Traumatic Brain Injury Patients Admitted on High-Census Days Receive Less Critical Care and Have an Increased Risk for Delirium.

INTRODUCTION: The utilization of healthcare services in a growing population has raised concerns about its impact on clinical outcomes. Studies have shown that increased hospital census is associated with higher admission rates and unnecessary consults, tests, and procedures in various areas of healthcare. Traumatic brain injuries (TBIs), a significant concern due to their potential for long-term disabilities, are commonly encountered in intensive care units (ICUs) and are a leading cause of patient mortality. Despite extensive research on various aspects of TBI, the effect of the patient census on TBI outcomes remains unexplored. This study aims to investigate the relationship between healthcare provider patient census and clinical outcomes in TBI patients at a level I trauma center. METHODS: A retrospective review was conducted from 2017 to 2022. The mean number of patients per day in the trauma service was determined, with patients below this average considered to be present on low-census days and those above it on high-census days. Patient demographics, mechanisms of injury, vital signs, TBI severity, and associated injuries were analyzed. Adjusted regression analyses were conducted. RESULTS: Over the study period, 1,527 TBI patients were identified. Demographics were similar between patients admitted on high- and low-census days. Patients with moderate TBI were 30% less likely to be admitted to the ICU on high-census days, whereas there was no difference in ICU admission for patients with mild or severe TBI. Delirium was significantly higher in patients admitted on high-census days compared to those on low-census days. This was further identified to be predominantly driven by patients with mild TBI admitted on high-census days. CONCLUSION: While most outcomes remained consistent, significant rates of delirium were found in our mild TBI patients admitted on high-census days suggesting the need for additional factors in the evaluation of these patients on admission. This study also reveals potential under-triage in moderate TBI patients on high-census days as they had significantly lower rates of ICU admission. These findings emphasize the need for further investigations to optimize patient care strategies within the context of fluctuating healthcare system demands.

Program Factors Associated With Improved American Board of Surgery Examination Pass Rates.

INTRODUCTION: The American Board of Surgery awards board certification after successful completion of both the Qualifying Exam and Certifying Exam. Although multiple studies have evaluated board performance at the resident level, fewer studies have evaluated board performance at the program level. METHODS: Program pass rates, available through the American Board of Surgery, for 2019-2021 were compared to program information through the American Medical Association Fellowship and Residency Electronic Interactive Database Access (FREIDA). RESULTS: A significant positive correlation of Certifying Exam performance to residency length, resident class size, and number of total physician faculty within the program was seen. Greater average hours of didactics per week had a significant positive correlation to improved Qualifying Exam performance but not Certifying Exam. Programs with higher percentages of residents graduating from a United States MD program, compared to international or DO schools, were associated with improved performances. It also appears that more established programs performed better than younger programs <20 years old. Programs in the West and Midwest performed significantly better on the Qualifying Exam than programs in the South and Northeast. CONCLUSION: Board certification serves as the capstone for surgeons after completing general surgery residency. Multiple program factors demonstrate a significant correlation to board performance.

Quality of life, functional and radiological outcomes of treatment of three-part and four-part proximal humerus fractures with locking plates and comparison in young versus older than 70 years: a retrospective cohort study.

PURPOSE: Verify if the use of locking plates in displaced three- and four-part proximal humerus fractures has meant an improvement even in patients over 70 years of age. MATERIAL AND METHODS: We performed surgery with locking plate fixation in 56 consecutive patients with three- and four-part proximal humerus fractures according to Neer's classification between 1/1/15 and 12/31/20 at our Hospital. Patient satisfaction, quality of life, functionality and radiological variables, as well as the comparison between patients older and younger than 70 years were the main outcomes. Likewise, factors and complications that may have influenced these variables were analyzed as secondary outcomes. The analysis of all these variables was performed after a minimum follow-up time of 24 months after surgery. RESULTS: 51 patients (92%) ended up satisfied or very satisfied according to the SF-36 test and with no disability or mild disability according to the DASH Score questionnaire. 46 patients (82%) obtained a satisfactory or excellent result according to the Neer scale modified by Cofield and 38 (68%) a good or excellent function according to the Constant Murley questionnaire. In 47 cases (84%) good radiological alignment was observed. Complications occurred in 20 patients (36%). The complications and the results of the SF-36, DASH Score, Neer scale modified by Cofield and Constant Murley tests depended on the radiological alignment (p = 0.009, p = 0.006, p = 0.025, p = 0.0008 and p = 0.0004). There were 37 patients younger than 70 years and 19 older than 70 years with no statistically significant differences when comparing the two groups. CONCLUSIONS: This study demonstrates that satisfactory results can be obtained with osteosynthesis with locking plates in displaced proximal humerus fractures even in patients older than 70 years of age. LEVEL OF EVIDENCE III: Retrospective Cohort, Treatment Study.

