The mechanism and pattern of injuries of undocumented immigrants crossing the Texas-Mexico border along the Rio Grande Valley.

BACKGROUND: Apprehensions of undocumented immigrants in the Rio Grande Valley sector of the U.S.-Mexico border have grown to account for nearly half of all apprehensions at the border. The purpose of this study is to report the prevalence, mechanism, and pattern of traumatic injuries sustained by undocumented immigrants who crossed the U.S.-Mexico border at the Rio Grande Valley sector over a span of 5 years and were treated at a local American College of Surgeons verified Level II trauma center. METHODS: A retrospective chart review was conducted from January 2014 to December 2019. Demographics, comorbidities, injury severity score (ISS), mechanism of injury, anatomical part of the body affected, hospital and ICU length of stay (LOS), and treatment costs were analyzed. Descriptive statistics for demographics, injury location and cause, and temporal trends are reported. The impact of ISS or surgical intervention on hospital LOS was analyzed using an analysis of covariance (ANCOVA). RESULTS: Of 178 patients, 65.2% were male with an average age of 31 (range 0-67) years old and few comorbidities (88.8%) or social risk factors (86%). Patients most commonly sustained injuries secondary to a border fence-related incident (33.7%), fleeing (22.5%), or motor vehicle accident (16.9%). There were no clear temporal trends in the total number of patients injured, or in causes of injury, between 2014 and 2019. The majority of patients (60.7%) sustained extremity injuries, followed by spine injuries (20.2%). Border fence-related incidents and fleeing increased risk of extremity injuries (Odds ratio (OR) > 3; p < 0.005), whereas motor vehicle accidents increased risk of head and chest injuries (OR > 4; p < 0.004). Extremity injuries increased the odds (OR: 9.4, p < 0.001) that surgery would be required. Surgical intervention was common (64%), and the median LOS of patients who underwent surgery was 3 days more than those who did not (p < 0.001). CONCLUSION: In addition to border fence related injuries, undocumented immigrants also sustained injuries while fleeing and in motor vehicle accidents, among others. Extremity injuries, which were more likely with border fence-related incidents, were the most common type. This type of injury often requires surgical intervention and, therefore, a longer hospital stay for severe injuries.

3D-Bioprinted Inflammation Modulating Polymer Scaffolds for Soft Tissue Repair.

Development of inflammation modulating polymer scaffolds for soft tissue repair with minimal postsurgical complications is a compelling clinical need. However, the current standard of care soft tissue repair meshes for hernia repair is highly inflammatory and initiates a dysregulated inflammatory process causing visceral adhesions and postsurgical complications. Herein, the development of an inflammation modulating biomaterial scaffold (bioscaffold) for soft tissue repair is presented. The bioscaffold design is based on the idea that, if the excess proinflammatory cytokines are sequestered from the site of injury by the surgical implantation of a bioscaffold, the inflammatory response can be modulated, and the visceral adhesion formations and postsurgical complications can be minimized. The bioscaffold is fabricated by 3D-bioprinting of an in situ phosphate crosslinked poly(vinyl alcohol) polymer. In vivo efficacy of the bioscaffold is evaluated in a rat ventral hernia model. In vivo proinflammatory cytokine expression analysis and histopathological analysis of the tissues have confirmed that the bioscaffold acts as an inflammation trap and captures the proinflammatory cytokines secreted at the implant site and effectively modulates the local inflammation without the need for exogenous anti-inflammatory agents. The bioscaffold is very effective in inhibiting visceral adhesions formation and minimizing postsurgical complications.

A Multifaceted Research Engagement Program Improved the Academic Productivity of General Surgery Residents.

