Aleksandra Krajewski

Implementation of an intern boot camp curriculum to address clinical competencies under the new Accreditation Council for Graduate Medical Education supervision requirements and duty hour restrictions.

IMPORTANCE Todays general surgery interns are faced with increased duty hour restrictions and stringent competency-based supervision milestone requirements (ie, from direct to indirect supervision). Working within these constraints, we instituted a unique 2-month intern curriculum (boot camp) incorporating knowledge-based, experiential, and practical components. OBJECTIVES To describe our curriculum and the effect on resident performance and teaching faculty and nursing staff perceptions. DESIGN All interns underwent a 2-month (July and August 2011) boot camp curriculum consisting of two 2½-hour knowledge-based and procedural skills (SimMan) didactic sessions per week and completion of 25 core intensive introductory American College of Surgeons Fundamentals of Surgery web-based self-study modules, followed by a standardized patient clinical skills assessment. SETTING Integrated general surgery residency program at the University of Connecticut School of Medicine, Farmington. PARTICIPANTS Postgraduate year 1 general surgery categorical and preliminary residents. MAIN OUTCOMES AND MEASURES We used several assessment tools, including an intern boot camp survey, clinical skills assessment scores, intern American Board of Surgeons In-Training Examination scores, and nursing staff and teaching faculty surveys of intern performance and aptitudes compared with the previous years interns. Data were analyzed by independent group t test, χ2 tests of proportions, and Fisher exact test for small sample cross tables. RESULTS In total, 84% (91 of 108) of intern respondents agreed or strongly agreed with the usefulness, relevance, and execution of the boot camp. Compared with the previous years interns, the nursing staff agreed or strongly agreed that the cohort interns were better at patient assessment, collaboration, and effective communication and provided compassionate and respectful patient care. More than 40% (7 of 17) of surveyed teaching faculty agreed or strongly agreed that the cohort interns demonstrated better patient care and procedural skills and self-confidence compared with the previous years interns. The clinical skills assessment scores after the 2-month boot camp paralleled the scores typically seen at the end of the previous 2 internship years (P > .25 for all). The proportion of nondesignated and categorical interns pursuing careers in general surgery scoring in the top quartile on the American Board of Surgery In-Training Examination increased from 7% (2 of 28) to 50% (5 of 10) compared with the previous 2 internship years (P = .01). CONCLUSIONS AND RELEVANCE Recent changes in intern duty hours and supervision rules mandate that residency training programs must institute a competency-oriented curriculum to provide interns with the necessary knowledge and practical skills to attain clinical competence.

Post-appendectomy visits to the emergency department within the global period: a target for cost containment.

BACKGROUND Postoperative visits to the emergency department (ED) instead of the surgeons office consume enormous cost. HYPOTHESIS Postoperative ED visits can be avoided. SETTING Fully accredited, single-institution, 617-bed hospital affiliated with the University of Connecticut School of Medicine. PATIENTS Retrospective analysis of 597 consecutive patients with appendectomies over a 4-year period. METHODS Demographic and medical data, at initial presentation, surgery, and ED visit were recorded as categorical variables and statistically analyzed (Pearson chi(2) test, Fisher exact test, and linear-by-linear). Costs were calculated from the hospitals billing department. RESULTS Forty-six patients returned to the ED within the global period with pain (n = 22, 48%), wound-related issues (n = 6, 13%), weakness (n = 4, 9%), fever (13%), and nausea and vomiting (n = 3, 6%). Thirteen patients (28%) required readmission. Predictive factors for ED visit postoperatively were perforated appendicitis (2-fold increase over uncomplicated appendicitis) and comorbidities (cardiovascular or diabetes). The cost of investigations during ED visits was

Phagocytosis: reemerging roles for a primitive function.

55,000 plus physician services. CONCLUSIONS ED visits during the postoperative global period are avoidable by identifying patients who may need additional care; improving patient education, optimizing pain control, and improving patient office access.

Surgical management and reconstruction of sincipital encephalocele presenting in adulthood

Background: Described by Metchnikoff, it has been 100 years since the discovery of phagocytosis was awarded the Nobel Prize. Since then, advances in phagocytosis research have vastly expanded its potential clinical application to health and disease. In this article, the authors revisit this process of evolution and chart out its relevance to plastic surgery. Methods: The discovery and evolution of the concept of phagocytosis are described. Its role in innate and adaptive immune responses is reviewed in the light of converging new discoveries in allied fields. Lastly, how the Rubicon of phagocytosis research could specifically address brittle plastic surgical problems is examined and currently available research tools that would specifically facilitate this work are described. Results: Phagocytosis is centrally important in an expanded repertoire of plastic surgical problems. These include aging, wherein a rapid rate of elimination of apoptotic elements could slow chronologic damage. Other examples include problematic wound repair; skin cancers including melanoma; in radiation and metabolic tissue insult; keloid and hypertrophic scarring; burns and antibiotic-resistant infections; transplantation immunology; regenerative medicine; and lastly “cosmeceuticals,” wherein nanoparticle-based drug delivery systems could be explored using novel phagocytic carriers. Conclusions: For plastic surgeons, phagocytosis research is an attractive opportunity to solve some tough clinical problems. For biologists, the collaboration with plastic surgeons opens a vista of novel translational research. It holds the robust promise of developing a new class of drugs with which to address vast unmet clinical needs. For phagocytosis, its reemergence is a well-deserved encore. Lastly, for Metchnikoff, it is a befitting 100-year anniversary.

Ortho-Plastic Reconstruction of Massive Rotator-Cuff Tears Using the Latissimus Dorsi Tendon

Sincipital encephaloceles presenting in adulthood are misdiagnosed until they present with persistent cerebrospinal fluid (CSF) rhinorrhea or, in extreme cases, meningeal infection. The basic approach to their repair is a frontal craniotomy and bandeau-type removal of the orbital framework, and reconstruction using dural patch for watertight dural closure, split calvarial bone graft fixation for rigid repair of the bony framework, and a vascularized pericranial flap to provide the soft tissue interposition. We emphasize the pitfall of biopsy when encephalocele is included in the differential diagnosis of a nasal mass and include a step-by-step operative technique that ensures safe and effective reconstruction of the skull base defect.

Pretraining and Posttraining Assessment of Residents' Performance in the Fourth Accreditation Council for Graduate Medical Education Competency: Patient Communication Skills

INTRODUCTION: Massive rotator cuff tears refractory to conservative measures present a therapeutic challenge. Patients are narcotic-dependent, significantly debilitated and conventional surgical repair is unsuccessful. The latissimus tendon has been used for repair of these large defects. Here we describe an ortho-plastic approach (a combined team of orthopedic and plastic surgeons) for the safe and effective harvest of the latissimus dorsi tendon for repair of the defects following extensive resection of the scarred rotator cuff.