Esclerodermia y alteraciones esofágicas documentadas por manometría / Scleroderma and Esophageal Alterations Documented by Manometry

Introducción: Las manifestaciones gastrointestinales y en especial la disfunción esofágica son frecuentes en pacientes con diagnóstico de esclerosis sistémica. Objetivos: Determinar los hallazgos manométricos en el esófago de pacientes con esclerosis sistémica. Métodos: Se realizó un estudio descriptivo de corte transversal, en 86 pacientes con diagnóstico de esclerosis sistémica que fueron atendidos en el Servicio de Reumatología del Hospital Hermanos Ameijeiras, en el período comprendido de enero de 2020 a diciembre de 2021. Resultados: La edad media fue de 49,5 ± 15,3 años, (94,3 por ciento) en el sexo femenino. El (90,7 por ciento) tenía trastornos de la motilidad esofágica, principalmente los trastornos mayores (58,1por ciento) y el esfínter esofágico corto (62,8 por ciento). La presencia de síntomas como la regurgitación, la pirosis y la disfagia se relacionaron de forma significativa en la mayoría de los parámetros manométricos. De igual forma, el tiempo de evolución de la enfermedad (10,1 ± 9,1 frente a 5,9 ± 5,9 años), el fenómeno de Raynaud (93,9 por ciento frente a 25,0 por ciento) y la esclerosis sistémica difusa (96,2 por ciento frente a 82,4 por ciento) fueron significativamente mayores en pacientes con trastornos de la motilidad esofágica. La edad y el sexo no mostraron una asociación significativa con las alteraciones manométricas. Conclusiones: Se concluye que los pacientes con esclerosis sistémica difusa, fenómeno de Raynaud, a partir de la presencia de los síntomas y de la evolución de la enfermedad tienen una elevada probabilidad de padecer trastornos de la motilidad esofágica(AU)

Introduction: Gastrointestinal manifestations, and especially esophageal dysfunction, are common in patients diagnosed with systemic sclerosis. Objectives: To determine the manometric findings in the esophagus of patients with systemic sclerosis. Methods: A descriptive cross-sectional study was carried out on 86 patients with a diagnosis of systemic sclerosis who were treated in the Rheumatology Service of Hermanos Ameijeiras Hospital from January 2020 to December 2021. Results: The mean age was 49.5 ± 15.3 years, (94.3percent) in females. 90.7percent had esophageal motility disorders, mainly major disorders (58.1percent) and 62.8percent had short esophageal sphincter. The presence of symptoms such as regurgitation, heartburn and dysphagia were significantly related to most manometric parameters. Similarly, the duration of the disease (10.1 ± 9.1 versus 5.9 ± 5.9 years), Raynaud's phenomenon (93.9percent versus 25.0percent) and sclerosis diffuse systemic (96.2percent vs. 82.4percent) were significantly higher in patients with esophageal motility disorders. Age and sex did not show significant association with manometric alterations. Conclusions: It is concluded that patients with diffuse systemic sclerosis, Raynaud's phenomenon, based on the presence of symptoms, and the evolution of the disease, have high probability of suffering from esophageal motility disorders(AU)

The cognitive benefits of basketball training compared to a combined endurance and resistance training regimen: a four-month intervention study.