OBJECTIVE: Surgeon-scientists are becoming increasingly scarce, and therefore, engaging residents in research during their training is important. We evaluated whether a multifaceted research engagement program was associated with increased academic productivity of general surgery residents. DESIGN: Our research engagement program has 4 pillars: A research requirement, a structured research curriculum, infrastructure to support residents' research, and an annual resident research day to highlight trainees' work. We compared the number of manuscripts published per chief resident during the 4 years before and after program implementation in 2013. We performed subgroup analyses to examine productivity of research track residents and clinical track residents. SETTING: A general surgery residency program in an academic setting. PARTICIPANTS: The participants were 57 general surgery residents (23 research track and 34 clinical track) graduating between 2010 and 2017. RESULTS: There was a significant increase in overall research productivity, with 28 chief residents publishing an average of 2.3 ± 1.0 manuscripts before and 29 chief residents publishing an average of 8.5 ± 3.2 manuscripts after program implementation (p = 0.01). Research track residents had a nonsignificant increase in publications from an average of 6.3 ± 3.1 before to 15.4 ± 8.9 after the new program (p = 0.10). Clinical track residents had a significant increase in publications from a median of 0.9 (interquartile range: 0.5, 1.0) before to a median of 1.3 (interquartile range: 1.2, 8.6) after the new program (p = 0.03). CONCLUSIONS: Implementation of a multifaceted research engagement program was associated with a significant increase in manuscripts published by general surgery residents, including clinical track residents. Components of our program may be of use to other programs looking to improve resident research engagement and productivity.

Great Expectations? Future Competency Requirements Among Candidates Entering Surgery Training.

INTRODUCTION: We describe a multimethod, multi-institutional approach documenting future competencies required for entry into surgery training. METHODS: Five residency programs involved in a statewide collaborative each provided 12 to 15 subject matter experts (SMEs) to participate. These SMEs participated in a 1-hour semistructured interview with organizational psychologists to discuss program culture and expectations, and rated the importance of 20 core competencies derived from the literature for candidates entering general surgery training within the next 3 to 5 years (1 = importance decreases significantly; 3 = importance stays the same; 5 = importance increases significantly). RESULTS: Seventy-three SMEs across 5 programs were interviewed (77% faculty; 23% resident). All competencies were rated to be more important in the next 3 to 5 years, with team orientation (3.87 ± 0.81), communication (3.82 ± 0.79), team leadership (3.81 ± 0.82), feedback receptivity (3.79 ± 0.76), and professionalism (3.76 ± 0.89) rated most highly. CONCLUSIONS: These findings suggest that the competencies desired and required among future surgery residents are likely to change in the near future.

Using an anonymous, resident-run reporting mechanism to track self-reported duty hours.

BACKGROUND: Implementation of resident duty hour policies has resulted in a need to document work hours accurately. We compared the number of self-reported duty hour violations identified through an anonymous, resident-administered survey to that obtained from a standardized, ACGME-sanctioned electronic tracking system. METHODS: 10 cross-sectional surveys were administered to general surgery residents over five years. A resident representative collected and de-identified the data. RESULTS: A median of 54 residents (52% male) participated per cohort. 429 responses were received (79% response rate). 111 violations were reported through the survey, while the standardized electronic system identified 76, a trend significantly associated with PGY-level (p < 0.001) and driven by first-year residents (n = 81 versus 37, p = 0.001). CONCLUSIONS: An anonymous, resident-run mechanism identifies significantly more self-reported violations than a standardized electronic tracking system alone. This argues for individual program evaluation of duty hour tracking mechanisms to correct systematic issues that could otherwise lead to repeated violations.

How Much Are We Spending on Resident Selection?

INTRODUCTION: Rigorous selection processes are required to identify applicants who will be the best fit for training programs. This study provides a national snapshot of selection practices used within surgical residency programs and their associated financial costs. METHODS: A 17-item online survey was distributed to General Surgery Program Directors (PDs) via the Association of Program Directors in Surgery listserv. The survey examined program characteristics, applicant pool size, and interview day components of the prior match year. PD/coordinator teams also provided hard costs associated with interview day components, as well as time and effort estimations among program faculty, residents, and staff during the past interview season. Effort estimates were translated to dollar values via national salary data reports of hourly wages for faculty and annual wages for administrative staff and residents. Descriptive statistics and one-way analysis of variance via SPSS 24.0 were used to examine the data. RESULTS: One-hundred and twenty-eight responses were received, reflecting 48% (128/267) of programs in the 2017 match. Average hard costs (±SD) were $8053 ± 6467, covering food ($3753 ± 4042), social sessions ($3175 ± 3749), supplies ($329 ± 866), hotel ($328 ± 1381), room reservations ($120 ± 658), shuttle fees ($84 ± 403), tour guide fees ($50 ± 379), and other ($146 + 824). Costs for personnel effort was $77,601 ± 62,413 for faculty, $12,393 ± 33,518 for residents, $6447 ± 11,107 for coordinators, and $1294 ± 1943 for staff. Total average cost associated with the interview process (hard + effort) was $100,438±87,919, with university-based programs ($128,686 ± 101,565) spending significantly more than independent-university affiliated ($61,162 ± 33,945), independent ($74,793 ± 73,261), and military ($62,495 ± 38,532) programs (p < 0.01). Average cost for each residency program per position being filled was $18,648 ± 13,383, and average cost per interviewee was $1221 ± 894. CONCLUSIONS: In an era of declining resources for medical education, PDs must understand the time and effort associated with resident selection. These data reveal that residency programs are spending significant time and resources on the current selection process. Program leaders can use these data to assess their current selection strategies, review faculty and staff time allocation, and identify opportunities for making the process more efficient.

