Alan H. Tyroch

Case Based Review Questions, Review Sessions, and Call Schedule Type Enhance Knowledge Gains in a Surgical Clerkship

INTRODUCTION Medical students in surgical clerkships must gain surgical knowledge while doing clinical rotations. We developed a self-learning program, which is case based, the Case Review Question (CRQ) system. Our hypothesis was that students who used CRQs would score higher on the summative test, Surgery NBME (National Board of Medical Examiners). METHODS The setting is a surgical clerkship in a Liaison Council for Medical Education (LCME) approved Medical School, with summative examination using the NBME shelf examination in Surgery. Each CRQ document is a series of 20 to 25 questions based on cases. The cases are a paragraph, with pertinent medical facts and extra facts as distracters. The students are encouraged to use these questions to guide study. Students must come to a review session to hear the answers and a discussion. We review the NBME Surgery shelf examination scores taken before and after this program was initiated, along with changes in rotation group size, call schedule type, and other changes. RESULTS CRQs, review sessions, and call schedule changes improved scores. NBME examination average rose from 77.12 to 82.01 (p = 0.004) after the CRQ program was initiated. Call schedule revision improved scores: intermittent call NBME score was 80.98, whereas night float schedule mean NBME was 84.66 (p < 0.001). During night float call, the CRQ program was already in effect, so that there is no non-CRQ program comparison group. Students scored higher in the second semester, throughout the study. First semester students scored a mean of 79.11, whereas second semester students scored 84.195 (p < 0.001). By the end of the study, there were no failures on the NBME examination, even in the first semester. The factors of presence of the CRQ program, review sessions, call schedule type, and which semester were all significant in a correlation matrix against NBME scores and in a regression analysis (p < 0.001). CONCLUSIONS The CRQ program of case-based self-study was associated with higher scores on the NBME shelf examination, as a summative test of medical knowledge in surgery.

Injuries sustained after falls from bridges across the United States-Mexico border at El Paso

OBJECTIVE To compare demographics and motivations for falls from bridges at the United States-Mexico border and in El Paso County, Texas, and to analyze injuries and injury patterns to support intentionality and to provide treatment recommendations. METHODS A retrospective observational review was conducted of hospital admissions to a trauma center after falls from bridges from 1995 to 2009. Statistical methods used were chi-square testing, T-test for means comparison, univariate correlations, and regression analysis. RESULTS Of the 97 evaluated patients, 81.4% fell from U.S.-Mexico border bridges, including one patient who fell from a railway bridge; 74.7% of those falling from border bridges had a non-U.S. address, contrasting with 22.2% of those who fell within the United States. Falls over the border were associated with more immigration-related motivations and fewer suicide attempts. Injuries included lower extremities in 76 (78.4%) and thoracolumbar spine in 27 (27.8%) patients; 16 patients with a thoracolumbar spine fracture (59.3%) also had a lower extremity injury. Mean hospital length of stay was 7.2 days. Mean injury severity score was 8.45 (range 1-43). Age, injury severity score, and pelvic fracture increased the hospital length of stay. CONCLUSIONS Patients fell while emigrating-immigrating based on residence and motivating factors. A dyad of lower extremity and thoracolumbar spine injuries coincided in 59.3% of those with a thoracolumbar spine injury; thoracolumbar spine imaging of patients evaluated after falls from bridges is recommended. Proposed prevention strategies include posting signs on bridges and installing catch-net safety barriers.

