New Trends at 25 Years: An American Board of Surgery Academic Certifying Examination Review Course.

BACKGROUND: In the 1980s, a small research group began identifying variables affecting applicant success on the American Board of Surgery (ABS) Certifying Examination (CE). We now report success and trends as we complete 25 years. We had multiple challenges as identified through faculty focus groups and participant feedback that needed to be addressed: increase the national optics of the program, integrate new innovative experiences, maintain the integrity of the collected data on excel files, incorporate national trends in surgery, attract experienced clinical volunteer faculty and staff, security of capital, and schedule management. METHOD: The primary purpose of the program is to define the root cause interfering with success on the ABS CE. All of the listed changes in course design (2012-2016) were entered into excel files along with participants demographics, including results of the pretesting modules, the communication inventory, all self-reported stressors, and interview results to track the effect of faculty interventions, trends and ABS outcomes. RESULTS: The profiles of the participants have changed over time, including: marital status, presence of DSM-5 stressors, gender, fellowship training, study habits, financial burdens, and international graduate status. International graduates demonstrated communication issues that were present, though rarely addressed, during residency training. The gradual absorption of junior faculty allowed a seamless transition over time as part of the succession plan. Although the national success rates on the CE were 72% to 80%, this program's success rate still remained in the 90 percentile (94%-97%) for those who followed their education improvement plan. Deidentified excel files will be converted to REDCap for preservation and analysis. DISCUSSION: The small course design has continued to be effective at identifying variables that interfere with success on the CE examination. The inclusion of additional PhD education scientists facilitated focused individual interventions. A pilot program for international graduate status residents is in development.

Evolution in the management of the complex liver injury at a Level I trauma center.

BACKGROUND: Management of the severe liver injury evolved from mandatory surgical repair to a more selective approach. This paper reviews the changes in management of the severe liver injury at a Level I trauma center. METHODS: We reviewed the records of patients with severe liver injury admitted to a Level I trauma center between January 1984 and December 1995. The patients were divided into two groups, G1 and G2, based on their date of admission before or after January 1991. The two groups were compared for blood products use, management of the liver injury, and outcome. RESULTS: One hundred six patients were compared for age, sex, Acute Physiology and Chronic Health Evaluation II score, Injury Severity Score, abdominal Abbreviated Injury Scale score, and the presence of concomitant injuries. There was no difference in management or outcome of the victims of penetrating injury between G1 and G2 (n = 48). The blunt injury patients in G1 (n = 22) had more liver surgery (p = 0.006), blood transfusion (p = 0.040), intra-abdominal sepsis (6 vs. 0), and higher mortality (p = 0.041) than those in G2 (n = 36). CONCLUSION: Isolated severe blunt liver injury may be managed nonoperatively with better survival and less blood products use.

The efficacy of sequential compression devices in multiple trauma patients with severe head injury.

Thirty-two multiple trauma patients with severe head injury and a Glasgow Coma Scale (GCS) score of 8 or less were prospectively studied to assess the occurrence of deep venous thrombosis (DVT) and pulmonary embolism (PE). All patients required mechanical ventilation. A sequential compression device (SCD) was used in 14 patients and 18 patients received no prophylaxis for thromboembolism. Bilateral lower extremity technetium venoscans and ventilation/perfusion (V/Q) lung scans were performed within 6 days of admission and every week for 1 month or until the patient developed DVT or PE or was discharged from the SICU. Deep venous thrombosis occurred in two patients (6%) at 16 and 28 days following trauma. Twenty-five patients had normal or low probability V/Q scans. Six had high probability V/Q scans confirmed by pulmonary arteriograms (PAGs) at 12.5 +/- 4 days. Clinical signs of PE were absent in all patients with a positive PAG. There were no differences in age, Injury Severity Score (ISS), GCS Score, APACHE II Score, or Trauma Score between the patients who developed DVT or PE and those who did not. A SCD was used in four of the eight patients with DVT or PE. All but one patient with DVT or PE underwent placement of a vena caval filter. Multiple trauma patients with severe head injury (GCS score < or = 8) are at high risk for thromboembolism. The available means of prevention and diagnosis of DVT or PE in multiple trauma patients with severe head injury are not entirely effective.

Survival determinants in patients undergoing emergency room thoracotomy for penetrating chest injury.

