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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., (Copyright © 2019 Elsevier Inc. All rights reserved.)

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., (Copyright© Wisconsin Medical Society.)

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.

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., (Copyright © 2018 Elsevier Inc. All rights reserved.)

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.

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.

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.

Background: A significant consequence of the 2003 Accreditation Council for Graduate Medical Education duty hour restrictions has been the dramatic increase in patient care handoffs. Ineffective handoffs have been identified as the third most common cause of medical error. However, research into health care handoffs lacks a unifying foundational structure. We sought to identify a conceptual framework that could be used to critically analyze handoffs., Methods: A scholarly review focusing on communication theory as a possible conceptual framework for handoffs was conducted. A PubMed search of published handoff research was also performed, and the literature was analyzed and matched to the most relevant theory for health care handoff models., Results: The Shannon-Weaver Linear Model of Communication was identified as the most appropriate conceptual framework for health care handoffs. The Linear Model describes communication as a linear process. A source encodes a message into a signal, the signal is sent through a channel, and the signal is decoded back into a message at the destination, all in the presence of internal and external noise. The Linear Model identifies 3 separate instances in handoff communication where error occurs: the transmitter (message encoding), channel, and receiver (signal decoding)., Conclusions: The Linear Model of Communication is a suitable conceptual framework for handoff research and provides a structured approach for describing handoff variables. We propose the Linear Model should be used as a foundation for further research into interventions to improve health care handoffs., (Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Small bowel obstruction (SBO) is a common condition, but little is known about its presentation, management, and outcomes in geriatric patients., Methods: A retrospective review was performed comparing geriatric (≥65 years of age) and nongeriatric patients admitted with SBO. Admission characteristics, treatment, and outcomes were compared. Data analysis included Student t test and chi-square test or Fisher's exact test., Results: Among 80 geriatric and 136 nongeriatric patients, no difference was observed among admission characteristics, treatment, time to or type of surgery, length of postoperative stay, or overall complications. Cardiac complications (15% vs 0%, P = .0082) and subacute care facility discharge (29% vs 5%, P < .001) were more common for geriatric patients., Conclusions: Compared with younger adults, elderly patients with SBO have similar presentations and overall outcomes with the exception of cardiac morbidity and discharge disposition. Preoperative attention to cardiac risk profile and discharge disposition discussion should be encouraged., (Copyright © 2015 Elsevier Inc. All rights reserved.)

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., Competing Interests: There are no real or potential conflicts of interest to disclose.

Background: Geriatric education is essential to ensure the competency of residents caring for the aging population. This study assesses and correlates resident and faculty perceptions of resident geriatric-related competencies to clinical care., Methods: A survey was sent to 40 general surgery residents and 57 faculty members. Five clinical care markers were identified for chart audit. A retrospective chart audit was performed of 22 injured elderly patients., Results: Among the respondents, 30 of 40 (75%) residents and 22 of 57 (39%) faculty completed the survey. Residents rated their competency higher than faculty on all competency-related questions (p = 0.0002). The following 4 questions had a mean faculty rating below acceptable: screening guidelines, delirium management, contraindicated medications, and medication adjustments. On chart review: code status was documented in 7 of 22 (32%) patients and goals of care in 1 of 22 (5%) patients. Pain control included rib block or epidural in 14 of 22 (64%) patients. Contraindicated medications were prescribed in 13 of 22 (59%) patients., Conclusion: A competency-based needs assessment of geriatric training in a general surgery residency has identified educational "gaps." This needs assessment supports implementation of geriatric education initiatives in our general surgery program., (Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Importance: A protected block curriculum (PBC) with postcurriculum examinations for all surgical residents has been provided to assure coverage of core curricular topics. Biannual assessment of resident competency will soon be required by the Next Accreditation System., Objective: To identify opportunities for early medical knowledge assessment and interventions, we examined whether performance in postcurriculum multiple-choice examinations (PCEs) is predictive of performance in the American Board of Surgery In-Training Examination (ABSITE) and clinical service competency assessments., Design: Retrospective single-institutional education research study., Setting: Academic general surgery residency program., Participants: A total of 49 surgical residents., Intervention: Data for PGY1 and PGY2 residents participating in the 2008 to 2012 PBC are included. Each resident completed 6 PCEs during each year., Main Outcome Measures: The results of 6 examinations were correlated to percentage-correct ABSITE scores and clinical assessments based on the 6 Accreditation Council for Graduate Medical Education core competencies. Individual ABSITE performance was compared between PGY1 and PGY2. Statistical analysis included multivariate linear regression and bivariate Pearson correlations., Results: A total of 49 residents completed the PGY1 PBC and 36 completed the PGY2 curriculum. Linear regression analysis of percentage-correct ABSITE and PCE scores demonstrated a statistically significant correlation between the PGY1 PCE 1 score and the subsequent PGY1 ABSITE score (p = 0.037, β = 0.299). Similarly, the PGY2 PCE 1 score predicted performance in the PGY2 ABSITE (p = 0.015, β = 0.383). The ABSITE scores correlated between PGY1 and PGY2 with statistical significance, r = 0.675, p = 0.001. Performance on the 6 Accreditation Council for Graduate Medical Education core competencies correlated between PGY1 and PGY2, r = 0.729, p = 0.001, but did not correlate with PCE scores during either years., Conclusions and Relevance: Within a mature PBC, early performance in a PGY1 and PGY2 PCE is predictive of performance in the respective ABSITE. This information can be used for formative assessment and early remediation of residents who are predicted to be at risk for poor performance in the ABSITE., (Copyright © 2014 Association of Program Directors in Surgery. All rights reserved.)

