Conocimiento en estudiantes de enfermería sobre sepsis quirúrgico / Knowledge in nursing students about surgical sepsis

Objetivo: Determinar el nivel de conocimiento de los estudiantes de enfermería de la Universidad Técnica de Ambato sobre sepsis quirúrgica. Material y método: La presente investigación tiene un diseño de desarrollo observacional, de tipo descriptivo, cohorte transversal, con un enfoque cuantitativo, ya que el nivel de cono-cimiento se verá representado mediante tablas y gráficos para des-cribir la problemática del periodo octubre 2023 febrero 2024. Re-sultados: Se evidencia un alto porcentaje de respuestas incorrectas por cada ítem por parte de los estudiantes. La categoría Nivel de Conocimiento sobre Definición de Sepsis, fue respondida de ma-nera incorrecta con un porcentaje del 83,9%, la categoría Nivel de Conocimiento sobre Diagnóstico de Sepsis obtuvo 51,7% y, por úl-timo, la Nivel de Conocimiento sobre Tratamiento de Sepsis con el 29,2%. Conclusiones: El nivel de conocimiento de los estudiantes sobre Sepsis Quirúrgica es malo, debido a que existe una subesti-mación de la gravedad de la sepsis como afección potencialmente mortal, lo que puede traer un impacto negativo en los pacientes[AU]

Objective: Determine the level of knowledge of nursing students at the Technical University of Ambato about surgical sepsis. Mate-rials and methods: This research has an observational, descriptive, transversal development design, with a quantitative approach since the level of knowledge will be represented through tables and gra-phs to describe the problems of the period October 2023-February 2024. Results: A high percentage of incorrect answers for each item by the students is evident. The category Level of Knowledge about Definition of Sepsis was answered incorrectly with a percentage of 83.9%, the category Level of Knowledge about Diagnosis of Sepsis obtained 51.7% and, finally, the category Level of Knowledge about Treatment of Sepsis. Sepsis with 29.2%. Conclusions: The level of knowledge of students about Surgical Sepsis is poor because there is an underestimation of the severity of sepsis as a potentially fatal condition, which can have a negative impact on patients[AU]

Objetivo: Determinar o nível de conhecimento dos estudantes de enfermagem da Universidade Técnica de Ambato sobre sepse ci-rúrgica. Material e método: Esta pesquisa possui desenho de coor-te observacional, descritivo, transversal, com abordagem quantita-tiva, uma vez que o nível de conhecimento será representado por meio de tabelas e gráficos para descrever o problema no período de outubro de 2023 a fevereiro de 2024. Resultados: Uma parada. É evidente o percentual de respostas incorretas para cada item por parte dos alunos. A categoria Nível de Conhecimento sobre Defi-nição de Sepse foi respondida incorretamente com percentual de 83,9%, a categoria Nível de Conhecimento sobre Diagnóstico de Sepse obteve 51,7% e por fim, a categoria Nível de Conhecimen-to sobre Tratamento de Sepse com 29,2%. Conclusões: O nível de conhecimento dos estudantes sobre a Sepse Cirúrgica é baixo, pois há uma subestimação da gravidade da sepse como uma condição potencialmente fatal, que pode ter um impacto negativo nos pa-cientes[AU]

Atraumatic splenic rupture as first presentation of hairy cell leukaemia-a case report.

Atraumatic splenic rupture is a complex surgical pathology owing to its rarity, non-specificity of symptoms and gravity of possible outcomes. This case outlines the investigation and management of a patient with atraumatic splenic rupture secondary to undiagnosed hairy cell leukaemia. While the patient was initially managed conservatively, they went on to have a splenectomy owing to ongoing transfusion requirements. A review of the literature has also been performed and presented to highlight the potential causes of atraumatic splenic rupture and the various options for confirming diagnosis and definitive management.

Robotic-Assisted Laparoscopic Repair of Petit's Hernia With Preperitoneal Mesh.

