Steven B. Holsten

It takes a village to raise research productivity: Impact of a Trauma Interdisciplinary Group for Research (TIGR) at an urban, Level 1 trauma center.

BACKGROUND Few interdisciplinary research groups include basic scientists, pharmacists, therapists, nutritionists, laboratory technicians, as well as trauma patients and families, in addition to clinicians. Increasing interprofessional diversity within scientific teams working to improve trauma care is a goal of national organizations and federal funding agencies such as the National Institutes of Health (NIH). This article describes the design, implementation, and outcomes of a Trauma Interdisciplinary Group for Research (TIGR) at a Level 1 trauma center as it relates to increasing research productivity, with specific examples excerpted from an ongoing NIH-funded study. METHODS We used a pretest/posttest design with objectives aimed at measuring increases in research productivity following a targeted intervention. A SWOT (strengths, weaknesses, opportunities, and threats) analysis was used to develop the intervention, which included research skill-building activities, accomplished by adding multidisciplinary investigators to an existing NIH-funded project. The NIH project aimed to test the hypothesis that accelerated biologic aging from chronic stress increases baseline inflammation and reduces inflammatory response to trauma (projected n = 150). Pre-TIGR/post-TIGR data related to participant screening, recruitment, consent, and research processes were compared. Research productivity was measured through abstracts, publications, and investigator-initiated projects. RESULTS Research products increased from 12 to 42 (approximately 400%). Research proposals for federal funding increased from 0 to 3, with success rate of 66%. Participant screenings for the NIH-funded study increased from 40 to 313. Consents increased from 14 to 70. Laboratory service fees were reduced from

Professionalism in the Twilight Zone: A Multicenter, Mixed-Methods Study of Shift Transition Dynamics in Surgical Residencies

300 per participant to

Peritoneal cavity lavage reduces the presence of mitochondrial damage associated molecular patterns in open abdomen patients

5 per participant. CONCLUSION Adding diversity to our scientific team via TIGR was exponentially successful in (1) improving research productivity, (2) reducing research costs, and (3) increasing research products and mentoring activities that the team before TIGR had not entertained. The team is now well positioned to apply for more federally funded projects, and more trauma clinicians are considering research careers than before.

Verification of resident bedside-procedure competency by intensive care nursing staff.

Purpose Duty hours rules sparked debates about professionalism. This study explores whether and why general surgery residents delay departures at the end of a day shift in ways consistent with shift work, traditional professionalism, or a new professionalism. Method Questionnaires were administered to categorical residents in 13 general surgery programs in 2014 and 2015. The response rate was 76% (N = 291). The 18 items focused on end-of-shift behaviors and the frequency and source of delayed departures. Follow-up interviews (N = 39) examined motives for delayed departures. The results include means, percentages, and representative quotations from the interviews. Results A minority (33%) agreed that it is routine and acceptable to pass work to night teams, whereas a strong majority (81%) believed that residents exceed work hours in the name of professionalism. Delayed departures were ubiquitous: Only 2 of 291 residents were not delayed for any of 13 reasons during a typical week. The single most common source of delay involved a desire to avoid the appearance of dumping work on fellow residents. In the interviews, residents expressed a strong reluctance to pass work to an on-call resident or night team because of sparse night staffing, patient ownership, an aversion to dumping, and the fear of being seen as inefficient. Conclusions Resident behavior is shaped by organizational and cultural contexts that require attention and reform. The evidence points to the stunted development of a new professionalism, little role for shift-work mentalities, and uneven expression of traditional professionalism in resident behavior.

Feasibility and Benefit of Incorporating a Multimedia Cadaver Laboratory Training Program into a Didactics Curriculum for Junior and Senior Surgical Residents

BACKGROUND Mitochondrial damage-associated molecular patterns (mtDAMPs), such as mitochondrial DNA and N-formylated peptides, are endogenous molecules released from tissue after traumatic injury. mtDAMPs are potent activators of the innate immune system. They have similarities with bacteria, which allow mtDAMPs to interact with the same pattern recognition receptors and mediate the development of systemic inflammatory response syndrome (SIRS). Current recommendations for management of an open abdomen include returning to the operating room every 48 hours for peritoneal cavity lavage until definitive procedure. These patients are often critically ill and develop SIRS. We hypothesized that mitochondrial DAMPs are present in the peritoneal cavity fluid in this setting, and that they accumulate in the interval between washouts. METHODS We conducted a prospective pilot study of critically ill adult patients undergoing open abdomen management in the surgical and trauma intensive care units. Peritoneal fluid was collected daily from 10 open abdomen patients. Specimens were analyzed via quantitative polymerase chain reaction (qPCR) for mitochondrial DNA (mtDNA), via enzyme immunoassay for DNAse activity and via Western blot analysis for the ND6 subunit of the NADH: ubiquinone oxidoreductase, an N-formylated peptide. RESULTS We observed a reduction in the expression of ND6 the day after lavage of the peritoneal cavity, that was statistically different from the days with no lavage (% change in ND6 expression, postoperative from washout: −50 ± 11 vs. no washout day, 42 ± 9; p < 0.05). Contrary to expectation, the mtDNA levels remained relatively constant from sample to sample. We then hypothesized that DNAse present in the effluent may be degrading mtDNA. CONCLUSION These results indicate that the peritoneal cavity irrigation reduces the presence of mitochondrial DAMPs in the open abdomen. It is possible that increased frequency of peritoneal cavity lavage may lead to decreased systemic absorption of mtDAMPs, thereby reducing the risk of SIRS. LEVEL OF EVIDENCE Prospective study, Case Series, Level V.

