Establishing a Rural General Surgery Residency Program: Identifying Community Stakeholder Perception and Obstacles of a de Novo Residency in Rural Appalachia.

BACKGROUND: Rural healthcare has become more challenging over the past several years with increasingly limited access to surgical care in the rural setting. The Accreditation Council for Graduate Medical Education (ACGME) has recently introduced the Rural Track Program (RTP) initiative to combat physician shortage in rural areas. We intend to start the first Rural General Surgery Residency program under the RTP designation in rural Appalachia. STUDY DESIGN: 430 community stakeholders were surveyed regarding the anticipated impact of a new training program. Questions focused on the understanding of a Residency Program, the care provided by residents, impact on availability of local care, current geographical limitation of surgical care, and potential benefits/obstacles of the training program. RESULTS: Over 90% of all surveyed approved of training surgeons locally, with the local government believing that the program would be a good investment for the community. Several locals had been treated by resident physicians at other facilities and the majority were satisfied with the care they received. Several families frequently travel to larger cities for surgical care, with 96% of all respondents believing that the program would provide better access to care locally. CONCLUSION: Our study demonstrated that the community is familiar with healthcare in a training facility and welcoming to a local training program, while believing that trainees will have a positive impact on local surgical care in rural Appalachia. We will continue to work with the local community and healthcare personnel while developing the program and tailor our Residency to the rural setting as able.

Gallstone Ileus: A Case Report in a 74-Year-Old Male.

Gallstone ileus is a rare complication of complicated gallbladder disease. Typically the result of a cholecystocholeduodenal fistula, a gallstone enters the small bowel and impacts in the ileum causing an obstruction. In this case study, a 74-year-old male presented to the emergency department with nausea, vomiting, and constipation for 2 weeks. CT revealed pneumobilia and a 3.1 cm calcified mass in the terminal ileum. The patient was successfully treated with a robotic-assisted enterotomy alone without complications.

Operative Rib Fixation at a Rural Trauma Center.

INTRODUCTION: Operative rib fixation is becoming more common in the management of rib fractures, with studies showing benefits of surgery in decreasing time on mechanical ventilation, ICU and total hospital length of stay, and mortality. This paper will review the data from our institution to determine if these benefits were seen in our trauma population. METHODS: A retrospective review of the institution's trauma database was conducted, including operative patients (n = 36), control patients (nonoperative patients from October 2018 to October 2019, n = 207), and selected control patients based on similar injury severity score range as operative patients (n = 181). Data reviewed included time on mechanical ventilation, ICU and total hospital length of stay, and disposition at discharge, including mortalities. Operative complications were also reviewed. RESULTS: The operative group had a higher ISS compared to both controls, longer average time on mechanical ventilation, longer average ICU and total hospital length of stay, and a higher percentage of patients discharged to inpatient facilities. However, the operative group had lower mortality compared to the control groups. The operative group had 3 surgical site infections requiring readmission and hardware removal. DISCUSSION: Unlike other studies, our operative patients did not see improvements in time on mechanical ventilation, ICU and total hospital length of stay, or disposition at discharge, but did see a mortality benefit. Confounding factors include higher average ISS in the operative group, and over-sedation in the ICU. Data collection is ongoing, and refinements are being made to perioperative and ICU management to minimize these confounding variables.

The Importance of the Institution of a Robotic Curriculum on Resident Training and Performance.

In 2018, general surgery topped the number of robotic cases. Over 90% of residents participate, but only 65% of programs have a formal curriculum, and less than half track progress. Many are insufficient at training due to an observational role. This paper reviews Marshall University General Surgery Residency program's robotic curriculum, which started in 2018. The curriculum consists of a weekend course and simulations, enabling residents obtain certification. Residents participated in Intuitive's Resident Robotic Olympics with first place in 2019 and second and third place in 2020. For the 2021 year, the robotic curriculum was revised into phases based on year. Deadlines and forms help improve and track progress. It is important to develop a curriculum with a protocol for training, monitoring, and credentialing to ensure proficiency. Marshall University General Surgery robotic curriculum has been successful at improving robotic skill, enabling residents to obtain a robotic surgery certification upon graduation.

The Effect of Substance Abuse Programs on Positive Drug Screening Tests in Trauma Patients.

BACKGROUND: According to the National Institute on Drug Abuse, West Virginia has the highest age-adjusted rate of drug overdose deaths involving opioids. To combat this crisis, comprehensive drug counseling support services were established within the Cabell Huntington Hospital (CHH) system in October 2018 in Huntington, WV, USA. The purpose of this study was to investigate whether these services significantly reduced the number of trauma patients with a positive urine drug screen (UDS) seen at CHH. METHODS: The trauma registry at CHH was used to obtain data on trauma patients with positive UDS from January 2017 to October 2019, which was divided into groups before and after October 2018. Exclusion criteria were any patients who were prescribed the drug. The percentages of the total number of positive drug screens within each group were calculated, and a t-test analysis was performed to determine the P values. RESULTS: 345 trauma patients with positive UDS were selected. Results showed that there was an overall decrease in the rate of nonprescribed use after October 2018 of benzodiazepines (18.1%-11.5%), cocaine (19.5%-15.3%), opioids (19.1%-12.3%), and oxycodone (10.2%-4.6%). However, none of these changes were statistically significant. There was an increase in the rate of nonprescribed use of amphetamine (20.0%-23.8%) and methamphetamine (14.4%-33.8%). DISCUSSION: Our hypothesis is that the support systems are relatively new, and may need more time to identify and intervene on patients before a statistically significant effect on drug abuse rates in our region can be seen.

