Stephen D. Helmer

FAMILY PRESENCE DURING TRAUMA RESUSCITATION: A SURVEY OF AAST AND ENA MEMBERS

BackgroundThe Emergency Nurses Association (ENA) has formally resolved that family presence (FP) during resuscitation and invasive procedures (TR) is the right of the patient and is beneficial for both patients and family members. Furthermore, FP during TR has been implemented at several trauma cent

Factors influencing a woman’s choice to undergo breast-conserving surgery versus modified radical mastectomy

BACKGROUND The use of breast-conserving surgery (BCS) rather than modified radical mastectomy (MRM) for the treatment of breast carcinoma is an option for the majority of women (75%) with early stage breast cancer, but only 20% to 50% choose to undergo this procedure nationwide. The objective of this study was to identify factors influencing a womans choice between BCS and MRM, and specifically, the surgeons influence on this choice. METHODS A total of 134 women eligible for BCS were sent a survey. Data obtained included demographics, influential factors in treatment choice, and satisfaction with preoperative discussion and postoperative results. RESULTS Ninety-six women completed the questionnaire. Mean patient age was 62 years. Most women surveyed felt their treatment options were satisfactorily explained to them. BCS, MRM with reconstruction (MRM-R), and MRM without reconstruction (MRM-NR) were performed in 45%, 15%, and 40% of patients, respectively. Overall, the most influential factor was the fear of cancer. Women choosing BCS indicated that the surgeon, cosmetic result, and psychological aspects were more influential in their decision than in women undergoing MRM-NR (P <0.02). Fear of cancer was the most important factor affecting the choice to undergo MRM-NR. In comparing MRM-R with MRM-NR, there was a similar fear of cancer; however, MRM-R had much greater concern with cosmesis (P = 0.0002). CONCLUSION The surgeons input is important in a womans choice to undergo BCS or MRM-R. However, it appears that if a woman wants to have MRM-NR, even when she is a candidate for BCS, the surgeons input is overshadowed by the patients fear of cancer.

American Board of Surgery examinations: can we identify surgery residency applicants and residents who will pass the examinations on the first attempt?

BACKGROUND The Residency Review Committee requires that 65% of general surgery residents pass the American Board of Surgery qualifying and certifying examinations on the first attempt. The aim of this study was to identify predictors of successful first-attempt completion of the examinations. METHODS Age, sex, Alpha Omega Alpha Honor Medical Society status, class rank, honors in third-year surgery clerkship, interview score, rank list number, National Board of Medical Examiners/United States Medical Licensing Examination scores, American Board of Surgery In-Training Examination scores, resident awards, and faculty evaluations of senior residents were reviewed. Graduates who passed both examinations on the first attempt were compared with those who failed either examination on the first attempt. RESULTS No subjective evaluations of performance predicted success other than resident awards. Significant objective predictors of successful first-attempt completion of the examinations were Alpha Omega Alpha status, ranking within the top one third of ones medical student class, National Board of Medical Examiners/United States Medical Licensing Examination Step 1 (>200, top 50%) and Step 2 (>186.5, top 3 quartiles) scores, and American Board of Surgery In-Training Examination scores >50th percentile (postgraduate years 1 and 3) and >33rd percentile (postgraduate years 4 and 5). CONCLUSIONS Residency programs can use this information in selecting residents and in identifying residents who may need remediation.

Breast cancer tumor size: correlation between magnetic resonance imaging and pathology measurements.

BACKGROUND As physicians increasingly use magnetic resonance imaging (MRI) for the evaluation of newly diagnosed breast cancers, a review of the correlation between MRI and pathology tumor size is imperative. METHODS A retrospective review of 91 breast tumors comparing preoperative MRI tumor size to final pathology tumor size was performed. RESULTS MRI and pathology tumor size were positively correlated (R = .650), but with an average overestimation by MRI of .63 cm (P <.0001). When stratified by MRI tumor size (< or = 2.0 cm and > 2.0 cm), a significant difference was found only in tumors greater than 2.0 cm (average overestimation = 1.06 cm; P <.0001). This trend continued for the histological subtypes of ductal carcinoma in situ (DCIS), invasive ductal carcinoma (IDC), and invasive lobular carcinoma (ILC). CONCLUSIONS MRI tumor size correlates with pathology size; however, a significant overestimation exists, particularly for tumors > 2.0 cm. Clinicians should therefore use caution in relying on MRI tumor size in determining candidacy for breast conservation therapy (BCT).

Debt and other influences on career choices among surgical and primary care residents in a community-based hospital system.