Background: Graduate medical education is undergoing a dramatic shift toward competency-based assessment of learners. Competency assessment requires clear definitions of competency and validated assessment methods. The purpose of this study is to identify criteria used by surgical educators to judge competence in Practice-Based Learning and Improvement (PBL&I) as demonstrated in learning portfolios., Methods: A total of 6 surgical learning and instructional portfolio entries served as documents to be assessed by 3 senior surgical educators. These faculty members were asked to rate and then identify criteria used to assess PBL&I competency. Individual interviews and group discussions were conducted, recorded, and transcribed to serve as the study dataset. Analysis was performed using qualitative methodology to identify themes for the purpose of defining competence in PBL&I. The assessment themes derived are presented with narrative examples to describe the progression of competency., Results: The collaborative coding process resulted in identification of 7 themes associated with competency in PBL&I related to surgical learning and instructional portfolio entries: (1) self-awareness regarding effect of actions; (2) identification and thorough description of learning goals; (3) cases used as catalyst for reflection; (4) reconceptualization with appropriate use and critique of cited literature; (5) communication skills/completeness of entry template; (6) description of future behavioral change; and (7) engagement in process--identifies as personally relevant., Conclusions: The identified themes are consistent with and complement other criteria emerging from reflective practice literature and experiential learning theory. This study provides a foundation for further development of a tool for assessing learner portfolios consistent with the Accreditation Council for Graduate Medical Education's Next Accreditation System requirements., (Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2013 Elsevier Inc. All rights reserved.)