Survival determinants were examined in patients undergoing ERT-PCI who were admitted to the Surgical Intensive Care Unit (SICU) between January 1, 1982 and August 1, 1991. Twenty-one of 290 patients undergoing ERT-PCI (aged 14-36 years) were admitted to the SICU. Of the 21, nine survived to discharge with normal neurologic function. Four survived with neurologic impairment. Eight expired 1 to 12 days after admission. The ERT was done immediately upon hospital arrival or subsequently in the Emergency Department for impending arrest despite resuscitation. All survivors had a pulse or blood pressure either in the field or upon arrival in the ER. Seven of nine who survived neurologically intact were awake on arrival in the ER, the other two were moving their extremities. One of four who survived with neurologic impairment was awake on arrival; three were comatose. Five of the eight who died were in full arrest in the field and upon arrival in the ER. Two of these patients were brain dead shortly after SICU arrival. All survivors had vital signs either in the field or on ER arrival. Patients with penetrating chest wounds without vital signs in the field who do not recover vital signs by hospital arrival do not benefit from emergency room thoracotomy. Evidence of mentation in the field or on arrival may predict ultimate neurologic outcome of survivors.

The clinical significance of myocardial contusion.

In an attempt to identify a group of blunt trauma victims with asymptomatic myocardial contusion (MC) who do not benefit from intensive cardiac monitoring, we prospectively divided 336 patients admitted to the SICU with possible MC following blunt trauma in the 6 years prior to January 1990 into three groups: Group 1 (n = 155, age 30.5 +/- 9 years) consisted of those patients admitted for mechanism of injury, J-point elevation, with or without minor chest injury. None developed arrhythmias. Their SICU length of stay (LOS) was 2.41 +/- 0.77 days. Group 2 (n = 43, age 31.5 +/- 10 years) patients had the same admission criteria as the patients in group 1 plus an abnormal emergency department ECG, i.e., arrhythmia, heart block, ischemia. None had cardiac complications. Their SICU LOS was 2.47 +/- 0.94 days. Group 3 (n = 138, age 40 +/- 20 years) patients had four or more rib fxs, a pulmonary contusion, a flail chest, or extra-thoracic injuries or were greater than 60 years of age. All required SICU admission for their non-cardiac injuries. Nineteen patients had cardiac complications requiring treatment. None had a cardiac death. Their SICU LOS was 10 +/- 22 days. We conclude that young patients with minor blunt thoracic trauma and a normal or minimally abnormal ECG do not benefit from cardiac monitoring.

Traumatic hemoperitoneum due to a Meckel's mesodiverticular band: case report.

The blood supply to a Meckel's diverticulum exists either within the small bowel mesentery, or within a separate mesodiverticular band. The latter is associated with bowel obstruction. It is a rare source of hemorrhage. The case report describes hemoperitoneum resulting from blunt trauma-induced disruption of a mesodiverticular band.

Right ventricular tardokinesis in cardiac contusion: a new observation on phase images.

The usefulness of gated blood pool (GBP) scintigraphy in evaluating cardiac contusion among trauma patients was examined. In ten of 62 patients who sustained blunt chest trauma, phase images of GBP studies demonstrated delayed onset of right ventricular (RV) contractions (RV tardokinesis). Clinical charts of these ten patients were reviewed to determine the significance of this finding. Only one had no supportive evidence of cardiac injury. Four patients were determined to have clinically significant cardiac contusion on the basis of the occurrence of arrhythmias of cardiac failure during their hospital course. These patients had ventricular histogram widths greater than 30 degrees of the entire cardiac cycle at half maximum height and had a bifid peak in their ventricular contraction histograms. Of the 52 patients who did not have RV tardokinesis, only one had a clinically significant cardiac contusion, resulting in a false-negative rate of 2% for the test. This new observation of RV tardokinesis may be clinically useful in establishing the difficult diagnosis of cardiac contusion.

Clinical characteristics of nosocomial sinusitis.

Paranasal sinusitis is an important source of sepsis and morbidity in head injury victims and requires aggressive pursuit and therapy. Of 208 head-injured patients, 24 developed paranasal sinusitis. The Glasgow Coma Scale score of the sinusitis patients was 7.1 +/- 3.9. Nineteen patients were intubated nasotracheally, and five were intubated orally. Sinus air fluid levels, indicative of bleeding into the sinus, were seen on 17 initial computed tomographic scans. Maxillary sinus suppuration occurred in 23 patients; in 20 it was the initial sinus involved. Twenty-one patients developed polymicrobial sinusitis. Coexisting infections were common. In 15 patients with concurrent tracheobronchitis or pneumonia, organisms identical to those in sinus aspirations were recovered from the sputum. Seven patients had associated bacteremia. Meningitis in six patients shared a common pathogen with their sinusitis. Nonoperative management successfully resolved sinus infection in 19 cases. Five patients required open sinusotomy.

Transvaginal injury of the duodenum, diaphragm, and lung.

