Evaluation of Gender Bias Through Autonomy During Laparoscopic Cholecystectomy at a Rural Community General Surgery Residency Program.

OBJECTIVE: Gender bias not only continues to exist in surgical specialties, but in the medical field overall. Despite females graduating from medical schools at the same rate as men, a discrepancy still exists in the number of females pursuing surgical specialties compared to their male counterparts. We hypothesized that surgical training occurring in smaller institutions with close-knit relationships between faculty and residents should decrease the likelihood of gender bias towards females, as measured by perceived autonomy during laparoscopic cholecystectomy. DESIGN: All 17 surgery residents at a community surgery residency program were asked to voluntarily and anonymously complete an investigator-created questionnaire after every laparoscopic cholecystectomy from October 2020 to May 2022. The questionnaire included details regarding overall resident operative experience, case complexity, patient diagnosis, resident autonomy throughout the case, and perceived autonomy compared to their peers. Each respondent estimated their percent autonomy from 0% to 100% during 5 distinct portions of the case, from which, a mean overall percent autonomy was calculated. RESULTS: A total of 233 questionnaires (98 female, 135 male) were completed during the study period, with 8 females and 9 males in the first study year and 7 females and 10 males in the second. Mean overall autonomy was statistically similar between males and females, 71% and 72% respectively (p = 0.967). Case difficulty was not statistically different between males and females (p = 0.445). There was a significant difference in autonomy of all residents with male and female attendings, 67.5% and 80.3%, respectively (p = 0.001), however this did not differ between male and female residents. Eighty-three percent of respondents felt that their level of autonomy was acceptable for their postgraduate year (PGY) level. Over 90 percent of respondents felt their autonomy was not affected by their gender. CONCLUSIONS: There was no significant difference in perceived autonomy between male and female residents during laparoscopic cholecystectomy at our small general surgery residency program. Gender bias did not appear to be a prohibiting factor in the amount of autonomy given to male and female residents.

Limited Resources at a Community Based Level 1 Trauma Center: Does This Affect Pelvic Angioembolization Times During Daylight Hours versus after Hours, Weekends, and Holidays?

Hemodynamically unstable patients with pelvic fractures require swift intervention due to the high mortality of their injuries. A delay in embolization of these patients significantly affects survival. We therefore, hypothesized that there would be a significant difference between time to embolization at our larger rural Level 1 Trauma Center. This study investigated the relationship between interventional radiology (IR) order time to IR procedure start time over 2 time periods at our large, rural Level 1 Trauma Center with those having sustained a traumatic pelvic fracture requiring IR, and having been identified as being in shock. The current study found no statistically significant difference from time from order to IR start between the 2 cohorts (Mann-Whitney U test, P = .902). The results suggest we are delivering a consistent standard of care at our institution for pelvic trauma, based on IR order time to start of the procedure.

Bronchoscopy Decreases Ventilator-Associated Pneumonia in Trauma Patients.

Health care-associated pneumonias (HAPs) are a significant comorbidity seen in hospitalized patients. Traumatic injury is a known independent risk factor for the development of HAP. Trauma-related injuries also contribute to an increase in the rate of pneumonia in mechanically ventilated patients requiring intensive care unit (ICU) treatment. In 2011, the ventilator-associated pneumonia (VAP) rate among ICU patients at our institution (CMMC) increased dramatically. As a result, our infection control specialists performed a focused review of these patients and found a likely association between these infections and patients requiring pre-hospital intubation. Their determination prompted a July 2012 revision of the CMMC Trauma/Surgery Admission ICU protocol for ventilated patients to include bronchoscopy for all patients who have been intubated pre-hospital providing no contraindications were present. Our aim was to ascertain any influence of the protocol change on the rate of VAP. We conducted a retrospective medical record review of trauma patients who were intubated in the field or ED and seen at our institution (an accredited Level 1 trauma center) from 2012 to 2018. Applying the current definition of VAP from the Centers for Disease Control and Prevention (CDC) to data collected from the CMMC trauma registry, we observed a 13% lower VAP rate in the bronchoscopy group (YB) as compared to the group that did not receive bronchoscopy (NB) (P < .025). Based on our results, we determined that bronchoscopy performed in this setting does support a statistically significant decrease in the rate of ventilator-associated pneumonia.

