Distractions during resident handoffs: incidence, sources, and influence on handoff quality and effectiveness.

IMPORTANCE: Handoffs have significantly increased in number following Accreditation Council for Graduate Medical Education (ACGME) work-hour restrictions. Studies have shown correlations between the number of handoffs and errors/patient harm. Distractions are common during handoffs and may interfere with handoff quality and effectiveness. OBJECTIVE: To examine the frequency of distractions and their impact on handoff quality. DESIGN, SETTING, AND PARTICIPANTS: In this prospective observational study, a total of 214 surgical resident handoffs (residents = 184; Bay area residents [moonlighters] = 30) were observed over 18 months (July 11, 2012-December 19, 2014) by 2 independent observers in 3 teaching hospitals (university, county, and veterans). MAIN OUTCOMES AND MEASURES: Handoff quality (both giver and receiver) was assessed using a standardized scoring system. The number and types of distractions were recorded. RESULTS: Pages were the most common distraction (37.5%), followed by telephone calls (32.8%), residents/medical students (9.3%), talking (5.2%), and noise (4.1%). Distractions from attending physicians, electronics, nursing, consults, and room changes were less common (collectively 11%, each <3%). Distractions were present in 102 resident handoffs (48%) (16% with 1 distraction; 15% with 2; 6% with 3, and 11% with ≥4). Distractions occurred in 54% of junior resident handoffs (mean, 1.4/handoff), 30% of moonlighter handoffs (mean, 0.5/handoff), and 38% of senior resident handoffs (mean, 0.89/handoff) (P = .01, junior vs moonlighter/senior). Distractions were more common during evening than morning handoffs (52% vs 36%; P = .045) and during team vs individual handoffs (58% vs 44%; P < .10). Handoffs without distractions were shorter in length (13.2 minutes without distractions vs 21.5 minutes with distractions; P < .001) and minutes per patient (1.78 without vs 2.15 with distractions; P = .04). Handoff quality was not diminished by distractions, as measured by handoff giver score (15.41 without vs 15.47 with distractions; P = .90) and receiver score (7.42 without vs 7.25 with distractions; P = .45). CONCLUSIONS AND RELEVANCE: To our knowledge, this is the largest study of distractions during surgical resident handoffs. Distractions were very common during handoffs; they were more common in the evening when junior residents more commonly performed the handoff and they increased the handoff length. However, distractions did not negatively affect the quality of resident handoffs. This may demonstrate the resilience of surgical residents to distractions.

Innovative approach using interprofessional simulation to educate surgical residents in technical and nontechnical skills in high-risk clinical scenarios.

IMPORTANCE: The Accreditation Council for Graduate Medical Education core competencies stress nontechnical skills that can be difficult to evaluate and teach to surgical residents. During emergencies, surgeons work in interprofessional teams and are required to perform certain procedures. To obtain proficiency in these skills, residents must be trained. OBJECTIVE: To educate surgical residents in leadership, teamwork, effective communication, and infrequently performed emergency surgical procedures with the use of interprofessional simulations. DESIGN, SETTING, AND PARTICIPANTS: SimMan 3GS was used to simulate high-risk clinical scenarios (15-20 minutes), followed by debriefings with real-time feedback (30 minutes). A modified Oxford Non-Technical Skills scale (score range, 1-4) was used to assess surgical resident performance during the first half of the academic year (July-December 2012) and the second half of the academic year (January-June 2013). Anonymous online surveys were used to solicit participant feedback. Simulations were conducted in the operating room, intensive care unit, emergency department, ward, and simulation center. A total of 43 surgical residents (postgraduate years [PGYs] 1 and 2) participated in interdisciplinary clinical scenarios, with other health care professionals (nursing, anesthesia, critical care, medicine, respiratory therapy, and pharmacy; mean number of nonsurgical participants/session: 4, range 0-9). Thirty seven surgical residents responded to the survey. EXPOSURES: Simulation of high-risk clinical scenarios: postoperative pulmonary embolus, pneumothorax, myocardial infarction, gastrointestinal bleeding, anaphylaxis with a difficult airway, and pulseless electrical activity arrest. MAIN OUTCOMES AND MEASURES: Evaluation of resident skills: communication, leadership, teamwork, problem solving, situation awareness, and confidence in performing emergency procedures (eg, cricothyroidotomy). RESULTS: A total of 31 of 35 (89%) of the residents responding found the sessions useful. Additionally, 28 of 33 (85%) reported improved confidence doing procedures and 29 of 37 (78%) reported knowing when the procedure should be applied. Oxford Non-Technical Skills evaluation demonstrated significant improvement in PGY 2 resident performance assessed during the 2 study periods: communication score increased from 3 to 3.71 (P=.01), leadership score increased from 2.77 to 3.86 (P<.001), teamwork score increased from 3.15 to 3.86 (P=.007), and procedural ability score increased from 2.23 to 3.43 (P=.03). There were no statistically significant improved scores in PGY 2 decision making or situation awareness. No improvements in skills were seen among PGY 1 participants. CONCLUSIONS AND RELEVANCE: The PGY 2 residents improved their skills, but the PGY 1 residents did not. Participants found interprofessional simulations to be realistic and a valuable educational tool. Interprofessional simulation provides a valuable means of educating surgical residents and evaluating their skills in real-life clinical scenarios.