Intraoperative hypotensive resuscitation for patients undergoing laparotomy or thoracotomy for trauma: Early termination of a randomized prospective clinical trial.

BACKGROUND: Hemorrhagic shock is responsible for one third of trauma related deaths. We hypothesized that intraoperative hypotensive resuscitation would improve survival for patients undergoing operative control of hemorrhage following penetrating trauma. METHODS: Between July 1, 2007, and March 28, 2013, penetrating trauma patients aged 14 years to 45 years with a systolic blood pressure of 90 mm Hg or lower requiring laparotomy or thoracotomy for control of hemorrhage were randomized 1:1 based on a target minimum mean arterial pressure (MAP) of 50 mm Hg (experimental arm, LMAP) or 65 mm Hg (control arm, HMAP). Patients were followed up 30 days postoperatively. The primary outcome of mortality; secondary outcomes including stroke, myocardial infarction, renal failure, coagulopathy, and infection; and other clinical data were analyzed between study arms using univariate and Kaplan-Meier analyses. RESULTS: The trial enrolled 168 patients (86 LMAP, 82 HMAP patients) before early termination, in part because of clinical equipoise and futility. Injuries resulted from gunshot wounds (76%) and stab wounds (24%); 90% of the patients were male, and the median age was 31 years. Baseline vitals, laboratory results, and injury severity were similar between groups. Intraoperative MAP was 65.5 ± 11.6 mm Hg in the LMAP group and 69.1 ± 13.8 mm Hg in the HMAP group (p = 0.07). No significant survival advantage existed for the LMAP group at 30 days (p = 0.48) or 24 hours (p = 0.27). Secondary outcomes were similar for the LMAP and HMAP groups: acute myocardial infarction (1% vs. 2%), stroke (0% vs. 3%), any renal failure (15% vs. 12%), coagulopathy (28% vs. 29%), and infection (59% vs. 58%) (p > 0.05 for all). Acute renal injury occurred less often in the LMAP than in HMAP group (13% vs. 30%, p = 0.01). CONCLUSION: This study was unable to demonstrate that hypotensive resuscitation at a target MAP of 50 mm Hg could significantly improve 30-day mortality. Further study is necessary to fully realize the benefits of hypotensive resuscitation. LEVEL OF EVIDENCE: Therapeutic study, level II.

More than a camera holder: teaching surgical skills to medical students.

BACKGROUND: Students often experience passive learning in their surgical rotations as they are delegated to holding the camera during laparoscopic cases. We introduced a laparoscopic skills course to medical students to provide hands-on experience. We hypothesized that the course will improve basic laparoscopic skills and increase interest in a surgical career. MATERIALS AND METHODS: All students on the core surgery rotation attended two sessions in the surgical simulation laboratory lead by Department of Surgery faculty members. Surveys were used before and after the course to assess video game (VG) use and interest in a surgical career. Course effectiveness was assessed with a laparoscopic peg transfer exercise. RESULTS: One hundred one students participated with 82 students documenting preinstruction and postinstruction peg transfer times. There was an overall improvement in median transfer times after instruction (before 63 s [interquartile range {IQR} 46-84.5] versus after 50.5 s [IQR 39-65.2], P < 0.001). When stratified by gender, men (n = 40) had faster median preintervention peg transfer times than women (n = 61; 65 s [IQR 51-88]) versus 81 s [IQR 65-98] (P = 0.030). However, both genders had equivalent postinstruction transfer times (men 48 s [IQR 36-61] versus women 51.3 s [IQR 43.2-68.3], P = 0.478). A similar trend was observed between students with and without prior VG use. Of the 50 students who completed both surveys, there was no significant increase (pre-24% versus post-34%, P = 0.29) or decrease (pre-32% versus post-22%, P = 0.13) in interest in a surgical career after the course. CONCLUSIONS: A laparoscopic course for medical students is effective in improving laparoscopic skills. Although male gender and VG use may be associated with better intrinsic skills, instruction and practice allow female students and non-VG users to "catch up." A longer follow-up study is warranted to determine true interest in a surgical career.