Benefit of continued noninvasive cardiac monitoring in geriatric trauma: A retrospective review of geriatric pelvis, hip, and femur fractures and analysis of cardiac events during immediate post-traumatic course.

OBJECTIVE: The geriatric population suffers from a predisposition to cardiac events due to physiologic changes commonly associated with aging. The majority of the trauma population seen at our facility is within the geriatric population (greater than 65 years old). Therefore, this study was aimed to determine which of those preexisting factors were associated with an increased risk for developing cardiac event. By assessing those risks, we hoped to determine a timeline for the highest risk of cardiac event occurrence, in order to identify a safe period of when cardiac monitoring was indicated. METHODS: A retrospective study performed over 6 months reviewing geriatric trauma patients with hip, pelvis, or femur fractures, n = 125. A list of predetermined risk factors including comorbidities, pathologies, laboratory values, electrocardiogram findings, and surgery was crossed with the patient's records in order to identify factors for increased risk of cardiac event. Once patients who had documented cardiac events were identified, a temporal pattern of cardiac event occurrence was analyzed in order to determine a period when noninvasive cardiac monitoring should remain in place. RESULTS: In 125 patients, 40 cardiac events occurred in 30 patients. The analyzed variables with statistically significant associations for having a cardiac event were comorbidities (p = 0.019), elevated body mass index (p = 0.001), abnormal initial phosphorus (p = 0.002), and an electrocardiogram finding of other than normal sinus rhythm (p = 0.020). Of the identified cardiac events, we found that by hospital day 3 68% of cardiac event had occurred, with 85% by hospital day 4, 95% by day 5, and 100% within the first 7 days of admission. CONCLUSION: Patient history of cardiac comorbidities, elevated body mass index, abnormal phosphorus, and abnormal electrocardiogram findings were found to be significant risk factors for cardiac event development in geriatric trauma. All recorded events in our study occurred within 7 days of the initial trauma.

Medical Degree Disparity Among Authors in Obstetrics and Gynecology Journals.

CONTEXT: With the transition to a single accreditation system for graduate medical education, the scholarly activity among core faculty in osteopathic and allopathic residency programs has come under scrutiny. Currently, major differences in scholarly activity requirements exist between core faculty in obstetrics and gynecology residencies accredited by the Accreditation Council for Graduate Medical Education and those accredited by the American Osteopathic Association. OBJECTIVE: To determine whether there is a disparity between osteopathic and allopathic physicians among authors with original research published in 4 high-impact obstetrics and gynecology journals during 4 select years. METHODS: The authors reviewed Obstetrics & Gynecology (Obstet Gynecol), the American Journal of Obstetrics and Gynecology (Am J Obstet Gynecol), Fertility and Sterility (Fertil Steril), and Menopause for the degree designation of the first and senior (last) author of each original manuscript for the years of 2000, 2005, 2010, and 2015. Data were analyzed using simple descriptive statistics and linear regression. RESULTS: In total, 3311 articles and 5909 authors were reviewed. Of these authors, 0.80% (47) had a DO degree. Of 1692 authors with dual advanced degrees, only 0.53% (9) had a DO degree. On subgroup analysis of each journal, 0.87% (13 of 1494) of identified authors in Obstet Gynecol, 1.03% (21 of 2038) in Am J Obstet Gynecol, 0.44% (9 of 2030) in Fertil Steril, and 2.20% (4 of 347) in Menopause were osteopathic physicians. During the years studied, no statistically significant trend could be established for first or senior author publication by osteopathic physicians over time, for all 4 journals or for any individual journal. CONCLUSION: Very few osteopathic physicians have served as either the first or the senior author in articles published in Obstet Gynecol, Am J Obstet Gynecol, Fertil Steril, or Menopause during the years studied, and no trend was seen for increased publication by osteopathic physicians in these journals over time.