Lumbar hernias are rare abdominal wall hernias that occur in the posterolateral abdominal wall. Intra-peritoneal or extra-peritoneal contents typically protrude through defects in one of two anatomical triangles. The superior lumbar triangle (Grynfeltt-Lesshaft triangle) is an inverted triangle bordered by the 12th rib superiorly, the internal oblique muscle laterally, and the erector spinae muscle medially. The inferior lumbar triangle (Petit's triangle) is an upright triangle bordered by the iliac crest inferiorly, the external oblique muscle laterally, and the latissimus dorsi muscle medially. Surgical repair has been described via open or laparoscopic approach. A 69-year-old male patient presented with right flank pain and swelling. He was involved in a motorcycle accident 10 months prior, which likely resulted in the development of a traumatic lumbar hernia which was demonstrated on the CT scan. The hernia was clinically incarcerated, and the defect contained the cecum and ileocecal valve. The defect was noted just superior to the iliac crest, by definition, making this an inferior lumbar hernia or a Petit's hernia. The hernia was repaired via robotic-assisted laparoscopic transabdominal approach. A peritoneal flap was created exposing the fascial defect. The fascia was primarily repaired with suture. The defect was reinforced with an 11.4 cm round Ventralight ST mesh in the preperitoneal space. The patient tolerated the procedure well with no acute complications. He was discharged the same day as an outpatient with appropriate pain control. Short-term follow-up demonstrated no recurrent hernia present and symptoms resolved. Lumbar hernias are a rare occurrence with no gold standard technique for repair. The benefits of the laparoscopic approach have been described over the open approach. This case report describes utilizing a minimally invasive approach to primarily repair a lumbar hernia defect while also reinforcing the hernia with mesh in the preperitoneal space.

Extramammary breast cancer of the vulva.

A woman in her 70s was seen in the gynaecology outpatient clinic with a swelling on the right side of the vulva. Surgical excision of the lesion revealed unexpectedly an extensive ductal carcinoma in situ with a focus of a grade 2 invasive ductal carcinoma arising in extramammary breast tissue of the vulva. Postoperative staging studies showed normal breasts, with no evidence of disease elsewhere. The patient underwent a wider excision of the right vulva and sentinel node biopsy of the right inguinal region, which revealed no further disease. The patient is currently taking adjuvant hormonal therapy and has remained disease free at 2-year follow-up. This case underscores the importance of considering rare presentations of vulvar malignancies and the necessity for a multidisciplinary approach in managing such cases.

Who should perform pediatric laparoscopic cholecystectomies? A systematic review of the literature.

Laparoscopic cholecystectomy (LC) is an increasingly common operation in the pediatric population, although numbers remain significantly lower than in adults. Currently, this operation is performed by both adult and pediatric surgeons and there is no consensus as to whether specialist low-volume or adult high-volume surgeons should be performing this operation. A literature search was performed to compare the outcomes following pediatric LC when performed by adult or pediatric surgeons. 19,993 patients were included in this analysis. Overall, post-operative complications were reduced when LC was performed by high-volume adult surgeons, along with reduced length of stay and associated cost. Overall morbidity following LC in children is comparable to adults. When performed by higher volume adult surgeons, there was a statically significant reduction in post-operative complications and re-admission rates. Morbidity was also reduced in patients with simple cholelithiasis. Initial results show that in pediatric patients presenting with cholelithiasis, LC performed by a high-volume adult general surgeon is safer. In more complex children with needs from other specialist pediatricians, surgery performed by a pediatric surgeon is recommended. Further research with direct comparisons is still required.

Impact of automated alerts on discharge opioid overprescribing after general surgery.

DISCLAIMER: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE: The objectives of this study were to identify the most performed surgical procedures associated with the highest rates of discharge opioid overprescribing and to implement an electronic health record (EHR) alert to reduce discharge opioid overprescribing. METHODS: This quality improvement, before-and-after study included patients undergoing one of the identified target procedures-laparoscopic cholecystectomy, unilateral open inguinal hernia repair, and laparoscopic appendectomy-at an academic medical center. The alert notified providers when the prescribed opioid quantity exceeded guideline recommendations. The preimplementation cohort included surgical encounters from January 2020 to December 2021. The EHR alert was implemented in May 2022 following provider education via email and in-person presentations. The postimplementation cohort included surgical encounters from May to August 2022. The primary outcome was the proportion of patients with a discharge opioid supply exceeding guideline recommendations (overprescribing). RESULTS: A total of 1,478 patients were included in the preimplementation cohort, and 141 patients were included in the postimplementation cohort. The rate of discharge opioid overprescribing decreased from 48% in the preimplementation cohort to 3% in the postimplementation cohort, with an unadjusted absolute reduction of 45% (95% confidence interval, 41% to 49%; P < 0.001) and an adjusted odds ratio of 0.03 (95% confidence interval, 0.01 to 0.08; P < 0.001). Among patients who received opioids, the mean (SD) opioid supply at discharge decreased from 92 (43) oral morphine milligram equivalents (MME) (before implementation) to 57 (20) MME (after implementation) (P < 0.001). The proportion of patients who received additional opioid prescriptions within 1 to 14 days of hospital discharge did not change (P = 0.76). CONCLUSION: Implementation of an EHR alert along with provider education can reduce discharge opioid overprescribing following general surgery.