Endovascular embolization for the treatment of right carotid-jugular arteriovenous fistula, with communicating left vertebral-right jugular arteriovenous fistula

Background:Recent efforts by the Accreditation Council for Graduate Medical Education to standardize resident education and demonstrate objective clinical proficiency have led toward more accurate documentation of resident competencies. Particularly with regard to bedside procedures, hospitals are now requiring certification of competency before allowing a provider to perform them independently. The current system at our institution uses a time-consuming, online verification system. This study provided an alternative method through an identification card with a list of bedside procedures. Our aim was an easier verification method for nurses, allowing fewer delays of bedside procedures and more time for nursing to patient care. Methods:We performed a prospective, controlled study, using general surgical residents and surgical intensive care nurses. Subjects performed an initial survey of their experience with the current online system in place to identify resident bedside procedure competency. Phase I involved educating the subjects about this current system followed by another survey. Phase II involved introducing our proficiency card. After 3 months, we conducted a final survey to evaluate opinions on the proficiency card, comparing it with the online verification method. Results:Nursing postintervention responses indicated that significantly less time was required to validate a residents proficiency (P = .04). Prior to the introduction of the proficiency card, only 15% of nurses reported a verification time of 5 minutes or less, compared with 64% postintervention. In addition, nurses rated the card validation as an easier, more efficient method of verification (P = .02). Conclusions:We believe that its continued use will not only improve the adherence to a mandatory hospital policy but also result in a less-cumbersome verification process, allowing more time for physician and nurse-to-patient care.

Mesenteric cavernous hemangioma involving small bowel and appendix: a rare presentation of a vascular tumor.

OBJECTIVE As operative experience in general surgery decreases and work hour limitations increase there is less exposure of surgical residents to advanced vascular and trauma exposures. Many institutions have demonstrated benefits of cadaver laboratory courses. We have incorporated a multimedia cadaver laboratory course into our general surgery residency didactics curriculum with the objective to demonstrate a benefit of the program as well as the feasibility of incorporation. STUDY DESIGN This is a prospective study at a tertiary care institution including general surgery residents within our residency program. A curriculum was designed, requiring residents to complete multimedia learning modules before both a trauma cadaver laboratory and vascular exposure cadaver laboratory. Outcome measures included self-efficacy/confidence (precourse and postcourse 5-point Likert surveys), knowledge (net performance on precourse and postcourse multiple choice examinations), and resident perception of the curriculum (postcourse 5-point Likert survey). Data were analyzed using ANOVA paired t-tests. RESULTS For the vascular cadaver laboratory, resident knowledge improved overall from an average of 41.2% to 50.0% of questions correct (p = 0.032) and self-efficacy/confidence improved by 0.59 from 1.52 to 2.11 out of 5 (p = 0.009). Median confidence is 1.37 out of 5 and 2.32 out of 5, before and after course, respectively. Wilcoxon nonparametric test reveals a p = 0.011. Residents perception of the usefulness of the laboratory evaluation was 3.85 out 5. There were 85.71% agreed that the laboratory is useful and 14.29% were disagree. The Z-score is -0.1579 (means 0.1579 standard deviations a score of 3.85 below the benchmark). The percentile rank is 56.27%. The coefficient of variation is 24.68%. For the trauma cadaver laboratory, resident knowledge improved overall from an average of 55.89% to 66.17% of questions correct (p = 0.001) and self-efficacy/confidence improved by 0.75 from 1.68 out of 5 to 2.43 out of 5 (p = 0.011). Median confidence level is 1.41 out of 5 before the training course and 2.64 out of 5 after the training course. Wilcoxon signed rank test gives a p value of 0.008. Residents perception of the usefulness of the laboratory evaluation was 3.94 out 5. There were 72.22% agreed that the laboratory is useful and 27.78% were neutral. The Z-score is -0.098 (means 0.098 standard deviations a score of 3.94 below the benchmark). The percentile rank is 53.90%. The coefficient of variation is 15.48%. CONCLUSIONS Incorporating a multimedia cadaver laboratory into a residency education didactics curriculum was both feasible and beneficial for resident education. We demonstrate an improvement in knowledge and self efficacy/confidence following both cadaver laboratory courses.

Traumatic rupture of a previously undiagnosed giant hepatic hemangioma.

Traumatic arteriovenous fistulas of the neck are a relatively uncommon injury, whose ramifications can include immediate or delayed neurological insults, massive bleeding, or death. Angiography and embolization have been increasingly used to manage this complex injury pattern. In this particular case, the patient underwent management of bilateral communicating arteriovenous fistulae using a commercially available plug occlusion device. Epidemiology, with an emphasis on patient management and outcomes, is discussed.