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., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Jeopardy!, Concentration, quiz bowls, and other gaming formats have been incorporated into health sciences classroom and online education. However, there is limited information about the impact of these strategies on learner engagement and outcomes. To address this gap, we hypothesized that gaming would lead to a significant increase in retained short- and long-term medical knowledge with high learner session satisfaction., Methods: Using the Jeopardy! game show model as a primary instructional technique to teach geriatrics, 8 PGY2 General Surgery residents were divided into 2 teams and competed to provide the "question" to each stated "answer" during 5 protected block curriculum units (1-h/U). A surgical faculty facilitator acted as the game host and provided feedback and brief elaboration of quiz answers/questions as necessary. Each quiz session contained two 25-question rounds. Paper-based pretests and posttests contained questions related to all core curriculum unit topics with 5 geriatric gaming questions per test. Residents completed the pretests 3 days before the session and a delayed posttest of geriatric topics on average 9.2 weeks (range, 5-12 weeks) after the instructional session. The cumulative average percent correct was compared between pretests and posttests using the Student t test. The residents completed session evaluation forms using Likert scale ratings after each gaming session and each protected curriculum block to assess educational value., Results: A total of 25 identical geriatric preunit and delayed postunit questions were administered across the instructional sessions. The combined pretest average score across all 8 residents was 51.5% for geriatric topics compared with 59.5% (p = 0.12) for all other unit topics. Delayed posttest geriatric scores demonstrated a statistically significant increase in retained medical knowledge with an average of 82.6% (p = 0.02). The difference between delayed posttest geriatric scores and posttest scores of all other unit topics was not significant. Residents reported a high level of satisfaction with the gaming sessions: The average session content rating was 4.9 compared with the overall block content rating of 4.6 (scale, 1-5, 5 = Outstanding)., Conclusions: The quiz type and competitive gaming sessions can be used as a primary instructional technique leading to significant improvements in delayed posttests of medical knowledge and high resident satisfaction of educational value. Knowledge gains seem to be sustained based on the intervals between the interventions and recorded gains., (Copyright © 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Learning portfolios have gained modest acceptance in graduate medical education because of challenges related to user satisfaction, time and resource commitment, and quality assessment. In 2001, the Department of Surgery implemented the Surgical Learning and Instructional Portfolio (SLIP) to help residents develop a case-based portfolio demonstrating practice-based learning. In 2008, the format was changed to a Web-based platform with open viewing of portfolios for all learners. This study was performed to evaluate the SLIP program using resident and faculty perspectives in the domains of satisfaction, compliance, and educational value., Methods: Likert scale surveys were distributed to residents to assess satisfaction. Using a semistructured format with subsequent qualitative analysis of the meeting transcript, a focus group discussion was held with the SLIP director, SLIP facilitator, and program coordinator. An analysis of the program compliance was performed by review of SLIP entry dates. Finally, the quality of the SLIP entries (n = 420) was analyzed in a blinded manner using a locally developed standardized SLIP assessment tool. Data analysis was performed using Pearson's correlation and Cronbach's alpha., Results: Residents were satisfied with the program and felt the Web-based format promoted self-reflection. They perceived that time spent was appropriate. Residents also believed they gained medical knowledge of their own specific entry topics but did not learn routinely from others' entries. Faculty asserted that the Web-based platform eased the administrative burden but did not necessarily alter the quality of the SLIP entries. Compliance with the assignment was 100%. SLIP entry analysis demonstrated the reflection and understanding of the topics chosen. However, the overall quality assessment of entries was hindered by suboptimal interrater reliability (inter-rater reliability (IR) = 0.636)., Conclusions: The SLIP program allows residents to demonstrate practice-based learning and improvement of medical knowledge. The Web-based format provides transparency and ease of administration. Quality assessment of individual portfolio entries remains a challenge to the widespread adoption of portfolios., (Copyright © 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

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.

Background: To test the value of a simulated Family Conference Objective Structured Clinical Exam (OSCE) for resident assessment purposes, we examined the generalizability and construct validity of its scores in a multi-institutional study., Methods: Thirty-four first-year (PG1) and 27 third-year (PG3) surgery residents (n = 61) from 6 training programs were tested. The OSCE consisted of 2 cases (End-of-Life [EOL] and Disclosure of Complications [DOC]). At each program, 2 clinicians and 2 standardized family members rated residents using case-specific tools. Performance was measured as the percentage of possible score obtained. We examined the generalizability of scores for each case separately. To assess construct validity, we compared PG1 with PG3 performance using repeated measures multivariate analysis of variance (MANOVA)., Results: The relative G-coefficient for EOL was .890. For DOC, the relative G-coefficient was .716. There were no significant performance differences between PG1 and PG3 residents., Conclusions: This OSCE provides reliable assessments suitable for formative evaluation of residents' interpersonal communication skills and professionalism., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: The Accreditation Council for Graduate Medical Education (ACGME) Learning Portfolio is recommended as a tool to develop and document reflective, practice-based learning and improvement. There is no consensus regarding the appropriate content of a learning portfolio in medical education. Studying lessons selected for inclusion in their learning portfolios by surgical trainees could help identify useful subject matter for this purpose., Methods: Each month, all residents in our surgery residency program submit entries into their individual Surgical Learning and Instructional Portfolio (SLIP). The SLIP entries from July 2008 to 2009 (n = 420) were deidentified and randomized using a random number generator. We conducted a thematic content analysis of 50 random portfolio entries to identify lessons learned. Two independent raters analyzed the "3 lessons learned" portion of the portfolio entries and identified themes and subthemes using the constant comparative method used in grounded theory., Results: The collaborative coding process resulted in theme saturation after the identification of 7 themes and their subthemes. Themes in decreasing order of frequency included complications, disease epidemiology, disease presentation, surgical management of disease, medical management of disease, operative techniques, and pathophysiology. Junior residents chose to focus on a broad array of foundational topics including disease presentation, epidemiology, and overall management of diseases, whereas postgraduate year-4 (PGY-4) and PGY-5 residents most frequently chose to focus on complications as learning points., Conclusions: Lessons learned reflect perceived needs of the trainees based on training year. When given a template to follow, junior and senior residents choose to reflect on different subject matter to meet their learning goals.