Neurocognitive function, especially executive functioning, is positively associated with better fitness or higher levels of physical activity (PA). Previous research suggests that combined endurance and resistance (AER+R) training leads to greater improvements than training in either modality separately. Dynamic team sports with cognitive dimensions, such as basketball (BAS), may be an excellent context for improving cognition. This study compared the effects of following a four-month PA training program in BAS versus AER+R on executive functions along with a control group with low PA. Fifty participants completed the training period and were randomly distributed into three groups: BAS (16 participants), AER+R (18), and control (16). Participants in the BAS group showed improved inhibition and working memory and those in the AER+R group showed improved inhibition and cognitive flexibility, while inhibition deteriorated in the control group. There were significant differences between groups only in inhibition. It appears that following a four-month PA training program is enough to enhance executive functioning, and improvements in inhibition are more evident when the program includes an open sport such as BAS.

Surgical Management of an Intentionally Ingested Vape Device Chronically Impacted within the Duodenum of an Adult Male.

Most foreign body ingestion cases are accidental in the adult population. Intentional ingestion of foreign bodies in adults is typically associated with psychiatric disorders or developmental delay. In most cases, foreign bodies pass spontaneously through the gastrointestinal tract or can be managed endoscopically. Rarely, surgical intervention is indicated. We present a unique case of surgical management of an intentionally ingested vape device that was chronically impacted within the duodenum of an adult male present for six weeks before intervention without associated perforation. The foreign object was removed via exploratory laparotomy with duodenotomy and primary duodenorrhaphy with an uncomplicated postoperative course. There are only two previously reported cases of an ingested vape device. One was managed by observation, and the other was removed endoscopically. There are no previously reported cases of an ingested vape device that required surgical management.

Jean Baptiste Lucien Baudens: The father of trauma laparotomy.

Jean Baptiste Lucien Baudens (1804-1857) was a French military surgeon. He served in numerous military conflicts throughout his career. Baudens was an innovator and a leader. Going against traditional dogma, he was the first to attempt laparotomy in the setting of trauma. Although the first patient died, his second survived without further complication. Despite this historical landmark, little is known or written about him within the English literature. Jean Baptiste Lucien Baudens was a pioneer of surgery and the father of trauma laparotomy. He was a passionate educator and dedicated to the training of future surgeons. His contributions to the field of surgery deserve recognition and appreciation.

Jean Baptiste Lucien Bauden's Clinique des Plaies D'Armes a Feu: The First English Translation of the First Trauma Laparotomy.

Historically, abdominal trauma was managed nonoperatively with rest and local wound cares. Jean Baptiste Lucien Baudens (1804-1857) was a French military surgeon and performed the first 2 trauma laparotomies. The first patient died but the second survived. Laparotomy in trauma has since evolved, now a life-saving intervention and a fundamental tool in the management of abdominal trauma. Baudens documented these case reports in his 1836 work Clinical Reports of Gun Wounds (Clinique des Plaies D'Armes a Feu). The work of Baudens has been largely unrecognized and underappreciated in the English literature. This manuscript serves as the first translation of this event.

[2022 scientific breakthroughs in ambulatory general internal medicine]. / Avancées scientifiques de 2022 en médecine interne générale ambulatoire.

In patients aged 65 or older, the risk of dementia decreases with cataract surgery. Mental stress doubles the risk of a cardiac event in patients with stable coronary artery disease. The one-legged stance performance estimates total mortality in patients 50 years or older. Patients with chronic pain benefit from treatment with dronabinol or nabiximols. Salt substitutes are an alternative to regular salt in hypertensive patients aged 60 years or more. The promotion of physical activity in the office is effective in reducing sedentary behavior. Music has a favorable impact on the mental dimensions of quality of life. Colonoscopies performed on patients aged 75 years or more have a higher risk of non-gastrointestinal complications than gastrointestinal complications.

Chez les patients de 65 ans ou plus, le risque de démence diminue après une chirurgie de la cataracte. Le stress mental double le risque d'événements cardiaques chez des patients avec une coronaropathie stable. La station monopodale effectuée au cabinet permet d'estimer la mortalité totale chez les patients de 50 ans ou plus. Ceux souffrant de douleurs chroniques bénéficient d'un traitement par dronabinol ou nabiximols. Les substituts de sel sont une alternative au sel ordinaire chez les hypertendus de 60 ans ou plus. La promotion de l'activité physique au cabinet est efficace dans la diminution de la sédentarité. La musique a un impact favorable sur les dimensions mentales de la qualité de vie. Les coloscopies effectuées chez les patients de 75 ans ou plus présentent un risque supérieur de complications non gastro-intestinales comparativement à celles gastro-intestinales.