Randomized, controlled trial comparing the effects of anesthesia with propofol, isoflurane, desflurane and sevoflurane on pain after laparoscopic cholecystectomy.

BACKGROUND: Pain is the primary complaint and the main reason for prolonged recovery after laparoscopic cholecystectomy. The authors hypothesized that patients undergoing laparoscopic cholecystectomy will have less pain four hours after surgery when receiving maintenance of anesthesia with propofol when compared to isoflurane, desflurane, or sevoflurane. METHODS: In this prospective, randomized trial, 80 patients scheduled for laparoscopic cholecystectomy were assigned to propofol, isoflurane, desflurane, or sevoflurane for the maintenance of anesthesia. Our primary outcome was pain measured on the numeric analog scale four hours after surgery. We also recorded intraoperative use of opioids as well as analgesic consumption during the first 24h after surgery. RESULTS: There was no statistically significant difference in pain scores four hours after surgery (p=0.72). There were also no statistically significant differences in pain scores between treatment groups during the 24h after surgery (p=0.45). Intraoperative use of fentanyl and morphine did not vary significantly among the groups (p=0.21 and 0.24, respectively). There were no differences in total morphine and hydrocodone/APAP use during the first 24h (p=0.61 and 0.53, respectively). CONCLUSION: Patients receiving maintenance of general anesthesia with propofol do not have less pain after laparoscopic cholecystectomy when compared to isoflurane, desflurane, or sevoflurane.

Randomized, controlled trial comparing the effects of anesthesia with propofol, isoflurane, desflurane and sevoflurane on pain after laparoscopic cholecystectomy / Estudo randômico controlado que compara os efeitos da anestesia com propofol, isoflurano, desflurano e sevoflurano sobre a dor pós-colecistectomia videolaparoscópica / Estudio aleatorizado controlado comparando los efectos de la anestesia con propofol, isoflurano, desflurano y sevoflurano sobre el dolor poscolecistectomía videolaparoscópica

Background: Pain is the primary complaint and the main reason for prolonged recovery after laparoscopic cholecystectomy. The authors hypothesized that patients undergoing laparoscopic cholecystectomy will have less pain four hours after surgery when receiving maintenance of anesthesia with propofol when compared to isoflurane, desflurane, or sevoflurane. Methods: In this prospective, randomized trial, 80 patients scheduled for laparoscopic cholecystectomy were assigned to propofol, isoflurane, desflurane, or sevoflurane for the maintenance of anesthesia. Our primary outcome was pain measured on the numeric analog scale four hours after surgery. We also recorded intraoperative use of opioids as well as analgesic consumption during the first 24 h after surgery. Results: There was no statistically significant difference in pain scores four hours after surgery (p = 0.72). There were also no statistically significant differences in pain scores between treatment groups during the 24 h after surgery (p = 0.45). Intraoperative use of fentanyl and morphine did not vary significantly among the groups (p = 0.21 and 0.24, respectively). There were no differences in total morphine and hydrocodone/APAP use during the first 24 h (p = 0.61 and 0.53, respectively). Conclusion: Patients receiving maintenance of general anesthesia with propofol do not have less pain after laparoscopic cholecystectomy when compared to isoflurane, desflurane, or sevoflurane. .