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.

Background: Previous end-of-life and palliative care curricula for surgical residents have shown improved learner confidence, but have not measured cognitive knowledge or skill acquisition., Methods: A nonrandomized trial evaluated a structured palliative care curriculum for 7 postgraduate year 2 surgical residents (intervention group) compared with 6 postgraduate year 5 surgical residents (comparison group). Outcomes were measured using an 18-item knowledge test, a 20-minute objective structured clinical examination simulating an intensive care unit family conference, and a survey measuring self-confidence., Results: The mean knowledge test scores for the intervention group, both before and after undergoing the structured palliative care curriculum, were no different from the comparison group. There was also no difference in objective structured clinical examination scores between the 2 groups. The intervention group felt less comfortable managing pain, breaking bad news, or addressing ethical issues., Conclusions: Junior surgical residents have similar palliative care knowledge to senior residents without a palliative care curriculum. After participating in a palliative care curriculum, they have simulated skills that are similar to chief residents. However, self-confidence is lower among junior residents despite undergoing a palliative care curriculum., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Background: In 2005, a new curricular model was implemented for general surgery residents and a Division of Education created for administrative support. These changes forced an evaluation of available resources to maintain a new curricular model., Methods: A retrospective review of resources expended during curricular sessions (June 2007-June 2008) provided to 42 surgical residents was conducted. Resources were evaluated in terms of the number, division, department, and rank of faculty involved. Contact hours and monetary costs were calculated., Results: Total numbers of faculty involved in the postgraduate year (PGY)1, PGY2, and PGY3-5 curriculums were 79, 39, and 22, respectively. Faculty teaching time was 321 hours (PGY1), 187 hours (PGY2) and 36 hours (PGY3-5) for a combined 544 hours. Average teaching time commitment for faculty in the Division of Education was 26.5 hours, compared with 6.7 hours for departmental faculty in other divisions (P = .0002). Total monetary cost was $219,254., Conclusions: The cost to maintain an educational general surgery curriculum is substantial and administrative support must be considered. Faculty with an explicit teaching commitment and responsibility are needed.

Objective: General surgery workforce shortages in the rural United States are likely to worsen over the next decade. We sought to identify reasons that general surgery residency graduates choose rural versus urban practice., Design: Questionnaires were sent to 1994 through 2008 graduates of all 4 Wisconsin surgery residency programs (2 university and 2 community). The 51-item questionnaire was designed to evaluate residency graduates' background, interests, and factors influencing their choice of practice type and location. Graduates were divided into 2 groups based upon the size of the communities in which they currently practice: rural (<50,000) or urban (>or=50,000). Data were analyzed using chi(2) tests; level of confidence was defined as p < 0.05., Results: Forty-five percent (98/216) of surveys were completed. Factors associated with rural practice included attending a nonurban high school (p = 0.001) or college (p = 0.001), having a spouse/partner who grew up in a nonurban area (p = 0.022), and interest in hunting birds (p = 0.010) or large game (p = 0.001). Those choosing rural practice were more likely than their urban counterparts to have completed a rural clerkship during medical school (79% vs. 37%, p = 0.001). They were also more likely to have chosen a surgical residency program committed to rural training (p = 0.046). Graduates in rural practice more often cited "broad scope of practice" as an important reason for their decision. Both rural and urban surgeons reported similar rates of medical student teaching but urban surgeons were more likely to teach surgical residents (p = 0.001) and to have completed fellowship training (p = 0.001)., Conclusions: General surgery residency graduates and their spouses who choose rural practices are more likely than those selecting urban practices to have rural backgrounds and interests. Completing a rural clerkship during medical school and choosing a residency program committed to rural general surgery preparation are strongly correlated with rural practice. These findings may help formulate strategies to increase recruitment and retention of rural general surgeons.