BACKGROUND To evaluate debt and other factors that help formulate the career paths of future surgical and primary care physicians, a survey was undertaken. METHODS Surgical specialty (SS) and primary care (PC) residents were surveyed regarding demographics, factors influencing choice of specialty, methods of financing education, debt characteristics, and outlooks regarding future earnings and practice characteristics. RESULTS The clinical years of medical school and personalities of specialists and residents were important factors in career choices for both PC and SS. The length of residency, desirable lifestyle, and working hours were all more important to PC residents. Surgeons found intellectual challenge and procedure-based practice of greater importance. Although not highly regarded by either group, scholarship obligation and student loans had a significantly greater impact on specialty choice and practice plans for PC residents. At the completion of training, 55% of SS and 28% of PC residents anticipate owing more than

Thoracic epidural versus patient-controlled analgesia in elective bowel resections

100,000. Debt was especially significant in specialty choice and practice plans for PC residents with debt over

Confirmation of surgical decompression to relieve migraine headaches.

100,000. CONCLUSION Surgical residents are less concerned about personal sacrifices in their quest to become surgeons. It appears state funded scholarships are successful in attracting students to primary care. Both SS and PC residents have significant debt, although, SS residents have greater financial debt than primary care residents. However, the anticipation of indebtedness was a more significant factor in determination of career path for PC.

Changing trends in the management of splenic injury

BACKGROUND This study was undertaken to determine if thoracic epidural analgesia is of practical benefit after bowel resection. METHODS Patients were prospectively randomized to receive either a thoracic epidural or patient-controlled analgesia for pain control after bowel resection. A standardized postoperative protocol was instituted after surgery. RESULTS Pain scores were significantly lower in the epidural group. Return of bowel function, and interval to discharge was not different between groups. Cost and complication rates were significantly higher in the epidural group. CONCLUSIONS Although pain scores were significantly lower in the epidural group, this did not translate into a quicker return of bowel function or earlier discharge of the patient. Furthermore, the epidural group had a significantly higher complication rate and cost. Therefore, while thoracic epidural analgesia provides superior pain control, it does not offer a significant advantage over patient-controlled analgesia in return of bowel function after bowel resection.

Surgical, oncologic, and cosmetic differences between oncoplastic and nononcoplastic breast conserving surgery in breast cancer patients.

Background: Surgical decompression of various trigger sites has been shown by two authors to relieve migraine headaches. The purpose of this study was to evaluate the effectiveness of surgical decompression of multiple migraine trigger sites in a clinical practice setting, and to compare the results to those previously published. Methods: A retrospective, descriptive analysis was performed on 18 consecutive patients who had undergone various combinations of surgical decompression of the supraorbital, supratrochlear, and greater occipital nerves and zygomaticotemporal neurectomy performed by a single surgeon. All patients had been diagnosed with migraine headaches according to neurologic evaluation and had undergone identification of trigger sites by botulinum toxin type A injections. Results: The number of migraines per month and the pain intensity of migraine headaches decreased significantly. Three patients (17 percent) had complete relief of their migraines, and 50 percent of patients (nine of 18) had at least a 75 percent reduction in the frequency, duration, or intensity of migraines. Thirty-nine percent of patients have discontinued all migraine medications. Mean follow-up was 16 months (range, 6 to 41 months) after surgery. One hundred percent of participants stated they would repeat the surgical procedure. Conclusions: This study confirms prior published results and supports the theory that peripheral nerve compression triggers a migraine cascade. The authors have verified a reduction in duration, intensity, and frequency of migraine headaches by surgical decompression of the supraorbital, supratrochlear, zygomaticotemporal, and greater occipital nerves. A significant amount of patient screening is required for proper patient selection and trigger site identification for surgical success.

Perioperative supplementation with ascorbic acid does not prevent atrial fibrillation in coronary artery bypass graft patients.

BACKGROUND A gradual change in the management of splenic injuries has occurred at our institution. This study was therefore undertaken to determine whether changes in management of splenic injury influenced outcomes during the past 30 years. PATIENTS AND METHODS A retrospective study of patients admitted with splenic trauma between 1965 and 1994 was performed. Two hundred seven patients were identified and demographic and outcome data were recorded. Patients were then grouped based upon the period in which they received treatment (ie, Period I [1965 to 1974], Period II [1975 to 1984], and Period III [1985 to 1994]), and the type of treatment received (ie, splenectomy, splenorrhaphy, or observation). RESULTS More patients were treated in Period III than in the other two periods, and Period III patients had shorter hospital stays. Splenectomy was solely used during Period I; splenorrhaphy and observation were occasionally performed during Period II; and splenectomy, splenorrhaphy, and observation were performed in near-equal numbers during Period III. Mortality was similar for each period, though Injury Severity Scores (ISS) were higher during later years. When compared by treatment modality, patients receiving splenectomy had higher ISS and splenic injury classifications. CONCLUSION Patients treated by splenorrhaphy and observation for splenic injury have markedly increased over the past 30 years without adverse outcome.