Laparoscopic vertical sleeve gastrectomy: A 5-year veterans affairs review.

The aim of this study was to evaluate the outcomes after laparoscopic sleeve gastrectomy (SG) in a VA population.SG has recently gained popularity as a definitive bariatric surgery procedure. Data are lacking on long-term outcomes, particularly in a Veterans Affairs population.We retrospectively reviewed 223 patients who underwent SG for morbid obesity between January 2009 and June 2014. Data on length of stay, complications, interval weight loss, comorbidities, and number of therapies preoperatively and at long-term follow-up were collected.There were 164 males and 59 females who underwent SG. The mean body mass index was 45.4 kg/m. Mean excess weight loss at 1 year was 62.9%, and 47.0% at 5 years. Weight loss continued until 12 to 18 months, when there was a nadir in weight loss (P < .001). There were 4 deaths and 4 staple-line leaks, with 3 deaths related to late cardiac events. One early death occurred in a very high-risk patient. All staple-line leaks were managed nonoperatively. Of the 223 patients, 193 had hypertension, 137 diabetes, 158 hyperlipidemia, 119 obstructive sleep apnea (OSA), and 125 had gastroesophageal reflux disease. Preoperatively, patients were on a mean of 1.9 antihypertensive and 0.9 hyperlipidemic, anti-reflux and oral hypoglycemic agents. Fifty percent of patients with diabetes were on insulin and 68% with OSA used continuous positive airway pressure/bilevel positive airway pressure (CPAP/BiPAP). We found significant absolute reductions in mean antihypertensive medications (-0.8), hyperlipidemic agents (-0.4), antireflux agents (-0.4), oral hypoglycemics (-0.6), insulin use (-25%), and use of CPAP/BiPAP (-55%) (all P < .001).Laparoscopic sleeve gastrectomy is a safe and effective bariatric surgery procedure, resulting in significant early weight loss up to 18 months and long-term improvement in all major obesity-related comorbid conditions.

Knowledge of medical professionalism in medical students and physicians at Shahid Beheshti University of Medical Sciences and affiliated hospitals-Iran.

Although medical professionalism is a fundamental aspect of competence in medicine and a distinct facet of physicians' competence, evidence suggests that the subject of professionalism is not taught or assessed as part of medical students' curricula in Iran and many other countries. Assessing the knowledge of medical students and physicians about medical professionalism seems to be helpful in identifying the weaknesses of training in the field of professionalism and devise plans for future training on the subject.The present cross-sectional, quantitative, observational, and prevalence study recruited 149 medical interns, clinical residents, physicians, and professors working in hospitals selected through stratified random sampling using a questionnaire designed by the researchers and confirmed for its validity and reliability. The results were analyzed by Stata at a significance level of 0.05.Out of 149 cases, 61.64% were male with the mean age of 30.81 years. A total of 66 participants (44.29%) (95% confidence interval [CI]: 36.44%-52.44%) had heard and 83 (55.70%) (95% CI: 47.55%-63.55%) had not heard the term "medical professionalism" before the study. After adjusting for potential confounders, age and degree did not have statistically significant difference in assessed knowledge of medical professionalism, but sex had (mean difference: 5.88, P = 0.045), and the mean of the female was significantly higher than that of the male participants. The mean percentage of correct answers was 47.67.The present study demonstrated that the medical professionals working in the national healthcare system have an unfavorable theoretical knowledge about medical professionalism in Iran; although this does not indicate that their practices are unethical, it should be noted that one of the prerequisites of possessing a high level of medical professionalism and for establishing a proper relationship between the medical community and the patients is to have a proper knowledge of this concept. Improving behaviors and performances in medical professions requires adequate training on the concepts of medical professionalism and consequently the assessment of the levels of professionalism achieved in medical professionals.

Malignant mucosal melanoma of the paranasal sinuses: Two case presentations.

Primary mucosal melanoma of the paranasal sinuses is a rare tumor of the head and neck which can be a devastating disease. Cancers arising in the sinonasal cavity are extremely rare, with a poor survival rate. There is inherent difficulty in diagnosing these lesions due to their complex anatomic locations and symptoms which are often confused with more common benign processes. The primary treatment of this rare disease process is resection, except in advanced stages where surgical resection is not an option. Diagnostic accuracy in consideration of size, location, and presence of metastatic disease of these malignant tumors tailors individual patients to different management in order to achieve the longest possible survival.