Background: Changes in medical education require a rethinking of our training paradigm. We implemented a protected block curriculum for postgraduate year (PGY)-1 and PGY-2 surgery residents., Hypothesis: A protected block curriculum promotes adult learning consistent with the 6 competencies., Design: Prospective static-group comparison with pretesting and posttesting., Setting: Medical College of Wisconsin, Milwaukee., Participants: Eight university-based surgical residents (curriculum group) and 8 residents who did not participate in the curriculum (control group)., Main Outcome Measures: The curriculum occurs during protected time away from clinical activity. Predefined learning objectives and competencies were identified for PGY-1 and PGY-2 residents. Multiple choice examinations were administered to assess knowledge. The first 3 tests of the year in the PGY-2 curriculum were also given to the PGY-3 and PGY-4 and -5 residents for comparison with curriculum residents. In-training examination scores of control and curriculum residents were compared. Surgical and communication skills were assessed using checklist assessment forms. Curriculum residents evaluated the content and delivery., Results: Pretest and posttest results demonstrated acquisition of knowledge with improved aggregated mean scores from 57.5% to 71.4% for PGY-1 residents and 58.6% to 72.6% for PGY-2 residents. The average curriculum test results were 76.7% for curriculum residents, 56.9% for control residents, and 57.3% for all residents. The 2-year average in-training scores were 71.2% for curriculum and 60.3% for control residents. Assessments demonstrated improvements in communication and surgical skills., Conclusions: A protected block curriculum enhanced surgical residents' learning compared with a traditional model. Improvement in medical knowledge was easiest to measure, but performance in other Accreditation Council for Graduate Medical Education competency areas also demonstrated improvement.

Purpose: Geriatric patients have specific medical and social needs for which surgeons must become adept at caring. In an effort to improve the care of the elderly, we have committed to developing a geriatric component for our surgical curriculum that is part of our PGY2-protected block curriculum. Competencies covered by this curriculum plan include medical knowledge, systems-based practice, professionalism, patient care, practice-based learning, and communication skills., Methods: The geriatrics curriculum is imbedded in our current protected block curriculum and includes 5 separate sessions during the PGY2 year. During the protected block curriculum, the residents (N = 7) are relieved of all clinical activity, including call. A needs assessment survey assessed the residents' perceptions of the residency program's current focus on geriatric principles. The geriatric portion of this curriculum uses small-group instructional methods consistent with adult learning principles that include practice-based learning, case-based learning, patient simulation using Objective Structured Video Examination (OSVE), and didactic sessions. Faculty instruction is a shared responsibility between geriatricians and general surgeons. The longitudinal geriatrics curriculum includes approximately 10 hours of learner activities over a single-year period., Evaluation: The curriculum will be evaluated by assessing participant knowledge through the use of multiple-choice testing. Resident performance on OSVEs will likewise be assessed. This method will allow for assessment of higher decision making and clinical reasoning. Finally, a family meeting OSCE will be used to assess professionalism and communication skills further. Overall, all 6 competencies will be assessed using our specific assessment tools. The curriculum content and instructional delivery will be evaluated using longitudinal and session evaluation forms. RESULTS AND EXPERIENCE TO DATE: The geriatrics curriculum will be implemented fully over 2 years. Three sessions will be introduced during the 1st year, and 2 more will be implemented in the 2nd year. The needs assessment survey results demonstrated a lack of sufficient educational focus on geriatrics topics and a low comfort level in caring for the elderly patient. The 1st session of the curriculum has taken place with positive results. The 1st session was a case-based session that focused on critical care and end-of-life issues in the elderly. Although the medical knowledge data are limited thus far, the average pretest score was 57% compared with the 86% posttest score. The resident evaluations (N = 7) of the session demonstrated an average 4.7 (1-5 Likert scale) for content and a 3.9 (1-4 Likert scale) for instructional delivery. CONCLUSION AND NEXT STEPS: Elderly surgical patients have multiple challenges. Specific geriatric training for surgical trainees is lacking. Over the next 2 years, the curriculum will be developed and evaluated even more for its ability to provide adequate instruction in the specific care of the elderly surgical patient. The ultimate goal is to improve the care of the elderly surgical patient.

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.