Justificativa e objetivo: a dor é a principal queixa e também o motivo principal de recuperação prolongada pós-colecistectomia laparoscópica. A nossa hipótese foi que os pacientes submetidos à colecistectomia laparoscópica apresentariam menos dor quatro horas após a cirurgia se recebessem manutenção anestésica com propofol em comparação com isoflurano, desflurano ou sevoflurano. Métodos: neste estudo prospectivo e randômico, 80 pacientes agendados para colecistectomia laparoscópica foram designados para receber propofol, isoflurano, desflurano ou sevoflurano para manutenção da anestesia. Nosso desfecho primário foi dor mensurada em escala analógica numérica quatro horas após a cirurgia. Também registramos o uso intraoperatório de opiáceos, bem como o consumo de analgésicos durante as primeiras 24 horas pós-cirúrgicas. Resultados: não houve diferença estatisticamente significante nos escores de dor quatro horas após a cirurgia (p = 0,72). Também não houve diferença estatisticamente significativa nos escores de dor entre os grupos de tratamento durante as 24 horas pós-cirúrgicas (p = 0,45). O uso intraoperatório de fentanil e morfina não variou significativamente entre os grupos (p = 0,21 e 0,24, respectivamente). Não houve diferença no consumo total de morfina e hidrocodona/APAP durante as primeiras 24 horas (p = 0,61 e 0,53, respectivamente). Conclusão: os pacientes que receberam propofol para manutenção da anestesia geral não apresentaram menos dor pós-colecistectomia videolaparoscópica em comparação com os que receberam isoflurano, desflurano ou sevoflurano. .

Justificación y objetivo: el dolor es el principal motivo de queja y también la principal razón de una prolongada recuperación tras una colecistectomía laparoscópica. Nuestra hipótesis fue que los pacientes sometidos a colecistectomía laparoscópica tenían menos dolor 4 h después de la cirugía cuando recibían propofol para la anestesia en comparación con isoflurano, desflurano o sevoflurano. Métodos: en este estudio prospectivo y aleatorizado, 80 pacientes programados para colecistectomía laparoscópica fueron designados para recibir propofol, isoflurano, desflurano o sevoflurano para el mantenimiento de la anestesia. Nuestro primer resultado fue el dolor medido en escala analógica numérica 4 h después de la cirugía. También registramos el uso intraoperatorio de opiáceos y el consumo de analgésicos durante las primeras 24 h del postoperatorio. Resultados: no hubo diferencias estadísticamente significativas en las puntuaciones del dolor 4 h después de la cirugía (p = 0,72). Tampoco hubo diferencias estadísticamente significativas en las puntuaciones del dolor entre los grupos de tratamiento durante las 24 h del postoperatorio (p = 0,45). El uso intraoperatorio de fentanilo y morfina no varió significativamente entre los grupos (p = 0,21 y 0,24 respectivamente). No hubo una diferencia en el consumo total de morfina e hidrocodona/APAP durante las primeras 24 h (p = 0,61 y 0,53 respectivamente). Conclusiones: los pacientes que recibieron propofol para el mantenimiento de la anestesia general no tenían menos dolor poscolecistectomía videolaparoscópica en comparación con los que recibieron isoflurano, desflurano o sevoflurano. .

Emergency endovascular management of penetrating gunshot injuries to the arteries in the face and neck: a case series and review of the literature.

INTRODUCTION: Penetrating gunshot injuries (GSI) to supra-aortic arteries that cause life-threatening blood loss or major neurologic deficits are increasingly managed using modern endovascular treatment (EVT). We report our experience with EVT of acute GSIs and review the existing literature. METHODS: Emergency EVT was performed in nine of 10 patients (7 men, age 17-50 years) with acute GSIs to supra-aortic arteries requiring acute management. One patient presented with acute and delayed injuries and underwent EVT 4 weeks after initial admission. Patient selection was based on clinical presentation and radiographic findings from a cohort of 55 patients with GSIs to the face, neck or head between February 2009 and March 2012. RESULTS: EVT was successfully performed in all patients. Two transections of the vertebral arteries were embolized with coils and/or liquid embolic agent (acrylic glue). Eight penetrated external carotid artery branches were occluded with liquid embolic agents (acrylic glue or Onyx) or particles. One severe dissection of the internal carotid artery with a subsequent thromboembolic event was treated with stenting. All except one patient survived with minor or no residual deficits. CONCLUSIONS: Emergency management of GSI injuries to the head and neck may involve all aspects of current EVT. Understanding endovascular techniques and being able to make rapid and appropriate treatment decisions in the setting of acute GSI to the face and neck can be a life-saving measure and greatly benefits the patient's outcome.

