.8% versus 7.7% and 7.6%, respectively; P 0.001), and longer median LOS (1 day versus 2 days and 2 days, respectively; P 0.001). PA and PAWA were associated with increased odds of postoperative abscess (odds ratio [OR]: 7.18, 95% confidence interval [CI]: 5.2-9.8 and OR: 9.94, 95% CI: 7.3-13.5, respectively), readmission (OR: 2.70, 95% CI: 2.1-3.3 and OR: 2.66, 95% CI: 2.2-3.3, respectively), and conversion (OR: 5.51, 95% CI: 4.0-7.5 and OR: 7.43, 95% CI: 5.5-10.1, respectively). PA was associated with an increased LOS of 1.7 days and PAWA with 1.9 days of LOS (95% CI: 1.5-1.8 and 1.7-2.1, respectively).Individual features of CA were independently associated with outcomes. Further research is needed to determine if surgical management is superior to nonoperative management for CA.

INTRODUCTION: The COVID-19 pandemic has abruptly altered the landscape of surgical education Universities and healthcare institutions have been forced to drastically alter the way in which they operate, and educational curricula at academic hospitals similarly disrupted Fortunately, largescale lectures and surgical boot-camps have transitioned to online platforms with good success and reasonable quality across training programs However, in-person, team-based learning and interactions, specifically surgical simulation, have stalled given the need to limit possible exposure to COVID-19 In light of this ?new normal?, our institution sought to balance competing educational needs and clinical skill degradation while reducing the risk of exposure In this pilot project, we implemented a strategy to incorporate simulation during the COVID-19 pandemic METHODS: Small-scale trauma simulation was combined with real-time trauma video review (TVR) live-streamed on a virtual platform to increase participation to multiple trainees Trainees and trauma nurses and staff were limited to 5 maximum in a room and wore appropriate personal protective equipment, including eye protection and masks Trainees participated in a 20-minute, case-based simulation requiring hands-on procedures as tube thoracostomy, vascular access and pelvic binder placement Debriefing was held in-person and streamed live by video review from a laptop to maximize participation RESULTS: 4-5 surgical trainees, trauma nurse and staff participated in the live, hands-on simulation, and other trainees and faculty observed remotely via a virtual platform Total simulation and debriefing time approached approximately 40 minutes for one scenario CONCLUSIONS: To our knowledge, this is the first combined trauma simulation and trauma video review in the COVID-19 pandemic amplified on a virtual platform to improve trainee and faculty participation Small-scale simulation is feasible and can benefit a larger audience when amplified by a virtual platform Key components include a basic trauma simulation and trauma video review program, maintaining small groups, and rotating trainees through simulation to maximize trainee participation

IntroductionOur study explores the extent to which teams are accurate assessors of their own performance and teamwork, and how simulation can help this critical skill develop over time.MethodsSurgery residents in teams of three completed five daily simulations. After each scenario, each team reviewed their performance and jointly completed a scenario-specific team performance evaluation and a 17-item Communication and Teamwork Skills tool. Videos were rated to obtain discrepancy values. Paired-samples t-tests and mean comparisons were used to examine changes in team self-assessment accuracy and comparisons between high-performing and low-performing teams.ResultsResident (n=30) teams rated team performance higher than faculty across the first 3 days (pConclusionTeams that continue to work together over time may become more accurate judges of their own performance, but do not become more accurate assessors of teamwork competencies.

Little information exists on the value of online question banks in preparing residents for the American Board of Surgery In-Training Examination (ABSITE).We reviewed surgical residents' use of an online question bank (TrueLearn) and compared it to their ABSITE performance.The 2016-2017 records of 44 PGY 2-5 general surgery residents were examined. The total number of TrueLearn questions answered significantly correlated (p 0.05) with correct answers and percentile rank on the 2017 ABSITE. If a resident was to complete the entire online TL question bank consisting of 1000 questions, the overall percentage correct and overall percentile on the ABSITE is estimated to increase by 3% and 20%, respectively.The use of the TrueLearn question bank is associated with an improved percentage of ABSITE questions answered correctly and improved PGY percentile scores.