Background: The "warm up" effect in angina may represent ischaemic preconditioning, which is mediated by adenosine A(1) receptors in most models., Objective: To investigate the effect of a selective A(1) agonist, GR79236 (GlaxoSmithKline), on exercise induced angina and ischaemic left ventricular dysfunction in patients with coronary artery disease., Design: A double blind crossover study., Patients: 25 patients with multivessel coronary artery disease., Interventions: On mornings one week apart, patients received intravenous GR79236 10 microgram/kg or placebo, and then carried out two supine bicycle exercise tests separated by 30 minutes. Equilibrium radionuclide angiography was done before and during exercise., Results: The onset of chest pain or 1 mm ST depression was delayed and occurred at a higher rate-pressure product during the second exercise test following either placebo or GR79236. Compared with placebo, GR79236 did not affect these indices during equivalent tests. GR79236 reduced resting global ejection fraction from (mean (SD)) 63 (7)% to 61 (5)% (p < 0.05) by a selective reduction in the regional ejection fraction of "ischaemic" left ventricular sectors (those where the ejection fraction fell during the first exercise test following placebo). Ischaemic sectors showed increased function during the second test following placebo (72 (21)% v 66 (20)%; p = 0.0001), or during the first test following GR79236 (69 (21)% v 66 (20)%; p = 0.0001). Sequential exercise further increased the function of ischaemic sectors even after drug administration., Conclusions: GR79236 failed to mimic the warm up effect, and warm up occurred even in the presence of this agent. This suggests that ischaemic preconditioning is not an important component of this type of protection. The complex actions of the drug on regional left ventricular function at rest and during exercise suggest several competing A(1) mediated actions.

Objectives: The goal of this study was to investigate whether the "warm-up" effect in angina protects against ischemic left ventricular (LV) dysfunction., Background: After exercise, patients with coronary disease demonstrate persistent myocardial dysfunction, which may represent stunning, as well as warm-up protection against further angina, which may represent ischemic preconditioning. The effect of warm-up exercise on LV function during subsequent exercise has not been investigated., Methods: Thirty-two patients with multivessel coronary disease and preserved LV function performed two supine bicycle exercise tests 30 min apart. Equilibrium radionuclide angiography was performed before, during and up to 60 min after each test. Global LV ejection fraction and volume changes and regional ejection fraction for nine LV sectors were calculated for each acquisition., Results: Onset of chest pain or 1 mm ST depression was delayed and occurred at a higher rate-pressure product during the second exercise test. Sectors whose regional ejection fraction fell during the first test showed persistent reduction at 15 min (68 +/- 20 vs. 73 +/- 20%, p < 0.0001). These sectors demonstrated increased function during the second test (71 +/- 20 vs. 63 +/- 20%, p = 0.0005). The reduction at 15 min and the increase during the second test were both in proportion to the reduction during the first test. Effects on global function were only apparent when the initial response to exercise was considered., Conclusions: The warm-up effect is accompanied by protection against ischemic regional LV dysfunction. The degree of stunning and protection after exercise is related to the severity of dysfunction during exercise, consistent with results from experimental models.

In 1986, a population study of school children in the city of Coventry gave an overall prevalence in males and females for fragile X syndrome of 1/952. The 29 children diagnosed as having fragile X syndrome in this study have been re-evaluated with molecular diagnostic techniques. Eighteen of the original 29 children have been found not to have the expansion of the FMR1 gene associated with fragile X syndrome. Revised prevalence figures have been calculated giving rise to an overall prevalence figure of 1/2720 (range 1/2198-1/3089). If the four children lost to follow up are also assumed not to have the fragile X syndrome, the revised prevalence figure was 1/5714 (range 1/4762-1/6349). Clinical review of boys with severe mental retardation from this and a subsidiary study show that the clinical features of head circumference greater than the 50th centile, testicular volume greater than the 50th centile, and IQ between 35 and 70 remain helpful in distinguishing boys with fragile X syndrome from those who have non-specific mental retardation.

This paper describes a community based study of 156 boys with idiopathic, severe mental retardation. The boys were examined and a pedigree taken before the cytogenetic results were known. The prevalence of the fragile X chromosome among this group of boys was high: 9% in the whole group and 11% after 39 boys with specific features had been excluded. The fragile X syndrome is therefore an important cause of idiopathic, severe retardation. Its clinical features of large head, large testes, and IQ in the 35 to 70 range were often but not always present in the 14 boys identified in this study. In the whole group, the recurrence of severe mental subnormality was high: 1 in 8 for brothers and 1 in 25 for sisters. This high recurrence was partly due to the fragile X syndrome, partly to X linked mental retardation not accompanied by cytogenetic abnormalities, and partly due to autosomal recessive disease. Autosomal recessive disease was perhaps higher in the West Midlands than elsewhere (such as British Columbia, for example 1) because of the disproportionate contribution by Asian immigrants.