Early follow-up colonoscopy after colorectal cancer resection detects significant pathology.

BACKGROUND: Colonoscopy is a key component of surveillance after colorectal cancer (CRC) resection. Surveillance intervals for colonoscopy vary across the world, with a limited evidence-base to support guidelines. OBJECTIVE: To evaluate the timing and outcome of colonoscopies after CRC resection. METHODS: Retrospective cohort study on prospectively collected data. Included adult patients under surveillance following CRC resection. Patients with organ transplant, inflammatory bowel disease or colon cancer syndromes were excluded. The outcomes of the first (up to) three follow-up colonoscopies were audited and classified for presence of advanced neoplasia (advanced adenoma or adenocarcinoma). RESULTS: 980 patients underwent at least one follow-up colonoscopy with a median time to first colonoscopy of 12.4 months. The findings included 2.7% CRC and 13.2% advanced adenoma. Older age, stage IV disease, and synchronous cancers at surgery were significantly associated with a finding of advanced neoplasia at first colonoscopy. 562 patients underwent a second colonoscopy (median of 35 months after the first surveillance colonoscopy) with findings of 1.8% CRC and 11.4% advanced adenoma. Advanced adenoma on prior colonoscopy was associated with finding advanced neoplasia at the second colonoscopy. 288 patients underwent a third colonoscopy (median of 37 months from the preceding colonoscopy), with similar outcomes of advanced neoplasia being associated with advanced adenoma at the previous colonoscopy. 43 (4.4%) patients developed CRC whilst on surveillance. CONCLUSIONS: Timely surveillance after CRC resection is important for detecting advanced neoplasia, and prolonged intervals between colonoscopies in the early years after surgery should be avoided.

Attitudes of Surgical Trainees and Faculty Towards Parental Leave During Surgical Training.

OBJECTIVE: Our aim was to better understand attitudes towards parental leave from the perspective of both surgeon faculty and current surgical trainees. We hypothesized that support for trainees to take parental leave would vary by year of residency graduation and by parental status. DESIGN: We conducted a web-based survey regarding opinions on trainee parental leave. Quantitative and conventional content qualitative analyses were performed. PARTICIPANTS: Surveys were sent to surgeon faculty and current trainees from 5 large academic surgical residency programs. RESULTS: Survey response rates were 11.5% for surgeon faculty (68/589), and 17.7% for trainees (50/281). There were 80/118 (67.8%) respondents who reported they had or were currently expecting children, 40/80 (50%) of whom were the gestational carrier. Most thought that 6-12 weeks of parental leave should be given to child-bearing trainees (62/118, 52.5%); another 32.2% (38/118) thought >12 weeks should be given. Responses were similar amongst surgeon faculty and trainees, parents and nonparents, and respondents who identified as men and women. Qualitative analysis revealed that most respondents felt parental leave did not put unreasonable strain on other trainees and felt support could be shown both informally and with formal written policies facilitating patient care coverage. Current surgeon faculty were less likely to feel moderately/extremely supported by their faculty compared to trainees (39% vs 77%, p = 0.004). Less than a third (37/117, 31.6%) of respondents knew the current leave policies. CONCLUSIONS: Amongst survey respondents, there was broad support for parental leave for surgical trainees of at least 6 weeks amongst trainees and faculty, and those with and without children. Current trainees felt more supported than current surgical faculty, suggesting that parental leave is increasingly more accepted. Support can be shown both informally and through easily accessible written policies and procedures that facilitate patient care coverage.

Robotic versus laparoscopic general surgery in the emergency setting: a systematic review.