Modern Didactic Formats in Surgery: A Systematic Review.

Introduction: "Traditional teaching" models often fail to engage millennial residents. Multiple modern didactic methods have been employed. The most frequently used objective measure to assess the effectiveness of didactic formats has been American Board of Surgery In-Training Examination performance.Methods: A literature search was conducted searching PubMed, EMBASE, and JAMA Network from June 2011 to June 2021, in accordance with the PRISMA guidelines. Searches were performed for the terms "ABSITE" and "American Board of Surgery In-Training Examination." Only studies discussing didactic structures were included.Results: A final 16 studies were included. Modern methods such as a "flipped classroom," Team Based Learning (TBL), and "gamification" have all shown increased engagement and significantly improved ABSITE performance. Structured biostatistics reviews may be used to supplement research and statistics which are often missed by other resources.Discussion: Programs have a duty to promote excellent resident education. In addition to fostering individual study habits, didactics and program structures should be optimized for resident development. As opposed to focusing on the pure amount of scheduled protected time, programs may instead consider focusing on the quality of the didactic format used and modern didactic methods may be beneficial.

[COVID-19 screening strategy in workplaces in the canton of Vaud: what lessons?] / Stratégie de dépistage du Covid-19 dans les entreprises vaudoises : quels enseignements ?

Repetitive screening in enterprises was one of the measures recommended in Switzerland in the fight against COVID-19. In the canton of Vaud, 70 companies participated in the program, 73 % of which were small and medium-sized enterprises. The SARS-CoV-2 positivity rate was 0.07 % out of 70'105 tests performed. The impossibility of teleworking and the reduction of transmission were the main motivations for joining the program. The facilitating elements were the availability of the Cantonal Medical Office, the existence of a starter kit and the support of the hierarchy within the companies. The main obstacles were the arrival of vaccination, the multiplicity of screening providers and the workload. The program was a pragmatic action tool for companies rather than a population-based strategy.

Le dépistage en entreprise était une des mesures de lutte contre l'épidémie de Covid-19 promues par la Confédération. Dans le canton de Vaud, 70 entreprises ont participé au programme, dont 73 % de petites et moyennes entreprises. Le taux de positivité au SARS-CoV-2 a été de 0,07 % sur 70 105 tests réalisés. L'impossibilité du télétravail et la réduction de la transmission ont été les principales motivations d'adhésion. Les éléments facilitateurs ont été la disponibilité de l'Office du médecin cantonal, l'existence d'un starter kit et le soutien de la hiérarchie au sein des entreprises. Les freins principaux ont été l'arrivée de la vaccination, la multiplicité des prestataires de dépistage et la charge de travail. Le programme a représenté un outil d'action pragmatique pour les entreprises plutôt qu'une stratégie à visée populationnelle.

Recurrent Idiopathic Spontaneous Pneumoperitoneum: A Case Report.

The most common cause of pneumoperitoneum is perforated hollow viscus, which generally necessitates emergent surgical intervention. Idiopathic spontaneous pneumoperitoneum (ISP) is a rare condition less commonly described. This report outlines the case of a 79-year-old male with recurrent idiopathic spontaneous pneumoperitoneum managed by repeated laparotomy. Knowledge of this rare phenomenon and appropriate workup may allow for the avoidance of unnecessary laparotomies. Despite this, definitively ruling out perforated hollow viscus is difficult outside of the operating room, and many patients will ultimately be taken for surgical exploration and definitive diagnosis.

SUNBURN: a protocol for delivering bad news in trauma and acute care surgery.

INTRODUCTION: The delivery of bad news can be one of the most challenging tasks in surgery. There are numerous barriers specific to trauma and acute care surgery (TRACS) that make these conversations more difficult. Prior protocols have all been designed for oncology and primary care with poorer application to TRACS. The lack of guidance for leading these conversations in TRACS led us to develop the SUNBURN protocol. It draws elements from prior protocols and discards the irrelevant aspects and pays particular attention to the TRACS-specific concerns. SUNBURN PROTOCOL: Step 1: S-Set Up; Step 2: U-Understand Perceptions; Step 3: N-Notify ('Warning Shot'); Step 4: B-Brief Narrative and Break Bad News; Step 5: U-Understand Emotions; Step 6: R-Respond; Step 7: N-Next Steps. CONCLUSION: This protocol can provide a framework to help guide and ease the delivery of bad news in TRACS.