Assessment and standardization of resident handoff practices: PACT project.

BACKGROUND: Accreditation Council for Graduate Medical Education duty hour guidelines have resulted in increased patient care transfers. Although structured hand-over processes are required in the guidelines, how to implement these processes is not defined. The purpose of this study is to investigate current handoff methods at our center in order to develop an effective structured handoff process. MATERIALS AND METHODS: This is a prospective study conducted at two hospitals with large in-house patient censuses. Resident focus groups were used to define current practices and future directions. Based on this input, we developed a direct observation handoff analysis tool to study time spent in handoffs, content, quality, and number of interruptions. RESULTS: Trained medical students observed 86 handoffs. Survey response rates among junior and senior residents were 63% and 54%, respectively. Average daily patient census was 36 ± 10 patients with an average handoff time of 12 ± 9 min. There were 1.5 ± 1.8 interruptions per handoff. The majority of handoffs were unstructured. Based on information they were given in the handoff, junior residents had a 58% rate of incompletion of the assigned tasks and 54% incidence of being unable to answer a key patient status question. CONCLUSIONS: Current handoffs are primarily unstructured, with significant deficits. Determination of key elements of an effective handoff coupled with evaluation of existing deficiencies in our program is essential in developing an institution-specific method for effective handoffs. We propose utilization of the mnemonic PACT (Priority, Admissions, Changes, Task) to standardize handoff communication.

Endovascular therapy for overcoming challenges presented with blunt abdominal aortic injury.

Blunt abdominal aortic injury (BAAI) is a rare and lethal injury requiring surgical management. Injury patterns can be complex and surgical strategy should accommodate specific case circumstances. Endovascular solutions appear appropriate and preferred in certain cases of BAAI, which, however, may not be applicable due to device limitations in regard to patient anatomy and limited operating room capability. However, endovascular therapy can be pursued with limited fluoroscopy capability and consumable availability providing a solution that is expeditious and effective for select cases of BAAI.

Anemia and jejunal intussusception: An unusual presentation for a metastatic phyllodes breast tumor.

INTRODUCTION: Phyllodes tumor of the breast is a rare cause of breast cancer, accounting for less than 0.5% of breast cancers. These tumors are classified as benign, borderline, or malignant, with malignant tumors compromising nearly 25% of cases. Metastases occur in 20% of malignant tumors, lungs, bones, liver and brain being the frequent sites of metastases. PRESENTATION OF CASE: We present a case of a metastatic phyllodes tumor to the small bowel causing jejunal intussusception, symptomatic anemia, and small bowel obstruction. DISCUSSION: Patients with phyllodes tumor of the breast can develop disease recurrence even years after initial treatment. Phyllodes tumor metastasizing to the small bowel is extremely rare, with only three known previously described case reports in the literature. CONCLUSION: High risk patients, with a past medical history of phyllodes breast cancer, should be monitored closely. Even years after breast cancer treatment, these patients may present with gastrointestinal complaints such as obstruction or bleeding, and therefore metastatic disease to the small bowel should be considered on the differential with subsequent abdominal imaging obtained.

Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock: preliminary results of a randomized controlled trial.

BACKGROUND: Trauma is a leading cause of death worldwide and is thus a major public health concern. Previous studies have shown that limiting the amount of fluids given by following a strategy of permissive hypotension during the initial resuscitation period may improve trauma outcomes. This study examines the clinical outcomes from the first 90 patients enrolled in a prospective, randomized controlled trial of hypotensive resuscitation, with the primary aim of assessing the effects of a limited transfusion and intravenous (IV) fluid strategy on 30-day morbidity and mortality. METHODS: Patients in hemorrhagic shock who required emergent surgery were randomized to one of the two arms of the study for intraoperative resuscitation. Those in the experimental (low mean arterial pressure [LMAP]) arm were managed with a hypotensive resuscitation strategy in which the target mean arterial pressure (MAP) was 50 mm Hg. Those in the control (high MAP [HMAP]) arm were managed with standard fluid resuscitation to a target MAP of 65 mm Hg. Patients were followed up for 30 days. Intraoperative fluid requirements, mortality, postoperative complications, and other clinical data were prospectively gathered and analyzed. RESULTS: Patients in the LMAP group received a significantly less blood products and total i.v. fluids during intraoperative resuscitation than those in the HMAP group. They had significantly lower mortality in the early postoperative period and a nonsignificant trend for lower mortality at 30 days. Patients in the LMAP group were significantly less likely to develop immediate postoperative coagulopathy and less likely to die from postoperatively bleeding associated with coagulopathy. Among those who developed coagulopathy in both groups, patients in the LMAP group had significantly lower international normalized ratio than those in the HMAP group, indicating a less severe coagulopathy. CONCLUSIONS: Hypotensive resuscitation is a safe strategy for use in the trauma population and results in a significant reduction in blood product transfusions and overall IV fluid administration. Specifically, resuscitating patients with the intent of maintaining a target minimum MAP of 50 mm Hg, rather than 65 mm Hg, significantly decreases postoperative coagulopathy and lowers the risk of early postoperative death and coagulopathy. These preliminary results provide convincing evidence that support the continued investigation and use of hypotensive resuscitation in the trauma setting.

