Justin C. McCarty

Cosmesis, patient satisfaction, and quality of life after da Vinci Single-Site cholecystectomy and multiport laparoscopic cholecystectomy: short-term results from a prospective, multicenter, randomized, controlled trial

AbstractBackgroundSingle-incision laparoscopic cholecystectomy evolved from the traditional multiport laparoscopic technique. Prior trials have demonstrated improved cosmesis with the single-incision technique. Robotic single-site surgery minimizes the technical difficulties associated with laparoscopic single-incision approach. This is the first prospective, randomized, controlled study comparing robotic single-site cholecystectomy (RSSC) and multiport laparoscopic cholecystectomy (MPLC) in terms of cosmesis and patient satisfaction.MethodsPatients with symptomatic benign gallbladder disease were randomized to RSSC or MPLC. Data included perioperative variables such as operative time, conversion and complications and cosmesis satisfaction, body image perception, quality of life using validated questionnaires, at postoperative visits of 2, 6xa0weeks and 3xa0months.ResultsOne hundred thirty-six patients were randomized to RSSC (Nxa0=xa083) and MPLC (Nxa0=xa053) at 8 institutions. Both cohorts were dominated by higher enrollment of females (RSSCxa0=xa078%, MPLCxa0=xa092%). The RSSC and MPLC cohorts were otherwise statistically matched. Operative time was longer for RSSC (61xa0min vs. 44xa0min, Pxa0<xa00.0001). There were no differences in complication rates. RSSC demonstrated a significant superiority in cosmesis satisfaction and body image perception (P valuexa0<xa00.05 at every follow-up). There was no statistically significant difference in patient-reported quality of life. Multivariate analysis of female patients demonstrated significantly higher preference for RSSC over MPLC in cosmesis satisfaction and body image perception with no difference seen in overall quality of life.ConclusionsResults from this trial show that RSSC is associated with improved cosmesis satisfaction and body image perception without a difference in observed complication rate. The uncompromised safety and the improved cosmesis satisfaction and body image perception provided by RSSC for female patients support consideration of the robotic single-site approach.n ClinicalTrials.gov identifier NCT01932216.

Transition from Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair to Robotic Transabdominal Preperitoneal Inguinal Hernia Repair: A Retrospective Review of a Single Surgeon’s Experience

BackgroundThere is a paucity of literature comparing laparoscopic to robotic inguinal hernia repair. We present a single surgeon’s transition from laparoscopic totally extraperitoneal (L-TEP) to robotic transabdominal preperitoneal (R-TAPP) inguinal hernia repair and compare outcomes from the two approaches.MethodsThis retrospective review and analysis of prospectively collected data compare outcomes during the transition from L-TEP to R-TAPP inguinal hernia repair by a single surgeon at one institution. Operating times and surgical outcomes and complications are analyzed. All consecutive L-TEP cases from November 2012 to August 2014 and all consecutive R-TAPP cases from March 2013 to October 2015 were included in the analysis.ResultsA total of 157 and 118 patients underwent L-TEP and R-TAPP inguinal hernia repair, respectively. The groups were similar regarding demographics and ASA class. A significantly higher number of complex cases were performed in the R-TAPP group compared to L-TEP group (nxa0=xa011 vs. nxa0=xa01, pxa0=xa00.0001). Mean surgical times were nearly identical (69.12xa0±xa035.13xa0min, R-TAPP; 69.05xa0±xa026.31, L-TEP) as were intraoperative and postoperative complication rates—despite the significantly higher number of complex cases in the R-TAPP group.ConclusionsThis is the largest study in the literature comparing a single surgeon’s experience transitioning from L-TEP to R-TAPP inguinal hernia repair. Results from the R-TAPP cases were similar to those achieved from laparoscopic cases. The robotic platform may have facilitated the execution of complex hernia cases during the proficiency phase.

Identifying Asthma Triggers

Asthma has many triggers including rhinosinusitis; allergy; irritants; medications (aspirin in aspirin-exacerbated respiratory disease); and obesity. Paradoxic vocal fold dysfunction mimics asthma and may be present along with asthma. This article reviews each of these triggers, outlining methods of recognizing the trigger and then its management. In many patients more than one trigger may be present. Full appreciation of the complexity of these relationships and targeted therapy to the trigger is needed to best care for the patient with asthma.

Effectiveness of Instructional Interventions for Hemorrhage Control Readiness for Laypersons in the Public Access and Tourniquet Training Study (PATTS): A Randomized Clinical Trial