Preoperative decolonization to reduce infections in urgent lower extremity repairs.

PURPOSE: Medical implants and surgical site infections (SSIs) can be a burden on both patients and healthcare systems with a significant rise in morbidity, mortality and costs. Preoperatively, our practice of a chlorohexidine gluconate (CHG) washcloth bath or solution shower was supplemented with nasal painting using povidone-iodine skin and nasal antiseptic (PI-SNA). We sought to measure the effectiveness in reducing SSIs in patients undergoing repair of lower extremity fractures. METHODS: A retrospective review of trauma patients undergoing orthopedic operations conducted at Conemaugh Memorial Medical Center from 10/1/2012 through 9/30/2016. The intervention period was 10/1/2014 to 9/30/2016 which included the addition of nasal painting with PI-SNA preoperatively. All patients were followed for 1 year prior to January 2013 and 30 or 90 days thereafter for the development of a SSI. RESULTS: The pre-intervention group consisted of 930 cases with a 1.1% infection rate (10 SSIs). The intervention group consisted of 962 cases with a 0.2% infection rate (2 SSIs). This observed difference was statistically significant (P = 0.020). CONCLUSIONS: This retrospective review of a methicillin-resistant Staphylococcus aureus decolonization protocol using CHG bath/shower and PI-SNA nasal painting revealed a significant decrease in the infection rate of patients undergoing lower extremity fracture repairs. We recommend its use without contraindications, but recognize that additional investigations are necessary.

Comparison of intubation devices in level C personal protective equipment: A cadaveric study.

BACKGROUND: With the advancement of chemical, biological and nuclear warfare and the reemergence of infectious diseases, the possibility of intubating in personal protective equipment has become increasingly more real to the emergency physician. Human cadaveric models have been found to simulate real world conditions better than mannequins. The aim of the study was to determine the first pass success rate and average time to successful intubation while wearing Personal Protective Equipment (PPE). Secondarily, subjects were asked to rank their choice of a primary and back up device, as well as the most common encountered barriers using PPE. METHODS: Emergency medicine residents and pre-hospital providers were enrolled in a double randomized sequence to either intubation with direct laryngoscopy (DL), video laryngoscopy (VL), or the Supraglottic Airway Laryngopharyngeal Tube (SALT) in a cadaveric model while wearing level C PPE or without PPE. RESULTS: First pass success rate was 96% without PPE and 58% while wearing PPE when all devices were considered (p≤0.001). Time to intubation while wearing PPE was 35.0s while no PPE was 22.2s (p=0.012). While wearing PPE both DL and VL were found to allow for a faster intubation as compared to the SALT (23.0s and 18.8s; p=0.002 and p=0.006 respectively). No statistical difference was noted in intubations without PPE. Participants indicated the most common barrier to successful intubation included visibility while wearing hoods (73.7%). Furthermore, 52.6% of participants indicated they would choose DL as the primary method to intubate with if wearing PPE while 47.4% would choose VL. CONCLUSION: There is a statistically significant difference in first pass success and time to successful intubation while wearing and not wearing PPE in human cadaveric models.

Use of Patient-Authored Prehistory to Improve Patient Experiences and Accommodate Federal Law.