Robot-assisted general surgery, an advanced technology in minimally invasive procedures, is increasingly employed in elective general surgery, showing benefits over laparoscopy in specific cases. Although laparoscopy remains a standard approach for common acute abdominal conditions, the role of robotic surgery in emergency general surgery remains uncertain. This systematic review aims to compare outcomes in acute general surgery settings for robotic versus laparoscopic surgeries. A PRISMA-compliant systematic search across MEDLINE, EMBASE, Science Citation Index Expanded, and the Cochrane Library was conducted. The literature review focused on articles comparing perioperative outcomes of emergency general surgery managed laparoscopically versus robot-assisted. A descriptive analysis was performed, and outcome measures were recorded. Six articles, involving 1,063 patients, compared outcomes of robotic and laparoscopic procedures. Two articles covered cholecystectomies, while the others addressed ileocaecal resection, subtotal colectomy, hiatal hernia and repair of perforated gastrojejunal ulcers. The level of evidence was low. Laparoscopic bowel resection in patients with inflammatory bowel disease (IBD) had higher complications; no significant differences were found in complications for other operations. Operative time showed no differences for cholecystectomies, but robotic approaches took longer for other procedures. Robotic cases had shorter hospital length of stay, although the associated costs were significantly higher. Perioperative outcomes for emergency robotic surgery in selected general surgery conditions are comparable to laparoscopic surgery. However, recommending robotic surgery in the acute setting necessitates a well-powered large population study for stronger evidence.

Failure to rescue following emergency general surgery: A national analysis.

Background: Failure to rescue (FTR) is increasingly recognized as a quality metric but remains understudied in emergency general surgery (EGS). We sought to identify patient and operative factors associated with FTR to better inform standardized metrics to mitigate this potentially preventable event. Methods: All adult (≥18 years) non-elective hospitalizations for large bowel resection, small bowel resection, repair of perforated ulcer, laparotomy and lysis of adhesions were identified in the 2016-2020 National Readmissions Database. Patients undergoing trauma-related operations or procedures ≤2 days of admission were excluded. FTR was defined as in-hospital death following acute kidney injury requiring dialysis (AKI), myocardial infarction, pneumonia, respiratory failure, sepsis, stroke, or thromboembolism. Multilevel mixed-effect models were developed to assess factors linked with FTR. Results: Among 826,548 EGS operations satisfying inclusion criteria, 298,062 (36.1 %) developed at least one MAE. Of those experiencing MAE, 43,477 (14.6 %) ultimately did not survive to discharge (FTR). Following adjustment for fixed hospital level effects, only 3.5 % of the variance in FTR was attributable to center-level differences. Relative to private insurance and the highest income quartile, Medicaid insurance (AOR 1.33; 95%CI, 1.23-1.43) and the lowest income quartile (AOR 1.22; 95%CI, 1.17-1.29) were linked with increased odds of FTR.A subset analysis stratified complication-specific rates of FTR by insurance status. Relative to private insurance, Medicaid coverage and uninsured status were linked with greater odds of FTR following perioperative sepsis, pneumonia, and AKI. Conclusion: Our findings underscore the need for increased screening and vigilance following perioperative complications to mitigate disparities in patient outcomes following high-risk EGS.

Assessing the impact of frailty in elderly patients undergoing emergency laparotomies in Singapore.

Introduction: The global rise in ageing populations poses challenges for healthcare systems. By 2030, Singapore anticipates a quarter of its population to be aged 65 or older. This study addresses the dearth of research on frailty's impact on emergency laparotomy (EL) outcomes in this demographic, emphasising the growing significance of this surgical intervention. Method: Conducted at 2 tertiary centres in Singapore from January to December 2019, a retrospective cohort study examined EL outcomes in patients aged 65 or older. Frailty assessment, using the Clinical Frailty Scale (CFS), was integrated into demographic, diagnostic and procedural analyses. Patient data from Tan Tock Seng Hospital and Khoo Teck Puat Hospital provided a comprehensive view of frailty's role in EL. Results: Among 233 participants, 26% were frail, revealing a higher vulnerability in the geriatric population. Frail individuals exhibited elevated preoperative risk, prolonged ICU stays, and significantly higher 90-day mortality (21.3% versus 6.4%). The study illuminated a nuanced connection between frailty and adverse outcomes, underlining the critical need for robust predictive tools in this context. Conclusion: Frailty emerged as a pivotal factor influencing the postoperative trajectory of older adults undergoing EL in Singapore. The integration of frailty assessment, particularly when combined with established metrics like P-POSSUM, showcased enhanced predictive accuracy. This finding offers valuable insights for shared decision-making and acute surgical unit practices, emphasising the imperative of considering frailty in the management of older patients undergoing emergency laparotomy.