Trauma patients may be at elevated risk for subsequent suicide; however, it is unclear whether patients at risk can be identified during their initial presentation following injury. The objectives of this study were to evaluate the use of a standardized clinical decision support system for suicide risk screening developed by our hospital system and to determine the incidence of positive suicide screenings in our trauma population.Adult trauma patient screenings were performed by nursing staff during the triage process using the Columbia Suicide Severity Rating Scale, Clinical Practice Screener, Recent (C-SSRS). Adult trauma patients who had a suicide risk screening completed from February 2015 to November 2015 were evaluated retrospectively. Patients were divided into cohorts consisting of those with positive and negative screening assessments. Significance was set at α = 0.05. Statistical analysis was performed using Student t test and a χ test where appropriate.Overall, 3,623 of 3,712 patients (98%) completed a suicide risk screening during the study period. Those who went unscreened were not evaluated due to altered mental status/intubation/emergent surgery (97%), death (1%), or an unwillingness to cooperate (2%). The suicide risk screening result was positive in 161 of 3,623 patients (4%) in the study cohort. On univariate analysis, patients with a positive suicide risk screen result were more likely to be white (43% vs 32%; p = 0.01), identify English as their primary language (91% vs 73%; p0.01), have insurance coverage (48% vs 28%; p0.01), and were more likely to initiate a low-level trauma activation (27% vs 16%; p0.01) than those who had a negative screening result. A positive suicide risk assessment result was moderately associated with patients of white race (odds ratio, 1.83; 95% confidence interval, 1.27-2.65) on multivariable logistic regression.Our universal suicide screening process identifies an at-risk subpopulation of trauma patients.Prognostic study, level III; therapeutic, level IV.

Although simulation is an effective method for enhancing team competencies, it is unclear how team familiarity impacts this process. We examined how team familiarity impacted team competencies.Trainees were assigned to stable or dynamic teams to participate in three simulated cases. Situation awareness (SA) data was collected through in-scenario freezes. The recorded performances were assessed for clinical effectiveness (ClinEff) and teamwork. All data are reported on a 1-100% (100% = perfect performance) scale.Forty-six trainees (23 General Surgery; 23 Emergency Medicine) were randomized by specialty into stable (N = 8) or dynamic (N = 7) groups. Overall changes from Sim 1 to Sim3 were 12.2% (p 0.01), -1.1% (ns), and 7.1% (p 0.01) for SA, ClinEff, and Teamwork, respectively. However, improvements differed by condition, with stable teams reflecting improvements in ClinEff (15.2%; p 0.05), whereas dynamic team ClinEff improvement (8.7%) was not significant. Both groups demonstrated improvements in teamwork (stable = 9%, p 0.05; dynamic = 4.9%, p 0.05).Teams who continued to work together demonstrated increased improvements in clinical effectiveness and teamwork, while dynamic teams only demonstrated improvements in teamwork.

Nearly half of all states have legalized medical marijuana or recreational-use marijuana. As more states move toward legalization, the effects on injured patients must be evaluated. This study sought to determine effects of cannabis positivity at the time of severe injury on hospital outcomes compared with individuals negative for illicit substances and those who were users of other illicit substances. A Level I trauma center performed a retrospective chart review covering subjects over a 2-year period with toxicology performed and an Injury Severity Score (ISS) of more than 16. These individuals were divided into the negative and positive toxicology groups, further divided into the marijuana-only, other drugs-only, and mixed-use groups. Differences in presenting characteristics, hospital length of stay, intensive care unit (ICU) stays, ventilator days, and death were compared. A total of 8,441 subjects presented during the study period; 2,134 (25%) of these had toxicology performed; 843 (40%) had an ISS of more than 16, with 347 having negative tests (NEG); 70 (8.3%) substance users tested positive only for marijuana (MO), 323 (38.3%) for other drugs-only, excluding marijuana (OD), and 103 (12.2%) subjects showed positivity for mixed-use (MU). The ISS was similar for all groups. No differences were identified in Glasgow Coma Scale (GCS), ventilator days, blood administration, or ICU/hospital length of stay when comparing the MO group with the NEG group. Significant differences occurred between the OD group and the NEG/MO/MU groups for GCS, ICU length of stay, and hospital charges. Cannabis users suffering from severe injury demonstrated no detrimental outcomes in this study compared with nondrug users. Language: en

Object Traumatic brain injury (TBI) is known to be a risk factor for Alzheimer-like dementia. In previous studies, an increase in β-amyloid (Aβ) monomers, such as β-amyloid 42 (Aβ42), in the CSF of patients with TBI has been shown to correlate with a decrease in amyloid plaques in the brain and improved neurological outcomes. In this study, the authors hypothesized that the levels of toxic high-molecular-weight β-amyloid oligomers are increased in the brain and are detectable within the CSF of TBI patients with poor neurological outcomes. Methods Samples of CSF were collected from 18 patients with severe TBI (Glasgow Coma Scale Scores 3–8) and a ventriculostomy. In all cases the CSF was collected within 72 hours of injury. The CSF levels of neuron-specific enolase (NSE) and Aβ42 were measured using enzyme-linked immunosorbent assay. The levels of high-molecular-weight β-amyloid oligomers were measured using Western blot analysis. Results Patients with good outcomes showed an increase in the levels of CSF Aβ42 (p = 0.003). Those with bad outcomes exhibited an increase in CSF levels of β-amyloid oligomers (p = 0.009) and NSE (p = 0.001). In addition, the CSF oligomer levels correlated with the scores on the extended Glasgow Outcome Scale (r = −0.89, p = 0.0001), disability rating scale scores (r = 0.77, p = 0.005), CSF Aβ42 levels (r = −0.42, p = 0.12), and CSF NSE levels (r = 0.70, p = 0.004). Additionally, the receiver operating characteristic curve yielded an area under the curve for β-amyloid oligomers of 0.8750 ± 0.09. Conclusions Detection of β-amyloid oligomers may someday become a useful clinical tool for determining injury severity and neurological outcomes in patients with TBI.