CONTEXT: Although federal law grants patients the right to view and amend their medical records, few studies have proposed a process for patients to coauthor their subjective history in their medical record. Allowing patients to fully disclose and document their medical history is an important step to improve the diagnostic process. OBJECTIVE: To evaluate patients' office experience before and after they authored their subjective medical history for the electronic health record. METHODS: Patients were mailed a prehistory form and presurvey to be completed before their family medicine office visit. On arrival to the office, the prehistory form was scanned into the electronic health record while the content was transcribed by hospital staff into the appropriate fields in the history component of the encounter note. Postsurveys were given to patients to be completed after their visit. Pre- and postsurveys measured the patients' perception of office visit quality as well as completeness and accuracy of their electronic health record documentation before and after their appointment. Medical staff surveys were collected weekly to measure the staff's viewpoint of the federal law that allows patients to view and amend their medical records. RESULTS: Of 405 patients who were asked to participate, 263 patients aged 14 to 94 years completed a presurvey and a prehistory form. Of those 263 patients, 134 completed a postsurvey. The pre- and postsurveys showed improved patient satisfaction with the office visit and high scores for documentation accuracy and completeness. Before filling out the prehistory form, 116 of 249 patients (46.6%) agreed or strongly agreed that they felt more empowered in their health care by completing the prehistory form compared with 110 of 131 (84.0%) who agreed or strongly agreed after the visit (P<.001). Staff members agreed that patients should have the right to view and amend their medical records in accordance with federal law. CONCLUSION: Empowering patients to contribute subjective information to their electronic health record has the potential to improve the diagnostic process. When conducting a medical encounter, the authors recommend having patients complete a prehistory form beforehand to improve the patient experience while accommodating federal law.

Retrievable inferior vena cava filters in geriatric trauma: Is there an age bias?

BACKGROUND: Trauma patients are at increased risk for developing venous thromboembolic (VTE) disease. The EAST (Eastern Association for the Surgery of Trauma) practice management guidelines identified risk factors for VTE, as well as indications for prophylactic inferior vena cava filters (IVCF). In a 2009 study, our institution found a 26% retrieval rate for IVCF. Lack of retrieval was most consistently due to lack of follow-up. Our study is a follow-up analysis for retrieval rate of IVCF, since the formation of a geriatric trauma service. We anticipated that geriatric trauma patients would have a lower rate of IVCF retrieval compared to the general trauma patient. METHODS: Our study population consisted of trauma patients admitted from January 2008 to August 2013, with documented VTE or high risk for VTE with contraindication to anticoagulation. INCLUSION CRITERIA: IVCF placed in trauma patients. EXCLUSION CRITERIA: permanent filters, retrievable filters placed permanently, non-trauma patients, superior vena cava filters and patients who died before discharge. RESULTS: During the study period, 160 trauma patients had an IVCF placed, of which 147 survived and were discharged. Of those patients, 66% (97/147) were planned for retrieval. Overall, the retrieval rate was 34% (33/97). Following age categorization, rates were 47% (30/64) and 9% (3/33) for those <65 and >/=65 years old, respectively. Applying Fisher's Exact Test to a crosstab of planned retrieval by age category yielded a statistically significant difference, p<0.0005 at alpha=0.05. In the geriatric population with IVCFs not retrieved, 23% (7/30) died and 67% (20/30) were lost to follow-up. CONCLUSION: IVCF plays a critical role in the management of trauma patients with VTE, particularly the geriatric population. Since our 2009 study, we have improved nearly ten percentage points (26% to 34%); however, we exposed an age bias with retrieval rate being lower in patients >/=65 compared to those <65 (9% vs. 47%).

Patient and Health-Care Provider Interpretation of do not Resuscitate and do not Intubate.

BACKGROUND: Advance directives and end of life care are difficult discussions for both patients and health-care providers (HCPs). A HCP requires an accurate understanding of advanced directives to educate patients and their family members to allow them to make an appropriate decision. Misinterpretations of the do not resuscitate (DNR), do not intubate (DNI), and the Physicians Orders for Life-Sustaining Treatment (POLST) form result in ineffective communication and confusion between patients, family members, and HCPs. METHODOLOGY: An anonymous, multiple choice online and paper survey was distributed to patients, family members of patients (PFMs), and HCPs from December 12, 2012 to March 6, 2013. Data regarding demographics, the accuracy of determining the correct definition of DNR and DNI, the familiarity of the POLST form and if a primary care physician had discussed advanced directives with the participants were collected. RESULTS: A total of 687 respondents participated in the survey. Patients and PFMs could not distinguish the definition of DNR (95% confidence interval [CI] [1.453-2.804]) or DNI (95% CI (1.216-2.334)) 52% of the time while HCPs 35% and 39% of the time (P < 0.0005). Regarding the POLST form, 86% of patients and PFMs and 50% of HCPs were not familiar with the POLST form. Sixty-nine percent of patients and family members reported that their primary care physician had not discussed advance directives with them. Twenty-four percent of patients and family members reported that they had previous health-care experience and this was associated with increased knowledge of the POLST form (P < 0.0005). An association was also seen between the type of HCP taking the survey and the ability to correctly identify the correct definition of DNR (P < 0.0005). CONCLUSION: Discussion of end of life care is difficult for patients and their family members. Often times multiple discussions are required in order to effectively communicate the definition of DNR, DNI, and the POLST form. Education of patients, family members, and HCPs is required to bridge the knowledge gap of advance directives.