Current insights on social media as a tool for the dissemination of research and education in surgery: a narrative review.

The purpose of our narrative review is to summarize the utilization of social media (SoMe) platforms for research communication within the field of surgery. We searched the PubMed database for articles in the last decade that discuss the utilization of SoMe in surgery and then categorized the diverse purposes of SoMe. SoMe proved to be a powerful tool for disseminating articles. Employing strategic methods like visual abstracts enhances article citation rates, the impact factor, h-index, and Altmetric score (an emerging alternative metric that comprehensively and instantly quantifies the social impact of scientific papers). SoMe also proved valuable for surgical education, with online videos shared widely for surgical training. However, it is essential to acknowledge the associated risk of inconsistency in quality. Moreover, SoMe facilitates discussion on specific topics through hashtags or closed groups and is instrumental in recruiting surgeons, with over half of general surgery residency programs in the US efficiently leveraging these platforms to attract the attention of potential candidates. Thus, there is a wealth of evidence supporting the effective use of SoMe for surgeons. In the contemporary era where SoMe is widely utilized, surgeons should be well-versed in this evidence.

Establishment of a 24/7 robotic acute care surgery program at a large academic medical center.

BACKGROUND: For many years, robotic surgery has been an option for various elective surgical procedures. Though robotic surgery has not traditionally been the first choice for acute surgical patients, recent work has shown promise in broader applications. However, there are limited data regarding how to establish an institutional robotics program for higher acuity patients. This project aimed to map a pathway for the creation of an acute care surgery robotic program at a large academic medical center. METHODS: Various stakeholders were gathered jointly with our surgical faculty: anesthesia, operating room leadership, surgical technologists, circulating nurses, Central Sterile Supply, and Intuitive Surgical Inc. representatives. Staff underwent robotics training, and surgical technologists were trained as bedside first assistants. Nontraditional robotic operating rooms were allocated for coordinated placement of appropriate cases, and pre-made case carts were arranged with staff to be available at all hours. A workflow was created between surgical faculty and staff to streamline add-on robotic cases to the daily schedule. RESULTS: Six faculty and two fellows are now credentialed in robotics surgery, and additional surgeons are undergoing training. Numerous staff have completed training to perform operative assistant duties. The operating capacity of robotic acute care surgeries has more than doubled in just one year, from 77 to 172 cases between 2022 and 2023, respectively. Two add-on cases can be accommodated per day. Select patients are being offered robotic surgeries in the acute surgical setting, and ongoing efforts are being made to create guidelines for which patients would best benefit from robotic procedures. CONCLUSIONS: Launching a successful robotic surgery program requires a coordinated, multidisciplinary effort to ensure seamless integration into daily operations. Additional assistance from outside technology representatives can help to ensure comfort with procedures. Further studies are needed to determine the acute patient population that may benefit most from robotic surgery.

Primary Invasive Paget's Disease in a Clinical Practice: A Case Report.

Invasive Paget's disease (IPDN) is a rare phenomenon characterised by invasive carcinoma localised to the nipple. It is associated with Paget's disease of the nipple (PDN) whereby Paget cells locally invade the underlying epidermis. Often in PDN, histopathological confirmation is needed, due to a lack of clear symptoms on clinical presentation. An 82-year-old female with single duct ectasia presented to the breast clinic in September 2023 with a tender, inflamed right nipple with a necrotic appearance. The lesion was excised, and an ultrasound scan showed right U2, implying no underlying malignancy. Microscopy showed Paget's disease with underlying ductal carcinoma in situ and two small (0.4 and 0.3mm) foci of dermal invasion by Paget cells in keeping with IPDN. Research suggests that dermal invasion by Paget cells has little effect on clinical outcome and prognosis depends largely on the associated underlying malignancy. However, all cases of IPDN with deep invasion or penetration of Paget cells into the dermis have the potential for regional and distant lymphatic spread. In extramammary Paget's disease, depth of invasion has been associated with poorer survival. Therefore, wide variability in clinical patterns and presentations of PDN mandates that a careful clinical approach correlated with in-depth histopathological evaluation is adopted in all cases.

The role of a dedicated Oncology Nurse Navigator in the surgical oncology pathways: 1 year experience from a General Surgery Unit in central Italy with follow up.