Characteristics and management of blunt renal injury in children

Background: Renal trauma in the pediatric population is predominately due to blunt mechanism of injury. Our purpose was to determine the associated injuries, features, incidence, management, and outcomes of kidney injuries resulting from blunt trauma in the pediatric population in a single level I trauma center. Methods: This was a retrospective chart and trauma registry review of all pediatric blunt renal injuries at a regional level I trauma center that provides care to injured adults and children. The inclusion dates were January 2001–June 2014. Results: Of 5790 pediatric blunt trauma admissions, 68 children sustained renal trauma (incidence: 1.2%). Only two had nephrectomies (2.9%). Five renal angiograms were performed, only one required angioembolization. Macroscopic hematuria rate was significantly higher in the high-grade injury group (47% vs. 16%; P = 0.031). Over half of the patients had other intra-abdominal injuries. The liver and spleen were the most frequently injured abdominal organs. Conclusion: Blunt renal trauma is uncommon in children and is typically of low American Association for the Surgery of Trauma injury grade. It is commonly associated with other intra-abdominal injuries, especially the liver and the spleen. The nephrectomy rate in pediatric trauma is lower compared to adult trauma. Most pediatric blunt renal injury can be managed conservatively by adult trauma surgeons.

Reversal of newer direct oral anticoagulant drugs (DOACs).

Anticoagulation therapy is indicated for management of various clinical conditions to prevent adverse events and introduction of direct oral anticoagulants (DOACs) has ushered in a new era in anticoagulation therapy. Major advantages of DOACS include fewer drug interactions and that they do not need periodic monitoring. Several patients who were not on anticoagulation before due to older age, polypharmacy/drug interaction concerns, and logistics of periodic monitoring are now on anticoagulation with DOACs. Despite their many advantages, a challenge while prescribing DOACs is very limited availability of specific reversal agents and lack of understanding or guidance about the treatment strategy in case of major life threatening bleeding or need for urgent surgery. So far only one reversal agent has been approved by the Food and Drug Administration (FDA), idarucizumab for one of the DOACs i.e., dabigatran. Several other reversal agents are under final phases of development such as andexanet alfa and PER977 (ciraparantag) and will help in developing specific strategies for reversal of these agents. In this article, we review current strategies to manage bleeding with DOACs and provide guidance to clinicians of inhibiting LF activity in vitro and in cells, as well as in animal models of anthrax infection.

Association of Atlanto-Occipital Dislocation, Retroclival Hematoma, and Hydrocephalus: Management and Survival in a Pediatric Patient

Atlanto-occipital dislocation (AOD) is an injury with high morbidity and mortality. We present a case of survival of a pediatric patient with the diagnoses of AOD, retroclival hematoma, and resulting hydrocephalus. The patients cervical spine was stabilized until occipital-cervical fusion provided definitive treatment, and the hydrocephalus was treated with a ventriculostomy. The patient survived with no neurological deficits. A better understanding and awareness of the radiologic criteria of AOD will lead to earlier recognition of AOD and improved outcomes, even in the presence of complications from AOD. Surgical fixation should be used for definitive treatment of injuries with AOD.

Trauma patients warrant upper and lower extremity venous duplex ultrasound surveillance

Background: Due to the high incidence of thromboembolic events (deep venous thrombosis [DVT] and pulmonary embolus [PE]) after injury, many trauma centers perform lower extremity surveillance duplex ultrasounds. We hypothesize that trauma patients are at a higher risk of upper extremity DVTs (UEDVTs) than lower extremity DVTs (LEDVTs), and therefore, all extremities should be evaluated. Materials and Methods: A retrospective chart and trauma registry review of Intensive Care Unit trauma patients with upper and LEDVTs detected on surveillance duplex ultrasound from January 2010 to December 2014 was carried out. Variables reviewed were age, gender, injury severity score, injury mechanism, clot location, day of clot detection, presence of central venous pressure catheter, presence of inferior vena cava filter, mechanical ventilation, and fracture. Results: A total of 136 patients had a DVT in a 5-year period: upper - 71 (52.2%), lower - 61 (44.9%), both upper and lower - 4 (2.9%). Overall, 75 (55.2%) patients had a UEDVT. Upper DVT vein: Brachial (62), axillary (26), subclavian (11), and internal jugular (10). Lower DVT vein: femoral (58), popliteal (14), below knee (4), and iliac (2). 10.3% had a PE: UEDVT - 5 (6.7%) and LEDVT - 9 (14.8%) P = 0.159. Conclusions: The majority of the DVTs in the study were in the upper extremities. For trauma centers that aggressively screen the lower extremities with venous duplex ultrasound, surveillance to include the upper extremities is warranted.