The hypermetabolic response to severe thermal injury is unlike any physiologic response seen in medicine. While some parallels can be drawn to shock and sepsis states, this response is typified by its intensity and duration. Our group has been interested in the myriad effects of estrogens after injury, specifically the ability of estrogens to reduce inflammatory responses. Given this, and the known link between severe inflammation and the hypermetabolic response, we examined the effects of a single dose of 17β estradiol administered after a severe thermal injury in rats.Twelve male Sprague-Dawley rats were subject to either a sham burn or a 40% total body surface area burn, followed by fluid resuscitation. Burned animals were divided into a vehicle and treatment group, with injections given 15 min after the injury. Animals were monitored for a period of 45 d, with markers of hypermetabolism (weight, fecal output, food intake, and serum insulin and glucose) measured daily.We identified a significant difference in daily measured weights between the burned groups. We observed a sparing of body mass during the acute phase lasting 2 wk after the injury and an improved recovery phase during the remainder of the study. Glucose and insulin levels during the first week of the study did not differ between the treatment groups.Estrogen may have a role in preserving body mass after severe thermal injury. Further studies are required to determine if this spared body mass composition.

Following a mild traumatic brain injury (TBI) event, the secondary brain injury that persists after the initial blow to the head consists of excitotoxicity, decreased cerebral glucose levels, oxidant injury, mitochondrial dysfunction, inflammation, and neuronal cell death. To date, there are no effective interventions used at decreasing secondary brain injury after mild TBI.In this study, male mice were treated with either placebo or resveratrol (100 mg/kg) at 5 minutes and 12 hours after mild TBI. The mice were injured using the controlled cortical impact device. In this closed-head model, a midline incision was made to access the skull and the impactor tip was aligned on the sagittal suture midway between the bregma and lambda sutures. The mice were injured at a depth of 2.0 mm, velocity of 4 m/s, and a delay time of 100 milliseconds. At 72 hours following injury, the animals were intracardially perfused with 0.9% saline followed by 10% phosphate-buffered formalin. The whole brain was removed, sliced, and stained for microglial activation (Iba1). In addition, using the enzyme-linked immunosorbent assay, tissue levels of interleukin 6 (IL-6) and IL-12 were measured in the cerebral cortex and hippocampus.In this study, we found that in the placebo treatment group, there was a significant increase in Iba1 staining in the brain. The levels of microglial activation was reduced by resveratrol in the cerebral cortex (p0.001), corpus callosum (p0.001), and dentate gyrus (p0.005) brain regions after mild TBI. In addition to Iba1, resveratrol decreased the brain levels of IL-6 (p0.0001) and IL-12 (p0.004), which were observed in the hippocampus of the placebo group. In our model, no increase of IL-6 or IL-12 was observed in the cerebral cortex following TBI.Resveratrol given acutely after TBI results in a decrease in neuroinflammation. These results suggest that resveratrol may be beneficial in reducing secondary brain injury after experiencing a mild TBI.

