Overnight In-House Critical Care Resource Intensivist Improves General Surgery Resident Education.

24/7 critical care staffing has become more commonplace, and their impact on resident training must be carefully considered. At our institution, the Critical Care Resource Intensivist (CCRI) model was implemented to provide in-house dedicated faculty responsible solely for the provision of critical care overnight. An anonymous survey was distributed to all general surgery residents to evaluate CCRI's impact on education and autonomy. Descriptive statistics were completed for quantitative data. Qualitative analysis of free text responses was completed to identify consensus themes. Responses from 26 residents demonstrated they associated CCRI with improved resident education, supervision, and patient care, without limiting autonomy. Qualitative analysis yielded 7 themes, reflecting improvements in patient care and safety, progression of care, operations and procedures, improved education, availability, and independence, but noted potential for conflict. Our findings show 24/7 dedicated intensivist staffing can enhance general surgery resident education without limiting autonomy.

An evaluation of survive and thrive: a 10-week group psychoeducational course for adult interpersonal trauma survivors in Scotland.

Emerging evidence supports a phased approach to trauma treatment, including manualised group-based interventions, to facilitate symptom reduction resulting from complex trauma sequelae. This study investigates the efficacy of Survive and Thrive, a 10-week group psychoeducational course for adult survivors of interpersonal trauma. Between August 2019 and February 2022, participants were enrolled on the course. The Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) and Difficulties in Emotion Regulation Scale-Short Form (DERS-SF) were administered pre-intervention and immediately post-intervention. In addition, thematic analysis was applied to qualitative feedback. Results revealed significant reductions in CORE-OM and DERS-SF scores post-intervention, with minimal variability in scores attributed to group delivery (either face-to-face or online). The thematic analysis demonstrated that normalising trauma symptoms and providing coping skills positively impacted participants' experiences. At the same time, the breadth and nature of the content were observed to be an occasional barrier to engagement. In summary, this study proposes that group-based psychoeducational interventions are generally effective for those with mild-to-moderate symptoms of complex trauma. However, further evidence is needed to offer more nuanced recommendations for identifying individuals who may benefit the most from these interventions.

Optimization of Care for the Elderly Surgical Emergency Patient.

Geriatric patients undergoing emergency surgery are at significantly higher risk for complications and death when compared with younger patients. Optimizing care for these patients requires a multidisciplinary team, special attention to physiologic changes and medication use, as well as targeted intervention to mitigate complications such as delirium, which can worsen overall outcomes. Frailty can be assessed preoperatively to identify patients at the highest risk for complications. Shared decision-making with both the family and patient during the consent process is integral to defining patient's goals of care in these high-risk situations.

A review of general surgery resident experience in common bile duct exploration in the ERCP era.

BACKGROUND: Use of minimally invasive techniques for management of common bile duct (CBD) stones has led to declining number of CBD explorations (CBDE) performed at teaching and non-teaching institutions. We evaluate the impact of this decline on surgery training in bile duct procedures. STUDY DESIGN: National operative data for general surgery residents (GSR) were examined from 2000 to 2018. Biliary operations including, cholecystectomy open and laparoscopic, and CBDE open and laparoscopic were evaluated for mean number of cases per graduating GSR. RESULTS: Despite increases in number of GSR, case numbers for laparoscopic cholecystectomy increased 39% from 84 to 117, p < .00001, per GSR. Mean number of cases for open CBDE, however, decreased 74% from 2.7 to 0.7, p < .00001, per GSR and laparoscopic CBDE declined 22% from 0.9 to 0.7 per resident. CONCLUSION: GSR operative case volume in CBDE has declined significantly creating a training deficiency for this complex skill. Novel simulation, including fresh cadavers, may offer the best option with high-fidelity, dynamic training to mitigate the loss of low volume, high acuity procedures.

The gender affirmative lifespan approach (GALA): A framework for competent clinical care with nonbinary clients.

Background: The limited research on nonbinary individuals suggests that this community experiences significant health disparities. Compared to binary transgender individuals, research suggests that nonbinary individuals are at elevated risk for discrimination and negative mental health outcomes, including depression, anxiety, traumatic stress, and suicidality. Even mental health providers who work with binary transgender individuals often lack knowledge of and training to work competently with nonbinary individuals. Methods: The authors of this conceptual article present the Gender Affirmative Lifespan Approach (GALA), a psychotherapy framework based in health disparities theory and research, which asserts that therapeutic interventions combating internalized oppression have the potential to improve mental health symptomatology resulting in improved overall health and well-being for gender diverse clients. GALA's therapeutic interventions are designed to promote positive gender identity development through five core components: (1) building resiliency; (2) developing gender literacy; (3) moving beyond the binary; 4) promoting positive sexuality; and (5) facilitating empowering connections to medical interventions (if desired). Results: The core components of the GALA model are individualized to each client's unique needs, while taking into consideration age and acknowledging developmental shifts in, or fluidity of, gender across the lifespan. This model represents an inclusive, trans-affirmative approach to competent clinical care with nonbinary individuals. Discussion: Application of the GALA model with nonbinary clients is discussed, including one clinical case vignette.