Management of giant congenital pulmonary airway malformations requiring pneumonectomy.

BACKGROUND: Congenital pulmonary airway malformation (CPAM) is a rare congenital anomaly that occurs sporadically throughout fetal development. CPAM is usually a lobar process, but involvement of an entire lung is exceedingly rare. We present a small series of patients with multilobar CPAM who, to the best of our knowledge, are the first reported cases of giant CPAMs treated with pneumonectomy at birth. METHODS: After institutional review board approval, 93 medical records were reviewed for infants 0 to 12 months with congenital cystic adenomatoid malformation (CCAM) from 1990 to 2011. Three patients with entire lung involvement were included. RESULTS: Two patients were identified prenatally by ultrasonography and 1 was diagnosed at birth. Prenatally, the 2 patients exhibited mediastinal shift and steroids were administered. A pericardial effusion and decreased movement developed in 1 patient, requiring an emergent cesarean section at 31 weeks' gestation. All 3 patients underwent immediate newborn resection. One infant went into cardiac arrest on delivery and was resuscitated and taken for emergent resection. The 2 patients delivered vaginally at term tolerated spontaneous ventilation without positive pressure. All 3 patients underwent an emergent pneumonectomy on the first day of life. The premature infant died intraoperatively after CPAM removal from severe pulmonary hypertension (HTN) and contralateral lung hypoplasia. The hospital course for these patients was characterized by prolonged stays in the intensive care unit (ICU), pneumonia, ventilator dependence, and pulmonary HTN. Bronchoscopy revealed tracheomalacia in 1 patient that was relieved by aortopexy; the other patient had bronchomalacia requiring tracheotomy. CONCLUSIONS: Emergent total pneumonectomy can be lifesaving, although significant pulmonary HTN can be expected. Management options may include fetal surgical intervention, ex utero intrapartum treatment (EXIT), and expectant management. Extracorporeal membrane oxygenation (ECMO), a prolonged ICU course, and symptomatic tracheomalacia/bronchomalacia may be anticipated. Families can be counseled that survival is achievable with adequate contralateral lung development.

Preclinical regulatory validation of an engineered diaphragmatic tendon made with amniotic mesenchymal stem cells.