Importance Several national initiatives have emerged to empower laypersons to act as immediate responders to reduce preventable deaths from uncontrolled bleeding. Point-of-care instructional interventions have been developed in response to the scalability challenges associated with in-person training. However, to our knowledge, their effectiveness for hemorrhage control has not been established. Objective To evaluate the effectiveness of different instructional point-of-care interventions and in-person training for hemorrhage control compared with no intervention and assess skill retention 3 to 9 months after hemorrhage control training. Design, Setting, and Participants This randomized clinical trial of 465 laypersons was conducted at a professional sports stadium in Massachusetts with capacity for 66 000 people and assessed correct tourniquet application by using different point-of-care interventions (audio kits and flashcards) and a Bleeding Control Basic (B-Con) course. Non-B-Con arms received B-Con training after initial testing (conducted from April 2017 to August 2017). Retesting for 303 participants (65%) was performed 3 to 9 months after training (October 2017 to January 2018) to evaluate B-Con retention. A logistic regression for demographic associations was performed for retention testing. Interventions Participants were randomized into 4 arms: instructional flashcards, audio kits with embedded flashcards, B-Con, and control. All participants received B-Con training to later assess retention. Main Outcomes and Measures Correct tourniquet application in a simulated scenario. Results Of the 465 participants, 189 (40.7%) were women and the mean (SD) age was 46.3 (16.1) years. For correct tourniquet application, B-Con (88% correct application [nu2009=u2009122]; Pu2009<u2009.001) was superior to control (nu2009=u2009104 [16%]) while instructional flashcards (nu2009=u2009117 [19.6%]) and audio kit (nu2009=u2009122 [23%]) groups were not. More than half of participants in point-of-care arms did not use the educational prompts as intended. Of 303 participants (65%) who were assessed 3 to 9 months after undergoing B-Con training, 165 (54.5%) could correctly apply a tourniquet. Over this period, there was no further skill decay in the adjusted model that treated time as either linear (odds ratio [OR], 0.98; 95% CI, 0.95-1.03) or quadratic (OR, 1.00; 95% CI, 1.00-1.00). The only demographic that was associated with correct application at retention was age; adults aged 18 to 35 years (nu2009=u200958; OR, 2.39; 95% CI, 1.21-4.72) and aged 35 to 55 years (nu2009=u2009107; OR, 1.77; 95% CI, 1.04-3.02) were more likely to be efficacious than those older than 55 years (nu2009=u2009138). Conclusions and Relevance In-person hemorrhage control training for laypersons is currently the most efficacious means of enabling bystanders to act to control hemorrhage. Laypersons can successfully perform tourniquet application after undergoing a 1-hour course. However, only 54.5% retain this skill after 3 to 9 months, suggesting that investigating refresher training or improved point-of-care instructions is critical. Trial Registration ClinicalTrials.gov Identifier: NCT03479112

Hemorrhage Control Training Promotes Resilience-Associated Traits in Medical Students

OBJECTIVEnGiven rising rates of physician burnout, the potential for clinical skills training programs to develop and reinforce resilience-associated traits in medical students warrants investigation. The primary objective of this study was to examine the impact of a hemorrhage control training program on resilience-associated traits (role-clarity, self-efficacy, and empowerment) in medical students. A secondary objective was to examine the differential impact of additional hands-on skills training.nnnDESIGNnThis was a prospective study of medical students participating in an established hemorrhage control training program, utilizing pre-, mid-, and post-training questionnaires. The program included both an in-person lecture and hands-on skills training. Primary endpoints were self-reported increases in role clarity (when the hemorrhage control skills would and would not be applicable), self-efficacy (confidence in ability to use the skill), and empowerment (to act in a situation where the skill was needed).nnnSETTINGnHarvard Medical School, Boston, Massachusetts.nnnPARTICIPANTSnOne hundred and twenty-six Harvard Medical School students participated.nnnRESULTSnThere was a significant increase at each stage of training in self-reported role clarity about when to apply hemorrhage control skills (p < 0.01) and when not to apply them (p < 0.01); confidence in application of the skill (p < 0.01); as well as empowerment to apply the skill when appropriate (p < 0.01).nnnCONCLUSIONSnHemorrhage control training, a first response-related clinical skills program, is a promising domain for development and reinforcement of resilience-associated traits in medical students, particularly when the program includes hands-on skills training. Providing experiential learning opportunities that are designed not only for skills-specific outcomes, but also to reinforce such resilience-associated traits as role-clarity, self-efficacy, and empowerment provides an essential integrated perspective.

Lethality of Civilian Active Shooter Incidents With and Without Semiautomatic Rifles in the United States

Lethality of Civilian Active Shooter Incidents With and Without Semiautomatic Rifles in the United States Semiautomatic rifles have been used in some of the largest active shooter incidents in US history.1 The weapons were banned in 1994 under the federal assault weapons ban but were reintroduced to the public marketplace in 2004.2 Currently, there are no comprehensive assessments of injuries from different types of firearms. We compared the number of persons wounded, killed, and either wounded or killed during active shooter incidents with and without semiautomatic rifles.

Can they stop the bleed? Evaluation of tourniquet application by individuals with varying levels of prior self-reported training

BACKGROUNDnApplication of extremity tourniquets is a central tenet of multiple national initiatives to empower laypersons to provide hemorrhage control (HC). However, the efficacy of the general population who self-report prior first-aid (FA) or HC training on individuals ability to control bleeding with a tourniquet remains unknown. Therefore, the objective of this study was to assess the effectiveness of laypeople with self-reported prior FA or HC training to control bleeding with a tourniquet.nnnSTUDY DESIGNnEmployees of a stadium were assessed via simulation in their ability to apply a Combat Application Tourniquet. As a subgroup analysis of a larger study, participants who self-reported: 1) No prior training, 2) FA training only or 2) FAu2009+u2009HC training were compared. Logistic regression adjusting for age, gender, education, willingness-to-assist, and comfort level in HC was performed.nnnRESULTSn317 participants were included. Compared to participants with no prior training (14.4%,nu2009=u200916/111), those with FA training only (25.2%,nu2009=u200935/139) had a 2.12-higher odds (95%CI:1.07-4.18) of correct tourniquet application while those with FAu2009+u2009HC (35.8%,nu2009=u200924/67) had a 3.50-higher odds (95%CI:1.59-7.72) of correct application. Participants with prior FAu2009+u2009HC were more willing-to-assist and comfortable performing HC than those without prior training (pu2009<u20090.05). However, reporting being very willing-to-assist [OR0.83,95%CI:0.43-1.60] or very comfortable [OR1.11,95%CI:0.55-2.25] was not associated with correct tourniquet application.nnnCONCLUSIONnSelf-reported prior FAu2009+u2009HC training, while associated with increased likelihood to correctly apply a tourniquet, results in only 1/3 of individuals correctly performing the skill. As work continues in empowering and training laypeople to act as immediate responders, these findings highlight the importance of effective layperson education techniques.