Correlation Between Scores on Weekly Quizzes and Performance on the Annual Resident In-Service Examination.

CONTEXT: Medical residency education relies heavily on the use of written and oral testing as a means of assessing a learner's knowledge acquisition. In the United States, osteopathic emergency medicine residents take an annual specialty-based resident in-service examination (RISE) for this purpose. Their performance on the RISE helps direct educators' approach to teaching and training. OBJECTIVES: To determine the correlative strength of residents' cumulative performance on a series of weekly in-house quizzes with their performance on the RISE. METHODS: In this prospective study, emergency medicine residents took a series of 15 quizzes between August 2013 and January 2014. The quizzes were administered using slides integrated with an audience-response system. Quizzes comprised questions gathered from various question banks and commercial test review resources specific to the specialty of emergency medicine. Effort was made to select questions covering topics tested on the RISE. Scores from each of the quizzes were recorded, and these data were analyzed for correlation with residents' scores on the RISE. RESULTS: Sixteen emergency medicine residents from all 4 postgraduate years participated in the study. For various reasons (vacation, illness, away rotations), not all 16 residents participated in each quiz. The mean participation rate over all 15 quizzes was 76.7%, with a mean quiz score of 57.8%. A correlation analysis was conducted between the achieved RISE score and the mean quiz score (excluding any quizzes not taken). Graphical analysis revealed a sufficiently linear relationship between the 2 variables, with no outliers. Both variables were normally distributed, as assessed by the Shapiro-Wilks test (P>.05). A strong positive correlation was found between RISE score and mean quiz score (r[14]=0.75; P=.001), with the mean quiz score over the quizzes taken explaining about 57% of the variance in the achieved RISE score. CONCLUSIONS: The results of this study imply that performance on weekly didactic quizzes may be strongly predictive of RISE performance and as such tracking these data may provide insight to educators and learners as to the most effective direction of their educational efforts.

Authorship Trends of Emergency Medicine Publications over the Last Two Decades.

INTRODUCTION: With the recent merger of the American Osteopathic Association (AOA) and the Accreditation Council for Graduate Medical Education (ACGME) a heightened pressure for publication may become evident. Our objective was to determine whether there was a gap in the type of both medical degree designation and advanced degree designation among authorship in three United States-based academic emergency medicine journals. METHODS: We reviewed the Journal of Emergency Medicine, Academic Emergency Medicine and Annals of Emergency Medicine for the type of degree designation that the first and senior authors had obtained for the years 1995, 2000, 2005, 2010 and 2014. RESULTS: A total of 2.48% of all authors held a degree in osteopathic medicine. Osteopathic physician first authors contributed to 3.26% of all publications while osteopathic physician senior authors contributed 1.53%. No statistical trend could be established for the years studied for osteopathic physicians. However, we noted an overall trend for increased publication for allopathic senior authors (p=0.001), allopathic first authors with a dual degree (p=0.003) and allopathic senior authors with a dual degree (p=0.005). For each journal studied, no statistical trend could be established for osteopathic first or senior authors but a trend was noted for allopathic first and senior authors in the Journal of Emergency Medicine (p-value=0.020 and 0.006). Of those with dual degrees, osteopathic physicians were in the minority with 1.85% of osteopathic first authors and 0.60% of osteopathic senior authors attaining a dual degree. No statistical trend could be established for increased dual degree publications for osteopathic physicians over the study period, nor could a statistical trend be established for any of the journals studied. CONCLUSION: Very few osteopathic physicians have published in the Journal of Emergency Medicine, Academic Emergency Medicine or Annals of Emergency Medicine over the last two decades. Despite a trend for increased publication by allopathic physicians in certain journals, there appears to be no trend for increased publication of osteopathic physicians in emergency medicine.