PURPOSE: Under a Food and Drug Administration directive, we examined definite long-term safety and efficacy aspects of an engineered diaphragmatic tendon graft as a regulatory prerequisite for clinical trials. METHODS: Newborn lambs (N = 27) underwent partial diaphragmatic replacement with a Teflon patch, a composite acellular bioprosthesis, or the same bioprosthesis seeded with autologous amniotic mesenchymal stem cells processed under Good Manufacturing Practice guidelines. Multiple safety and efficacy analyses were performed at different time points up to 14 months of age (ovine adulthood). RESULTS: There was no mortality. None of the blood tests or full body autopsy specimens showed any abnormality. There was a significantly higher failure rate in animals that received an acellular bioprosthetic graft vs an engineered graft, with no significant differences between Teflon and acellular bioprosthetic implants. Tensile strength and total collagen levels were significantly higher in engineered grafts than in acellular bioprosthetic grafts. On histology, lysozyme and myeloperoxidase stainings were unremarkable in all grafts. CONCLUSIONS: Diaphragmatic repair with a clinically viable autologous tendon engineered with amniotic mesenchymal stem cells leads to improved outcomes when compared with an equivalent acellular bioprosthesis, with no local or systemic adverse effects. Clinical trials of engineered diaphragmatic repair appear practicable within regulatory guidelines.

Serial amnioinfusions prevent fetal pulmonary hypoplasia in a large animal model of oligohydramnios.

BACKGROUND/PURPOSE: Severe neonatal pulmonary hypoplasia incurs mortality rates approaching 71% to 95%. We sought to determine the utility of serial amnioinfusions through a subcutaneously implanted intraamniotic catheter to prevent pulmonary hypoplasia in fetal obstructive uropathy. METHODS: Fetal lambs (n = 32) were divided into 3 groups. Group I (n = 12) underwent a sham operation, group II (n = 15) underwent a complete urinary tract obstruction via ligation of the urachus and urethra with a subcutaneous tunneled intraamniotic port-a-cath without amnioinfusions, and group III (n = 5) underwent a creation of a complete urinary tract obstruction with a port-a-cath as described in group II with serial amnioinfusions. Lung tissue was analyzed by lung volume to body weight ratios and stereology. Statistical analysis was performed by analysis of variance and Bonferroni comparisons (P < .05). RESULTS: Obstructed fetuses grossly had smaller lungs than treated and control animals. Lung volume to body weight ratios were statistically significant between groups. Airspace fractions were comparable between groups I and III (average = 0.53 and 0.55, respectively), although both were significantly greater than group II (average = 0.48) (P = .049). CONCLUSIONS: Serial amnioinfusions through an intraamniotic port-a-cath prevented pulmonary hypoplasia in an ovine model of complete obstructive uropathy. The use of an easily accessible device for amnioinfusions may be a viable option to treat oligohydramnios.

Correlation between prenatal urinary matrix metalloproteinase activity and the degree of kidney damage in a large animal model of congenital obstructive uropathy.

BACKGROUND/PURPOSE: We aimed to determine whether the profile of matrix metalloproteinase (MMP) activity in fetal urine correlates with the degree of kidney damage in the setting of congenital obstructive uropathy. METHODS: Fetal lambs underwent either a sham operation or creation of a complete urinary tract obstruction. Necropsies were performed before term, when urinary MMP profiling was performed by zymography; and kidney damage was assessed histologically by multiple semiquantitative analyses and histomorphometric measurements. RESULTS: There was a significant correlation between inner medullary thickness and MMP-9 (P = .005) and 63-kd MMP-2 (P = .019) activities. In like manner, the only MMPs associated with kidney fibrosis were MMP-9 and 63-kd MMP-2. Matrix metalloproteinase-9 activity was a highly significant independent predictor of the total combined kidney fibrosis score (P < .001) as well as of higher fibrosis grades in each of 6 kidney areas analyzed (all with P < .01). The activity of 63-kd MMP-2 correlated significantly with higher fibrosis in select areas. CONCLUSIONS: In a fetal ovine model, urinary MMP activity correlates with the degree of kidney damage. The presence of MMP-9 (in particular) and that of 63-kd MMP-2 are independent predictors of severity. Prenatal urinary MMP profiling may enhance patient stratification and counseling in the setting of congenital obstructive uropathy.

Conditional Gata4 deletion in mice induces bile acid absorption in the proximal small intestine.