A clinical and cytogenetic study of children attending schools for the educationally handicapped has been carried out in the City of Coventry. As a result of this an estimate of the population incidence of the Martin-Bell syndrome among schoolchildren has been made. Among school-boys the incidence of mental retardation due to the fra (X) was found to be 0.73 per 1000 and among schoolgirls 0.48 per 1000. The overall prevalence is 0.61 per 1000. Genetic and cytogenetic analysis of 14 families ascertained in an unbiased manner showed that the expected 50% ratio of affected to unaffected relatives was disturbed, the possible result of a segregation distortion.

An account is given of a pregnancy in an obligatory carrier of the fragile-X syndrome, in whom examination of chorionic villus cells and fetal blood cells showed the presence of a male fetus who lacked the fragile-X chromosome. However, at 3 months of age he had 14 per cent of fragile-X cells in his blood. Reasons are suggested for this error in diagnosis. The empirical risk for an error of this sort is 3 per cent.

A population study has been carried out among schoolchildren in the City of Coventry in order to ascertain the frequency of mental retardation associated with the fragile X chromosome. The prevalence of the fragile X mental retardation syndrome in the 11 to 16 year age group (the age of greatest ascertainment) was about 1.0 per 1,000 and therefore indicates that the syndrome is a major cause of mental retardation.

Clones of cytogenetically abnormal cells have been recognized in fibroblasts cultured from normal human adult skin. No such clones have been observed in human embryo skin fibroblasts cultured in the same way. Although the culture conditions may have played some part in the emergence of these clones, it is possible that the abnormal cells from which the clones were derived were present in vivo.

Nineteen pregnancies at risk for the Martin-Bell syndrome have been monitored during the second trimester for the presence of the fragile Xq27. Of the 19 potential carrier mothers, 14 showed the presence of the fragile X in their lymphocytes at a level of 4 per cent or above. As one was a twin pregnancy, fetal blood was obtained at fetoscopy from 20 fetuses and amniotic fluid obtained simultaneously from 19 of them. Of the 20 fetuses, 18 were males (including both of the twins) and two were females. Of these 18 males, seven were found to carry the fragile Xq27 in lymphocytes and subsequently six of the seven were terminated. The diagnosis was confirmed in five of the six terminated fetuses (the sixth case was a patient whose pregnancy was terminated abroad) and also in a full-term male baby. Five of the seven males without the marker X who came to term had their karyotypes confirmed post natally. Of the two female fetuses one was found to be a carrier of the fragile X and the other was not. Both babies had full-term deliveries and both had their karyotypes confirmed post natally. In some cases the diagnosis made in fetal lymphocytes was confirmed later in amniocytes.

Co-cultivation studies in different combinations have been carried out between cells which have been found to be positive for the fragile (X) (q27) and control cells. As no increase or decrease was discernible in the level of Fra(X) detected in 'positive' cells, and no fragility was introduced into the 'negative' cells, it was concluded that there had been no intercellular co-operation, and a diffusible expression or suppression factor was not involved.

Second trimester ultrasound-guided fetal blood sampling and placental biopsy were performed on 10 pregnancies at risk for fra(X)-linked mental retardation (Martin-Bell syndrome). Three cases were diagnosed as affected after cytogenetic analysis of fetal blood and placental cultures. The fra(X)(q27.3) and common fragile sites were shown to be expressed at a lower level in placenta than in fetal blood. Induction methods included methotrexate, 5-fluoro-2-deoxyuridine, and excess thymidine. Excess thymidine may give the best expression of fra(X)(q27.3). Enhancement of fra(X)(q27.3) expression was not shown with caffeine or 5-methoxybenzamide.

A cytogenetic survey has been carried out among mentally retarded schoolchildren in the West Midlands Region, England. The conclusions are that the Fragile-X syndrome is second only to Down's syndrome as a cytogenetic entity contributing to mental handicap among children of school age.