An unusual case of transvaginal impalement is presented. At initial exploration the broad ligament and vagina were repaired. When bile drained from suction catheters reexploration revealed an injury to the duodenum and diaphragm. Wounds that penetrate the vagina may injure nonpelvic viscera. Vaginal penetrating wounds should be managed like other abdominal penetrating injuries.

Acute paranasal sinusitis related to nasotracheal intubation of head-injured patients.

One hundred eleven head-injured patients were examined for paranasal sinusitis during early convalescence. Glascow coma scale (GCS) was less than 8 in 79 patients. Ninety-three patients had sustained blunt injuries, and 18 had penetrating ones. Sixty-five orotracheal intubations (OTI) and 31 nasotracheal intubations (NTI) were performed at the scene or on hospital arrival. Fifteen patients were not tracheally intubated. Paranasal sinus air fluid levels (AFL) were present in 30 patients on their admitting computerized tomography scans. Paranasal sinusitis developed in 19 patients with a mean GCS of 5.4 +/- 3.3 (SD). Sixteen of the 19 had NTI, and three had OTI (p less than .05). Of 30 patients with AFL, sinusitis occurred in 13. Ten of these 13 had NTI, and three had OTI (p less than .05). Penetrating injury did not increase the risk of sinusitis (p greater than .1). Seventeen of the 19 infections were polymicrobial. Sinusitis after head trauma is related to NTI, AFL, and severity of head injury.

Prognosis and survival as determined by visceral amino acid clearance in severe trauma.

Sepsis, the commonest cause of late death following severe trauma, is related in part to inadequate uptake of amino acids (AA) and synthesis by the liver and other central tissues of proteins essential to immunological defense. Since 'central plasma clearance rate' of amino acids (CPCR-AA) has been found to reflect these functions, serial measurements of CPCR-AA were made in 32 seriously injured patients of whom ten died (31%), nine of sepsis. The mean Index Severity Score on admission for survivors was 31 +/- 1.8 and in deaths 34 +/- 3.9 (N.S.). The blood plasma AA concentrations were not significantly different. However, early in the course before the onset of infection, CPCR-AA in surviving patients was 227 +/- 30 and in those who ultimately died 83 +/- 24 ml/M2/min (p less than 0.001). Later during sepsis the values of CPCR-AA were 176 +/- 28 and 85 +/- 14 ml/M2/min, respectively (p less than 0.01). Thus CPCR-AA appears to be of value as an indicator of amino acid utilization by central tissues and as a predictor of survival or death following severe trauma.

Naloxone versus placebo in treatment of septic shock.

Treatment of septic shock with naloxone was evaluated in a prospective, randomised, double-blind, placebo-controlled study in which ten episodes of shock were treated with naloxone (0.4 to 1.2 mg intravenously) and 13 with the vehicle for injection. Treatment groups were similar in terms of demographic characteristics, type of primary infection, prevalence of septicaemia, type of underlying disease, duration in shock, and vasopressor therapy. Mean systolic blood pressure rose by 13.3% in the naloxone group and 11.3% in the placebo group. Two-way analysis of variance for repeated measures of blood pressure, obtained over 30 min periods before and after treatment, revealed no significant difference (p greater than 0.10) between treatment groups. Survival rates in the two groups at 48 h and 7 days after the start of treatment were similar. Naloxone, 0.4 to 1.2 mg intravenously, was no better than placebo in ameliorating hypotension in septic shock.

The clinical consequences of an industrial aerosol plant explosion.

The factors relating to the clinical outcome of an industrial aerosol plant explosion are reviewed. Eighteen of 24 workers inside the plant required hospitalization and five died. Proximity to the blast was associated with extensive injuries unless workers were shielded by physical barriers or partitions. Burn severity and mortality were increased in those wearing synthetic garments compared to their counterparts wearing fiber clothing. Facial burns occurred in all unprotected workers. Forearm and hand burns in 11 patients required decompressive escharotomies. Topical treatment with silver sulfadiazine was associated with more significant leukopenia and neutropenia than treatment with silver nitrate. We conclude that industrial design should include safeguards which isolate workers from flammable materials, including isolation of explosive materials from working areas, alarm systems to detect leakage of flammable agents, protective barriers and shields, and the regulation and institution of flame and flash-resistant clothing.

Prostaglandin mediation of unstable hemodynamics during lung perfusion.

