Survey of student education in surgery.

BACKGROUND: Few data exist comparing medical student surgical education programs across the US and Canada. We conducted a 30-question, Web-based survey of 142 medical schools in the US and Canada about the administration of undergraduate surgical education programs at their institutions. STUDY DESIGN: From October 2005 to January 2006, 142 Association of American Medical Colleges (AAMC) medical schools in the US and Canada were asked to complete a 30-item, Web-based questionnaire. Descriptive statistics were compiled for all responses and data were analyzed using Student's t-test. RESULTS: One hundred two medical schools responded to the survey (90 of 125 US and 12 of 17 Canadian schools, overall response rate,=72%). The majority of surgical clerkships have between 16 and 30 students rotating at a time through 2 to 4 teaching sites. The most frequent overall clerkship duration was 8 weeks, divided most frequently between a 4- to 6-week general surgery rotation and a 4-week subspecialty rotation. There was no consensus about what services constitute general surgery rotations, although the most common subspecialty rotations were urology (68%) and orthopaedics (66%). American medical schools were more likely to use the National Board of Medical Examiners (NBME) subject examination for student assessment (90.9% US versus 50.0% Canadian, p < 0.05); Canadian medical schools were more likely to use an Objective Structured Clinical Examination (69.2% Canadian versus 37.7% US, p < 0.05) and other written examinations (69.2% Canadian versus 37.7% US, p < 0.05). CONCLUSIONS: There is wide variation in the structure and administration of medical student surgical education programs in the US and Canada. These findings underscore the need for a clerkship directors committee and a national dialog about a core student curriculum to ensure consistency in the quality of student education in surgery.

Nutrition support for the long-term ventilator-dependent patient.

This article discusses issues related to nutrition support for the critically ill (CCI), especially those who are dependent on ventilators for long periods. A large and growing population of patients survives acute critical illness only to become CCI with profound debilitation, weeks to months of hospitalization, and often permanent dependence on mechanical ventilation and other life-sustaining modalities. Despite resource-intensive treatment, outcomes for CCI remain poor. Topics addressed in this article include neuroendocrine profiles in CCI patients, allostatic overload, causes of prolonged mechanical ventilation, and the metabolism of chronic ventilator dependence. The article also describes issues related to assessing the nutrition, determining nutrition requirements, and deciding the route of nutrient delivery for CCI patients.

Temporary abdominal closure followed by definitive abdominal wall reconstruction of the open abdomen.

BACKGROUND: Inability to close the abdominal wall after laparotomy for trauma may occur as a result of visceral edema, retroperitoneal hematoma, use of packing, and traumatic loss of tissue. Often life-saving, decompressive laparotomy and temporary abdominal closure require later restoration of anatomic continuity of the abdominal wall. METHODS: The trauma registry, open abdomen database, and patient medical records at a level 1 university-based trauma center were reviewed from January 1988 to December 2001. RESULTS: During the study period, more than 15,000 trauma patients were admitted, with 88 patients (0.6%) requiring temporary abdominal closure (TAC). Patients ages ranged from 12 to 75 years with a mean injury severity score (ISS) of 28 (range 5 to 54). Forty-five patients (51%) suffered penetrating injuries, and 43 (49%) were victims of blunt trauma. Indications for TAC included visceral edema in 61 patients (70%), abdominal compartment syndrome in 10 patients (11%), traumatic tissue loss in 9 patients (10%), and wound sepsis and fascial necrosis in 8 patients (9%). Fifty-six patients (64%) underwent TAC at admission laparotomy, whereas 32 patients (36%) required TAC at reexploration. Seventy-one patients (81%) survived and 17 (19%) died. Of the survivors, 24 patients (34%) underwent same-admission direct fascial closure, and 47 patients (66%) required visceral skin grafting and readmission closure. Reconstructive procedures in the patients requiring skin graft excision included direct fascial repair (20 patients, 44%), components separation closure with or without subfascial tissue expansion (18 patients, 40%), pedicled or free-tissue flaps (4 patients, 8%), and mesh repair (4 patients, 8%). One patient refused closure. The mean follow-up was 48 months (range 6 to 144), with an overall recurrence rate of 15% (range 10% to 50%), highest in the mesh repair group. CONCLUSIONS: Silicone sheeting TAC provides a safe and reliable temporary abdominal closure allowing for later definitive reconstruction. Direct fascial repair or components separation closure with or without tissue expansion can be utilized in the majority of patients for definitive reconstruction with low recurrence rate.