BACKGROUND AND AIMS: The transcription factor GATA4 is expressed throughout most of the small intestine except distal ileum, and restricts expression of the apical sodium-dependent bile acid transporter (ASBT), the rate-limiting intestinal bile acid transporter, to distal ileum. The hypothesis was tested that reduction of GATA4 activity in mouse small intestine results in an induction of bile acid transport in proximal small intestine sufficient to restore bile acid absorption and homeostasis after ileocaecal resection (ICR). METHODS: Bile acid homeostasis was characterised in non-surgical, sham or ICR mice using two recombinant Gata4 models in which Asbt expression is induced to different levels. RESULTS: Reduction of intestinal GATA4 activity resulted in an induction of ASBT expression, bile acid absorption and expression of bile acid-responsive genes in proximal small intestine, and a reduction of luminal bile acids in distal small intestine. While faecal bile acid excretion and bile acid pool size remained unchanged, the bile acid pool became more hydrophilic due to a relative increase in tauro-beta-muricholate absorption. Furthermore, proximal induction of Asbt in both Gata4 mutant models corrected ICR-associated bile acid malabsorption, reversing the decrease in bile acid pool size and increase in faecal bile acid excretion and hepatic cholesterol 7alpha-hydroxylase expression. CONCLUSIONS: Reduction of intestinal GATA4 activity induces bile acid absorption in proximal small intestine without inducing major changes in bile acid homeostasis. This induction is sufficient to correct bile acid malabsorption caused by ICR in mice.

Prenatal urinary matrix metalloproteinase profiling as a potential diagnostic tool in fetal obstructive uropathy.

BACKGROUND/PURPOSE: The diagnostic evaluation, patient stratification, and prenatal counseling for congenital obstructive uropathy remain sub-optimal. Matrix metalloproteinase (MMP) expression profiles are emerging as a valuable diagnostic tool in assorted disease processes. We sought to determine whether congenital obstructive uropathy impacts MMP expression in fetal urine. METHODS: Fetal lambs (n = 25) were divided in two groups: group I (n = 12) underwent a sham operation and group II (n = 13) underwent creation of a complete urinary tract obstruction. Gelatin zymography panels for 4 MMP species were performed on fetal urine in both groups at comparable times post-operatively. Statistical analysis was by the Fisher's exact test (P < .05). RESULTS: Overall fetal survival was 80% (20/25). A variety of significant differences in MMP expression between the two groups were identified. The following profiles were present only in obstructed animals: any MMP other than MMP-2 (P = .029), including any MMP other than 63 kDa and 65 kDa (P = .009); 2 or more MMPs excluding MMP-2s (0.029); and 3 or more MMPs (P = .029). CONCLUSIONS: Limited matrix metalloproteinase expression is present in the urine of normal ovine fetuses. Fetal obstructive uropathy impacts urinary MMP expression in various distinguishable patterns. Prenatal urinary MMP profiling may become a practical and valuable diagnostic tool in the evaluation of congenital obstructive uropathy.

Removal of a sewing needle from an occult esophageal ingestion in a 9-month-old.

A healthy 9-month-old boy presented with a 1-month history of cough. A chest x-ray showed a linear metallic foreign body (FB) lying transversely in the posterior mediastinum. Computed tomographic scan confirmed the location and size of the metallic FB and also revealed a large pericardial effusion that was corroborated by echocardiogram. The patient underwent a right thoracotomy revealing a normal esophagus without mediastinitis and a 12-mm needle in the posterior mediastinum embedded in the pericardium with the sharp end abutting the left atrium. The needle was extracted uneventfully, and his postoperative course was unremarkable. The diagnosis and treatment for this case are discussed along with a review of the literature.

A case report of a congenital left subcostal hernia in a neonate.

We present an unusual case of a congenital left subcostal hernia in a female born at 39 weeks by caesarean delivery to a 39 year-old gravida(2)para(1-2)abortus(0) mother. The pregnancy was complicated by gestational diabetes, although she had normal prenatal imaging. After an uneventful caesarean delivery, the patient's initial physical examination was normal although subsequently was found to have a left subcostal hernia. During surgical evaluation, a reducible hernia was found along with left renal agenesis and no underlying masses. At 4 weeks of age, the patient's hernia was successfully repaired with no sequela. We present the first reported case of a congenital subcostal hernia, evaluation, and treatment.