The Nurse Navigator is a highly specialized nurse with technical and non-technical skills that offers individualized assistance to cancer patients, their family and caregivers to overcome health system barriers and facilitate access to care. This role was introduced in the General Surgery Unit of the Madonna del Soccorso Hospital in San Benedetto del Tronto from 1st January 2023. The primary endpoint is to compare the times taken for each step of the diagnostic-therapeutic pathway comparing the study group followed by Oncology Nurse Navigator (ONN) and the group not followed by this role. The secondary endpoints, only for the study group, were the number of patient contacts with the ONN and the time slots; the number of examinations and consultations organized by ONN; the evaluation of patient satisfaction at discharge; the number and type of problems noted during follow-up contact at 7 and 30 days after discharge. A prospective court study with historical control was conducted from 1st January 2023 in Madonna del Soccorso Hospital, Italy. The study group consists of all cancer patients cared for by ONN. The control group was created by selecting the same number of patients as the study group but taken care of in the previous 3 years (from 2020 to 2022) and, therefore, without the presence of the Nurse Navigator. The control group data come from clinical documentation. The number and time slots of contact with the ONN were recorded through the use of a company mobile phone active 24/7 through phone calls and messages. The number of examinations and consultations is known through online requests. The satisfaction assessment was carried out through the use of externally validated questionnaire Patient Satisfaction with Cancer Care (PSCC). The follow-up was performed by telephone and recorded on documentation according to established parameters. A total of 200 patients were analyzed. Both the study and control groups included 100 patients each. The average time between the first contact with the patient and the execution of the diagnostic test was 7 days in the cases compared to 28 days in the control group. The waiting time for the Multi-Disciplinary Team discussion (MDT) was 3 days for the study group compared to 6 days in the control group. The average time taken for the first oncological visit was 3 days in the study group compared to 18 days in the controls. The time from first contact to the operating session was 20 days compared to 45 in controls. Each patient had an average of 10 phone calls with the ONN. For all patients accompanied at the first diagnosis, at least 2 radiological and laboratory tests were organized. Oncology appointment for treatment evaluations after delivery of the histological report was communicated within a maximum of 3 working days. A patient satisfaction questionnaire achieved a response rate of 100%, with an average score of 87.0/90. The telephone follow-up had a response rate of 100% of patients and revealed a decrease in problems at the 30-day check-up compared to that of 7 days after discharge. (Activity of Daily Living 20% vs 8%; nutritional problems 40% vs 21%, pain 18% vs 2%; surgical wounds 45% vs 1%; mobilization 8% vs 0%). The data demonstrate that ONN service improves the quality and outcomes of surgical oncology patients' pathway. The professional role of the ONN, with predefined technical and non-technical skills, should also be officially recognized by the healthcare system and hospital administration.

Understanding Emotions Impacted by New Assessment Mandates Implemented in Medical Education: A Survey of Residents and Faculty Across Multiple Specialties.

Background Previous research findings show that the overall perception of residents regarding the new entrustable professional activity (EPA) assessment mandates is primarily negative. Hence, this study aims to explore the link between EPA assessment experiences and resident and faculty emotions and expectancy of successfully completing residency training. Methods A standardized questionnaire (Medical Emotions Scale (MES)), which measures 20 unique emotions on a 5-point Likert scale, was used to explore the emotions of residents and faculty members regarding EPA assessments and residents' expectancy of success. Data analysis included descriptive statistics and analysis of variance (ANOVA). Results Ninety-one (N=91) participants (46 faculty members and 45 residents) completed the survey. The results revealed that residents have more negative emotions toward EPA assessments compared to faculty. Additionally, resident and faculty emotions regarding EPA assessments vary across specialty and gender. Conclusions These findings will be crucial in providing the Royal College of Physicians and Surgeons of Canada and medical education programs with concrete evidence and guidance in understanding the perspectives and emotions of residents and faculty towards EPA assessments and residents' beliefs about successfully completing their medical training.

The Open Abdomen After Intra-abdominal Contamination in Emergency General Surgery.