Positive end-expiratory pressure (PEEP) leads to a fall in both mean arterial blood pressure (MAP) and cardiac output (CO). This study tests the hypothesis that humoral factors, particularly prostanoids, are important mediators of these events. A support dog was used for ex vivo perfusion of an isolated left lung lobe (LLL) at a fixed flow. In group I (n = 10) an isolated, isovolumetrically contracting dog heart was placed in circuit between the support dog and LLL. Indomethacin (5 mg/kg) was used to pretreat the support dogs and LLL donors of group II (n = 9); support dogs of group III (n = 5); and LLL donors of group IV (n = 4). This cyclooxygenase inhibitor was not used for groups I or V (n = 14). The last two groups were similar except that a heart was not included in the circuit of group V. In group V lobe perfusion during simple inspiratory mechanical ventilation led to decreases in support dog MAP from 141 +/- 3 to 118 +/- 15 mm Hg (P less than 0.01) and CO from 4.0 +/- 0.9 to 2.8 +/- 0.8 L/min (P less than 0.01). Application of PEEP further reduced MAP and CO (P less than 0.01). In the perfused isolated hearts of group I, Starling curves were shifted downward during PEEP at five of six left ventricular balloon volumes tested. In groups II and III MAP and CO were unchanged with mechanical ventilation or PEEP and were higher than groups I or V (P less than 0.05). Radioimmunoassay of the stable degradation products of prostacyclin and thromboxane (Tx) A2 demonstrated low concentrations of these prostanoids in support dogs of group III as compared with group V (P less than 0.05). Blocking the LLL donor dog (group IV) produced hemodynamic results and prostanoid concentrations intermediate between groups I and V. The results show that mechanical ventilation and PEEP can cause a circulating agent(s) to be released that results in a decline in MAP and CO. This is prevented with indomethacin.

Cardiopulmonary function following transfusion of three red blood cell products in elective abdominal aortic aneurysmectomy.

In order to evaluate the importance of red cell O(2) affinity of transfused blood on cardiac performance and adverse effects of transfusion on lung function, a prospective double-blind protocol was used in 27 patients undergoing abdominal aortic aneurysmectomy. Three types of blood were administered: packed red cells (PC), washed red cells (WC) and high 2,3 DPG red cells (2,3 DPG). An average of 4.5 units of blood was used per patient. Transfusion of 2,3 DPG blood resulted in maintenance of in vivo P(50) during surgery and an increase to 31.2 torr after operation (p < 0.001). An intraoperative fall in in vivo P(50) to 23.2 +/- 2.0 torr was observed in patients who were transfused with PC (p < 0.001) and to 25.1 +/- 2.6 torr with WC (p < 0.005). A fall in body temperature averaging 2.2 C intraoperatively was noticed in all three groups. After operation, in vitro P(50) decreased in patients transfused with PC (p < 0.005) and WC (p < 0.005) while it remained unchanged in the high 2,3 DPG group. This was consistent with the decrease of red cell 2,3 DPG in the PC (p < 0.001) and WC groups (p < 0.01) and maintenance in the 2,3 DPG group. Left ventricular stroke work and volume loading Starling type myocardial performance curves were similar for the three groups. Microaggregates measured by Coulter counting and screen filtration pressure were the same for all three products in samples drawn on both sides of the 40 microm transfusion filter. There was no relationship of transfusion volumes or type of blood product to changes in lung function (physiologic shunting, dynamic compliance and pulmonary arterial pressure) in the three groups of patients. The false negative, beta, error of missing a true 25% difference was less than 10%. It is concluded that 2,3 DPG enriched red cells improved oxygen availability, but that a 4.5 unit transfusion of any of the three blood products did not influence lung function or myocardial performance following aneurysmectomy.

Independence of renin production and hypertension in abdominal aortic aneurysmectomy.

Seventeen patients undergoing elective repair of abdominal aortic aneurysm were examined to determine the causal mechanism for postoperative hypertension. In nine patients who had elevated systemic pressure after surgery, there were no correlations between mean arterial pressure and values of peripheral renin activity or angiotensin II. Further, no relation was demonstrated between systemic pressure and the volumes of crystalloid, colloid infused or milliequivalents of sodium administered pre- and intraoperatively. Postoperative arterial pressure correlated best with the preoperative value.

Is respiratory failure a consequence of blood transfusion?

The pulmonary entrapment of microaggregates, platelets, and white cells in stored blood is thought to contribute to abnormalities in lung function. Washing of red cells removes these potentially damaging elements. This prospective, randomized, double-blind study compares the pulmonary function of patients undergoing abdominal aortic aneurysmectomy who received either washed or unwashed red cell concentrates. Both groups received equivalent volumes of blood, albumin, and balanced salt solution duing surgery. Postoperatively, no differences were observed in the physiologic shunt, QS/QT, pulmonary artery pressure, pulmonary vascular resistance, or effective dynamic compliance. The cardiac index at equivalent left ventricular filling pressures was the same. The results indicate that it is unlikely that microaggregates or other formed elements in stored blood lead to compromised pulmonary function.