The History of Hemorrhagic Shock and Damage Control Resuscitation.

The understanding and management of hemorrhagic shock have evolved significantly over the last 400 years. Injured patients in shock mandate immediate surgeon involvement. Every graduating surgical resident and every surgeon taking trauma call should thoroughly understand the concepts of damage control resuscitation and be prepared to care for these patients. This review seeks to revisit the history of hemorrhagic shock and the evolution of damage control resuscitation.

How to Prepare for the American Board of Surgery In-Training Examination (ABSITE): A Systematic Review.

INTRODUCTION: Performance on ABSITE is an important factor when monitoring resident progress. It predicts future performance and has lasting effects. Understanding the highest-yield preparation strategies can help residents in their study efforts and optimize performance. METHODS: A literature search was conducted searching PubMed, EMBASE and JAMA Network in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were performed for the terms "ABSITE" and "American Board of Surgery In-Training Examination". Only studies discussing individual study habits from May 2011 to May 2021 were included. RESULTS: 19 studies were included in qualitative synthesis. Year-round clinical study failed to show significant correlation to ABSITE performance although year-round ABSITE review was more consistently correlated. During a dedicated study period, increased time and increased total practice questions completed are associated with improved performance. The correlation of individual resources such as ABSITE review books, textbooks, audio podcasts and ABSITE preparatory courses to improved ABSITE performance was not proven. CONCLUSIONS: Residents should optimize study strategies based on methods that have consistently shown to improve performance. Recommendations for best preparation strategies are provided.

Prospective Factors that Predict American Board of Surgery In-Training Examination Performance: A Systematic Review.

INTRODUCTION: American Board of Surgery In-Training Examination (ABSITE) performance has become an important factor when monitoring resident progress. Understanding which prospective factors predict performance can help identify residents at risk. METHODS: A literature search was conducted searching PubMed, EMBASE, and JAMA Network from June 2011 to June 2021, in accordance with the PRISMA guidelines. Searches were performed for the terms "ABSITE" and "American Board of Surgery In-Training Examination." Prospective factors such as prior examination performance, clinical evaluations, and demographics were evaluated. RESULTS: A final 35 studies were included. The prospective factor most consistently found to predict ABSITE performance is performance on prior knowledge-based examinations such as the USMLE step exams. The ACGME Medical Knowledge 1 milestone evaluation also appears to correlate to ABSITE performance, although clinical evaluations, in general, do not. Demographics have no significant correlation to ABSITE performance. DISCUSSION: Using performance on prior knowledge-based examinations programs may be able to identify residents at risk for failing ABSITE. It may be possible to initiate early intervention before rather than only remediation after poor performance.

Clostridioides difficile Enteritis Induced Anastomotic Rupture: A Case Report and Literature Review.

Background. A 76-year-old male patient who suffered small bowel anastomotic dehiscence believed to be a complication provoked by Clostridioides difficile enteritis. Case Presentation. The patient was a 76-year-old male who underwent small bowel resection with primary anastomosis for a small bowel obstruction. On postoperative day #7, he rapidly decompensated and upon return to the operating room was found to have complete anastomotic dehiscence with copious enteric spillage. The presentation appeared as if the staple line had burst open. Enteric contents confirmed the diagnosis of Clostridioides difficile enteritis. Subsequent hospital course was complicated by ventilatory-dependent respiratory failure, hemodynamic instability, and persistent anemia secondary to gastric ulcer requiring endoscopic cauterization. After a prolonged hospital course, he eventually progressed and was transferred to a skilled nursing facility on hospital day #42. Discussion. Clostridioides difficile causes inflammation and copious large volume secretions that would theoretically increase intraluminal pressures creating an internal tension. This tension along with other factors from the infection itself would likely be inhibitory of anastomotic healing. Although it is rare, Clostridioides difficile enteritis is being reported with increasing frequency, and in the setting of recent small bowel anastomosis, it should be considered a possible risk factor for anastomotic leak.