Forced vital capacity less than 1: A mark for high-risk patients.

BACKGROUND: Rib fractures (RFx) continue to be a source of morbidity and mortality. A RFx care pathway has been used based on forced vital capacity (FVC). The objective of this study was to test the hypothesis that deterioration of FVC to less than 1 after admission is a marker for high-risk patients and affects outcomes. METHODS: A retrospective study of patients enrolled in an RFx care pathway at a Level 1 trauma center from 2009 to 2014. All patients had an admission FVC greater than 1. 2 groups were analyzed: patients with a lowest inpatient FVC less than 1 (Group A) compared to patients with lowest inpatient FVC of 1 or greater (Group B). Complications [pneumonia, upgrade to the intensive care unit, readmission, and intubation] and demographics were examined. Patients without documented admission FVCs were excluded. p < 0.05 was considered significant. RESULTS: A total of 1,106 patients were analyzed (Group A, 187; Group B, 919). Patients whose FVC dropped less than 1 (Group A) had a higher complication rate [15% (Group A) vs 3.2% (Group B); p < 0.001]. Rates of pneumonia, readmission, unplanned upgrade, and intubation were all significantly higher in Group A [pneumonia: 9% (Group A) vs 1.4% (Group B), p < 0.001; readmission: 4% (Group A) vs 1.7% (Group B), p = 0.04; upgrade; 3.7% (Group A) vs 0.2% (Group B), p < 0.001; intubation: 1.6% (Group A) vs 0.1% (Group B), p = 0.02]. Hospital length of stay was longer in Group A [10 days (Group A) vs 4 days (Group B), p < 0.001]. CONCLUSIONS: Forced vital capacity predicts complications in patients with RFx. Patients whose FVC falls less than 1 during admission are at high risk for pulmonary complications. Daily FVC testing for patients admitted with RFx can predict outcomes. Forced vital capacity less than 1 should be considered as a marker for complications. Once FVC drops less than 1, patients should be considered for increased interventions. Even if the patient has not yet clinically deteriorated, consideration for higher level of care is warranted. LEVEL OF EVIDENCE: Prognostic study, level III.

Clinical effectiveness of health visitor training in psychologically informed approaches for depression in postnatal women: pragmatic cluster randomised trial in primary care.

OBJECTIVE: To evaluate benefits for postnatal women of two psychologically informed interventions by health visitors. DESIGN: Prospective cluster trial randomised by general practice, with 18 month follow-up. SETTING: 101 general practices in Trent, England. PARTICIPANTS: 2749 women allocated to intervention, 1335 to control. INTERVENTION: Health visitors (n=89 63 clusters) were trained to identify depressive symptoms at six to eight weeks postnatally using the Edinburgh postnatal depression scale (EPDS) and clinical assessment and also trained in providing psychologically informed sessions based on cognitive behavioural or person centred principles for an hour a week for eight weeks. Health visitors in the control group (n=49 38 clusters) provided usual care. MAIN OUTCOME MEASURES: Score >or=12 on the Edinburgh postnatal depression scale at six months. Secondary outcomes were mean Edinburgh postnatal depression scale, clinical outcomes in routine evaluation-outcome measure (CORE-OM), state-trait anxiety inventory (STAI), SF-12, and parenting stress index short form (PSI-SF) scores at six, 12, 18 months. RESULTS: 4084 eligible women consented and 595 women had a six week EPDS score >or=12. Of these, 418 had EPDS scores available at six weeks and six months. At six months, 34% women (93/271) in the intervention group and 46% (67/147) in the control group had an EPDS score >or=12. The odds ratio for score >or=12 at six months was 0.62 (95% confidence interval 0.40 to 0.97, P=0.036) for women in the intervention group compared with women in the control group. After adjustment for covariates, the odds ratio was 0.60 (0.38 to 0.95, P=0.028). At six months, 12.4% (234/1880) of all women in the intervention group and 16.7% (166/995) of all women in the control group had scores >or=12 (0.67, 0.51 to 0.87, P=0.003). Benefit for women in the intervention group with a six week EPDS score >or=12 and for all women was maintained at 12 months postnatally. There was no differential benefit for either psychological approach over the other. CONCLUSION: Training health visitors to assess women, identify symptoms of postnatal depression, and deliver psychologically informed sessions was clinically effective at six and 12 months postnatally compared with usual care. TRIAL REGISTRATION: ISRCTN92195776.