Thoracoabdominal shotgun wounds: an evaluation of factors associated with the need for surgical intervention.

BACKGROUND: Shotgun wound classification systems attempt to predict the need for surgical intervention based on the size of wounds, pellet spread, or distance from the weapon rather than clinical findings. METHODS: A 5-year retrospective review of patients sustaining a thoracoabdominal shotgun wound was performed. Factors believed to be associated with the need for surgical intervention were examined using the Fisher exact test or an independent sample t test. RESULTS: Sixty-four patients suffered a thoracoabdominal shotgun wound. Fifty-nine percent required surgical intervention. Factors significantly associated with the need for surgical intervention were a low revised trauma score and systolic and diastolic blood pressure (P < .05). Distance from attacker, wound patterns, pellet size, and pellet spread were not found to have an association. CONCLUSIONS: Clinical indicators of hemorrhage and shock are associated with the need for surgical intervention, whereas pellet spread, pellet size, and distance from the attacker are not. This is a significant departure from traditional classification systems.

Impact of a novel education curriculum on surgical training within an academic training program.

BACKGROUND: The training of the 21st century surgeon has become increasingly complex with the Accreditation Council for Graduate Medical Education (ACGME) core competency requirements and work-hour restrictions. Herein we report the two-year results of a novel problem-based learning education module at a large academic surgery program. METHODS: All data were prospectively collected from 2004 to 2006 on all categorical residents in the department of surgery (n = 42). Analysis was performed to identify any correlation between class attendance and American Board of Surgery In-Service Training Exam (ABSITE) score performance (percentile change). All data were reported as a mean with a standard error of the mean. Categorical variables were analyzed using a paired Student's t-test. A bivariate correlation was calculated using Spearman's rho correlation. RESULTS: When comparing the 2004 scores (pre-program) to 2006 scores, there was significant score improvement (P

Incidence and clinical characteristics of methicillin-resistant Staphylococcus aureus necrotizing fasciitis in a large urban hospital.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) has become a prevalent health issue for soft-tissue infections. In severe soft-tissue infections such as necrotizing fasciitis, MRSA has been identified as an increasingly common pathogen. Herein, we report a 5-year experience of MRSA necrotizing fasciitis at a large urban hospital. METHODS: All cases of necrotizing fasciitis between 2001 and 2006 were reviewed. All patients were taken for surgical debridement. MRSA patients were identified and compared with the non-MRSA patients to identify any clinical variables that impacted incidence or severity of disease. A P value of less than .05 was considered significant. RESULTS: During the 5-year period, there were 74 cases of necrotizing fasciitis with a 39% prevalence of MRSA as the causative organism for the infection. The mean age of patients with MRSA fasciitis was 43 +/- 3 years. There were no discernible social variables (eg, smoking, ethanol use, intravenous drug use) that predisposed patients to MRSA infection. The overall mortality rate was 15%, with no significant difference between groups. One hundred percent of MRSA specimens were susceptible to vancomycin or rifampin, 93% were susceptible to sulfamethoxazole/trimethoprim, and only 62% were susceptible to clindamycin. CONCLUSIONS: The incidence of MRSA fasciitis may be much higher than initially suspected and prompt MRSA-directed antibiotic therapy should be administered. Clinicians should maintain a high index of suspicion for this organism in necrotizing fasciitis.