INTRODUCTION: Delayed fascial closure (DFC) is an increasingly utilized technique in emergency general surgery (EGS), despite a lack of data regarding its benefits. We aimed to compare the clinical outcomes of DFC versus immediate fascial closure (IFC) in EGS patients with intra-abdominal contamination. METHODS: This retrospective study was conducted using the 2013-2020 American College of Surgeons National Surgical Quality Improvement Program database. Adult EGS patients who underwent an exploratory laparotomy with intra-abdominal contamination [wound classification III (contaminated) or IV (dirty)] were included. Patients with agreed upon indications for DFC were excluded. A propensity-matched analysis was performed. The primary outcome was 30-d mortality. RESULTS: We identified 36,974 eligible patients. 16.8% underwent DFC, of which 51.7% were female, and the median age was 64 y. After matching, there were 6213 pairs. DFC was associated with a higher risk of mortality (15.8% versus 14.2%, P = 0.016), pneumonia (11.7% versus 10.1%, P = 0.007), pulmonary embolism (1.9% versus 1.6%, P = 0.03), and longer hospital stay (11 versus 10 d, P < 0.001). No significant differences in postoperative sepsis and deep surgical site infection rates between the two groups were observed. Subgroup analyses by preoperative diagnosis (diverticulitis, perforation, and undifferentiated sepsis) showed that DFC was associated with longer hospital stay in all subgroups, with a higher mortality rate in patients with diverticulitis (8.1% versus 6.1%, P = 0.027). CONCLUSIONS: In the presence of intra-abdominal contamination, DFC is associated with longer hospital stay and higher rates of mortality and morbidity. DFC was not associated with decreased risk of infectious complications. Further studies are needed to clearly define the indications of DFC.

The Impact of the COVID-19 Pandemic on Geographic Placement of Applicants to General Surgery Residency Programs.

OBJECTIVE: COVID-19 greatly influenced medical education and the residency match. As new guidelines were established to promote safety, travel was restricted, visiting rotations discontinued, and residency interviews turned virtual. The purpose of this study is to assess the geographic trends in distribution of successfully matched General Surgery applicants prior to and after the implementation of pandemic guidelines, and what we can learn from them as we move forward. DESIGN: This was a retrospective review of 129 Accreditation Council for Graduate Medical Education (ACGME) accredited, academic General Surgery Residency Programs across 46 states and the District of Columbia. Categorically matched residents' medical schools (i.e., home institutions), medical school states, and medical school regions as defined per the Association of American Medical Colleges (AAMC), were compared to the same geographic datapoints as their residency program. Preliminary residents were excluded. Residents in the 2018, 2019, and 2020 cycles were sub-categorized into the "pre-COVID" group and residents in the 2021 and 2022 applications cycles were sub-categorized into the "post-COVID" group. The percentages of residents who matched at their home institution, in-state, and in-region were examined. SETTING: Multiple ACGME-accredited, university-affiliated General Surgery Residency Programs across the United States of America. PARTICIPANTS: A total of 4033 categorical General Surgery residents were included. RESULTS: Of 4033 categorical residents who matched between 2018 and 2022, 56.1% (n = 2,263) were in the pre-COVID group and 43.9% (n = 1770) were in the post-COVID group. In the pre-COVID group 14.4% (n = 325) of residents remained in-home (IH), 24.4% (n = 553) in-state (IS), and 37.0% (n = 837) in- region (IR), compared to 18.8% IH (n = 333), 27.8% IS (n = 492), and 39.9% IR (n = 706) in the post-COVID group, respectively. Significant increases for IH and IS resident matching at 4.5% and 3.4%, respectively, were noted in the post-COVID period (p < 0.05). CONCLUSION: The COVID-19 pandemic, and the ensuing changes adopted to promote safety, significantly impacted medical student opportunities and the General Surgery residency application process. General Surgery match data over the last 5 years reveals a statistically significant increase in the percentage of applicants matching at in-home and in-state institutions after the pandemic.

Right-sided Morgagni diaphragmatic hernia presenting as isolated left shoulder pain.

A woman in her 60s presented to the emergency department with excruciating, deep left shoulder pain and was found to have a right-sided Morgagni hernia, a rare type of congenital diaphragmatic hernia (CDH). She did not have chest pain, palpitations, shortness of breath, cough, abdominal pain, constipation, diarrhoea, nausea, vomiting or other symptoms classically associated with CDHs in adults. Laparoscopic robotic-assisted repair with mesh placement was performed, and the patient's recovery was uncomplicated, with no recurrence of shoulder pain. Our patient's presentation was unusual due to the absence of symptoms typically seen with CDHs in adults, and the presence of contralateral, left-sided shoulder pain with a right-sided Morgagni hernia.