Standardized set-point acupuncture for migraines.

CONTEXT: Migraine headaches are common, debilitating, underdiagnosed, and undertreated, and medications are not always effective. Research has shown that acupuncture may be an effective and safe adjuvant or alternative migraine treatment. OBJECTIVE: The purpose of the current study was to evaluate whether a standardized set of acupuncture points, when used to deliver treatment over a predefined period of time, could reduce the frequency and intensity of migraines. DESIGN: This is a prospective interventional study using set point acupuncture for migraines. SETTING: The study took place at Conemaugh Memorial Medical Center in Johnstown, PA, USA. PARTICIPANTS: Participants were 59 individuals with a diagnosis of migraine. INTERVENTION: Acupuncture was administered 2 ×/wk for 4 wks, followed by 1 ×/wk for 4 more wks, using one set of acupoints. OUTCOME MEASURES: Participants collected daily headache diaries and migraine quality-of-life measurements on a personal digital assistant for 12 wks before starting the acupuncture intervention. Participants continued to record the frequency and intensity of their migraines during the intervention and for an additional 12 wks beyond the intervention. The Migraine Disability Assessment (MIDAS), Headache Impact Test (HIT-6), and Beck Depression Inventory (BDI-II) were completed 4 × during the study: 12 wks prior to the start of the intervention, immediately prior to the first acupuncture treatment, at the end of treatment, and 12 wks after the end of treatment. RESULTS: When preintervention measurements were compared to postintervention measurements, migraine frequency and pain intensity showed a significant decrease (α = 0.05) after acupuncture intervention. Results had not returned to the preintervention baseline even 12 wks after the last acupuncture session. Acupuncture significantly influenced migraine frequency and intensity in the study's participants when preintervention measurements were compared to postintervention measurements. CONCLUSIONS: These results indicate that not only did acupuncture decrease both the frequency and intensity of migraines, but also the benefit had not subsided for 12 wks after the final acupuncture session. Validated survey measurements used to assess migraine impact on quality of life showed statistically significant improvement over baseline.

Implications of neurophysiological parameters in persons with severe brain injury with respect to improved patient outcomes: a retrospective review.

PRIMARY OBJECTIVE: To determine whether neurophysiologic parameters-intracranial pressure (ICP), mean arterial pressure (MAP), cerebral perfusion pressure (CPP), partial brain tissue oxygenation (PbtO(2)) and pressure reactivity index (PRx, calculated)-captured during the management of traumatic brain injury (TBI) have a relationship to patient outcome. RESEARCH DESIGN: A retrospective analysis of neurophysiologic data collected from persons under medical management of TBI per Conemaugh Memorial Medical Center (CMMC) standard treatment algorithms. METHODS AND PROCEDURES: Nine patients' medical records that matched International Statistical Classification of Diseases and Related Health Problems (ICD-9) code for head injury and a Current Procedural Terminology (CPT) code for an ICP monitoring device or ventriculostomy were analysed on the aforementioned parameters. MAIN OUTCOMES AND RESULTS: Statistical significance by mortality (α = 0.05) was found for ICP, CPP and PbtO(2). PRx showed a pattern of significance over the last 72 hours. The couplets (CPP & ICP) and (CPP & MAP) demonstrated significant correlations. CONCLUSIONS: Improved autoregulation was associated with PRx values near zero. Controlling those parameters that affect PRx, namely MAP, ICP and CPP and more importantly cerebral oxygen perfusion (COP), would likely increase the probability of a better outcome while guarding against secondary insult.