Scheduled repeat head computed tomography after mild traumatic brain injury has been shown to have limited use for predicting the need for an intervention. We hypothesized that repeat computed tomography in persons with intracranial hemorrhage and a Glasgow Coma Scale (GCS) score of 13 to 15, without clinical progression of neurologic symptoms, does not impact the need for neurosurgical intervention or discharge GCS scores.This prospective cohort study followed all patients presenting to our urban Level I trauma center with intracranial hemorrhage and a GCS score of 13 to 15 from February 2010 to December 2010. Subjects were divided into two groups: those in whom repeat CT scans were performed routinely (ROUTINE) and those in whom they were performed selectively (SELECTIVE) based on changes in clinical examination. CT scanning decisions were made at the discretion of the neurosurgical service attending physician.One hundred forty-five patients met the inclusion criteria (ROUTINE, n = 92; SELECTIVE, n = 53). Group demographics, including age, sex, and presenting GCS score were not significantly different. Of SELECTIVE patients, six (11%) required a repeat head computed tomography for a neurologic change, with one having a radiographic progression of hemorrhage (16%) versus 26 (28%) of 92 in the ROUTINE group showing a radiographic progression. No patient in either group required medical or neurosurgical intervention based on repeat scan. The number of CT scans performed differed between the two groups (three scans in ROUTINE vs. one scan in SELECTIVE, p0.001), as did the intensive care unit (2 days vs. 1 day, p0.001) and hospital (5 days vs. 2 days, p0.001) lengths of stay. Discharge GCS score was similar for both groups (15 vs. 15, p = 0.37). One death occurred in the SELECTIVE group, unrelated to intracranial findings. The negative predictive value of a repeat CT scan leading to neurosurgical intervention with no change in clinical examination was 100% for both groups.A practice of selective repeat head CT scans in patients with traumatic brain injury admitted with a GCS score of 13 to 15 decreases use of the test and is associated with decreased hospital length of stay, without impacting discharge GCS scores.Diagnostic study, level II.

In various animal and human studies, early administration of 17β-estradiol, a strong antioxidant, anti-inflammatory, and anti-apoptotic agent, significantly decreases the severity of injury in the brain associated with cell death. Estrone, the predominant estrogen in postmenopausal women, has been shown to be a promising neuroprotective agent. The overall goal of this project was to determine if estrone mitigates secondary injury following traumatic brain injury (TBI) in rats. Male rats were given either placebo (corn oil) or estrone (0.5 mg/kg) at 30 min after severe TBI. Using a controlled cortical impact device in rats that underwent a craniotomy, the right parietal cortex was injured using the impactor tip. Non-injured control and sham animals were also included. At 72 h following injury, the animals were perfused intracardially with 0.9% saline followed by 10% phosphate-buffered formalin. The whole brain was removed, sliced, and stained for TUNEL-positive cells. Estrone decreased cortical lesion volume (p

Error management training is an approach that encourages exposure to errors during initial skill acquisition so that learners can be equipped with important error identification, management, and metacognitive skills. The purpose of this study was to determine how an error-focused training program affected performance, retention, and transfer of central venous catheter (CVC) placement skills when compared with traditional training methodologies.Surgical interns (N = 30) participated in a 1-hour session featuring an instructional video and practice performing internal jugular (IJ) and subclavian (SC) CVC placement with guided instruction. All interns underwent baseline knowledge and skill assessment for IJ and SC (pretest) CVC placement; watched a "correct-only" (CO) or "correct + error" (CE) instructional video; practiced for 30 minutes; and were posttested on knowledge and IJ and SC CVC placement. Skill retention and transfer (femoral CVC placement) were assessed 30 days later. All skills tests (pretest, posttest, and transfer) were videorecorded and deidentified for evaluation by a single blinded instructor using a validated 17-item checklist.Both the groups exhibited significant improvements (p0.001) in knowledge and skills after the 1-hour training program, but the increase of items achieved on the performance checklist did not differ between conditions (CO: IJ Δ = 35%, SC Δ = 29%; CE: IJ Δ = 36%, subclavian Δ = 33%). However, 1 month later, the CO group exhibited significant declines in skill retention on IJ CVC placement (from 68% at posttraining to 44% at day 30; p0.05) and SC CVC placement (from 63% at posttraining to 49% at day 30; p0.05), whereas the CE group did not have significant decreases in performance. The CE group performed significantly better on femoral CVC placement (i.e., transfer task; 62% vs 38%; p0.01) and on 2 of the 3 complication scenarios (p0.05) when compared with the CO group.These data indicate that incorporating error-based activities and discussions into training programs can be beneficial for skill retention and transfer.

While management of burns has been taking place for thousands of years, it has been the last half-century that significant strides have changed the outcome of patients suffering from this devastating injury. The important technological changes that have played an integral part in these advances are many, and include codification of burn center transfer criteria and development of safe systems for transfer through transportation advances. Telemedicine has led to improved ongoing assessment of patients from distances from the burn center. Burn providers have also been leading the vanguard for the increasing use of decision support technologies in resuscitation, provision of nutrition, and detection and treatment of infection. Other recent technologic advances in burns include bioengineering approaches to determination of burn severity through wound depth determination and mapping, novel wound coverage techniques, and new grafting techniques to minimize morbidity in the severely ill. The clinical condition of burns lends itself easily to the development and utilization of new technologies because the clinical event is relatively homogenous and common, which we believe will continue well into the future. This work reviews recent advances and reports on new vistas which should be addressed in the future.