Acute Colonic Pseudo-obstruction: Defining the Epidemiology, Treatment, and Adverse Outcomes of Ogilvie's Syndrome

Acute colonic pseudo-obstruction (ACPO) is a rare but often fatal disease. Herein, we present the largest study to date on ACPO. The National Inpatient Sample was queried for ACPO diagnoses from 1998 to 2011. Patients were analyzed by treatment into four groups: medical management (MM), colonoscopy alone [(endoscopy-only group) ENDO], surgery alone (SURG), or surgery and colonoscopy (SAC). Logistic regression was used to identify predictors of adverse outcomes by treatment group. There were 106,784 cases of ACPO: 96,657 (90.5%) MM, 2,915 (2.7%) ENDO, 6,731 (6.3%) SURG, and 481 (0.5%) SAC. The medical complication (45.7%), procedural complication (15.9%), and mortality rates (7.7%) were high. Increasing procedure invasiveness was independently associated with higher odds of medical complications, procedural complications, and death (P < 0.0125). The odds of death were significantly higher in the ENDO [odds ratio (OR) = 1.2], SURG (OR 1.4), and SAC (OR = 1.8) groups (P < 0.0125). Those who fail MM and require procedures have increasing morbidity and mortality with increasing invasiveness, likely reflecting the severity of their conditions.

Do not waste your time: straight to magnetic resonance imaging for pediatric burners and stingers

BACKGROUND

Permanent neurologic injury in pediatric patients with burner and stinger syndrome (BSS) is unlikely. This study aims to assess the feasibility of clinical observation without extensive radiologic workup in this selective population.

METHODS

A retrospective study was conducted of patients aged younger than 18 years evaluated at a level I trauma center from 2012 to 2014. Patients were grouped according to positive deficit (PD) or negative deficit (ND) upon physical examination. Demographics, clinical findings, and outcomes were analyzed.

RESULTS

Thirty patients (ND, n = 14; PD, n = 16) were evaluated for BSS, most often as a result of injurious football tackle. Age and length of stay were similar between groups. Injury Severity Score was lower in the ND group than the PD group (1.6 ± 1.2 vs 3.8 ± 3.1, respectively; P< .05). Cervical computed tomography was performed on 11 patients (78.6%) in the ND group and 15 patients (93.8%) in the PD group at considerable added cost, with only 1 positive result in the ND group and none in the PD group. Magnetic resonance imaging (MRI) revealed 2 positive findings in each group, and no surgical interventions were indicated. Ten ND (71.4%) and 12 PD (75%) patients reported complete resolution of symptoms at discharge (P> .05).

CONCLUSIONS

Children presenting with BSS experience temporary symptoms that resolve without surgical intervention. Magnetic resonance imaging identified more injuries than computed tomographic imaging; therefore, we suggest that management for BSS should include observation, serial neurologic examinations, and MRI evaluation as appropriate.

Femur fractures should not be considered distracting injuries for cervical spine assessment

INTRODUCTION

The National Emergency X-Radiography Utilization Study (NEXUS) clinical decision rule is extremely sensitive for clearance of cervical spine (C-spine) injury in blunt trauma patients with distracting injuries.

OBJECTIVES

We sought to determine whether the NEXUS criteria would maintain sensitivity for blunt trauma patients when femur fractures were not considered a distracting injury and an absolute indication for diagnostic imaging.

METHODS

We retrospectively analyzed blunt trauma patients with at least 1 femur fracture who presented to our emergency department as trauma activations from 2009 to 2011 and underwent C-spine injury evaluation. Presence of C-spine injury requiring surgical intervention was evaluated.

RESULTS

Of 566 trauma patients included, 77 (13.6%) were younger than 18 years. Cervical spine injury was diagnosed in 53 (9.4%) of 566. A total of 241 patients (42.6%) had positive NEXUS findings in addition to distracting injury; 51 (21.2%) of these had C-spine injuries. Of 325 patients (57.4%) with femur fractures who were otherwise NEXUS negative, only 2 (0.6%) had C-spine injuries (95% confidence interval [CI], 0.2%-2.2%); both were stable and required no operative intervention. Use of NEXUS criteria, excluding femur fracture as an indication for imaging, detected all significant injuries with a sensitivity for any C-spine injury of 96.2% (95% CI, 85.9%-99.3%) and negative predictive value of 99.4% (95% CI, 97.6%-99.9%).

CONCLUSIONS

In our patient population, all significant C-spine injuries were identified by NEXUS criteria without considering the femur fracture a distracting injury and indication for computed tomographic imaging. Reconsidering femur fracture in this context may decrease radiation exposure and health care expenditure with little risk of missed diagnoses.

Delays in transfer of elderly less-injured trauma patients can have deadly consequences

Transfer of severely injured patients to regional trauma centers is often expedited; however, transfer of less-injured, older patients may not evoke the same urgency. We examined referring hospitals' length of stay (LOS) and compared the subsequent outcomes in less-injured transfer patients (TP) with patients presenting directly (DP) to the trauma center. We reviewed the medical records of less-injured (Injury Severity Score [ISS] 9 or less), older (age older than 60 years) patients transferred to a regional Level 1 trauma center to determine the referring facility LOS, demographics, and injury information. Outcomes of the TP were then compared with similarly injured DP using local trauma registry data. In 2011, there were 1657 transfers; the referring facility LOS averaged greater than 3 hours. In the less-injured patients (ISS 9 or less), the average referring facility LOS was 3 hours 20 minutes compared with 2 hours 24 minutes in more severely injured patients (ISS 25 or greater, P < 0.05). The mortality was significantly lower in the DP patients (5.8% TP vs 2.6% DP, P = 0.035). Delays in transfer of less-injured, older trauma patients can result in poor outcomes including increased mortality. Geographic challenges do not allow for every patient to be transported directly to a trauma center. As a result, we propose further outreach efforts to identify potential causes for delay and to promote compliance with regional referral guidelines.

Delays in Transfer of Elderly Less-injured Trauma Patients Can Have Deadly Consequences

Transfer of severely injured patients to regional trauma centers is often expedited; however, transfer of less-injured, older patients may not evoke the same urgency. We examined referring hospitals’ length of stay (LOS) and compared the subsequent outcomes in less-injured transfer patients (TP) with patients presenting directly (DP) to the trauma center. We reviewed the medical records of less-injured (Injury Severity Score [ISS] 9 or less), older (age older than 60 years) patients transferred to a regional Level 1 trauma center to determine the referring facility LOS, demographics, and injury information. Outcomes of the TP were then compared with similarly injured DP using local trauma registry data. In 2011, there were 1657 transfers; the referring facility LOS averaged greater than 3 hours. In the less-injured patients (ISS 9 or less), the average referring facility LOS was 3 hours 20 minutes compared with 2 hours 24 minutes in more severely injured patients (ISS 25 or greater, P < 0.05). The mortality was significantly lower in the DP patients (5.8% TP vs 2.6% DP, P = 0.035). Delays in transfer of less-injured, older trauma patients can result in poor outcomes including increased mortality. Geographic challenges do not allow for every patient to be transported directly to a trauma center. As a result, we propose further outreach efforts to identify potential causes for delay and to promote compliance with regional referral guidelines.

Trauma intensive care unit 'bouncebacks': identifying risk factors for unexpected return admission to the intensive care unit

Return transfer (RT) to the intensive care unit (ICU) negatively impacts patient outcomes, length of stay (LOS), and hospital costs. This study assesses the most common events necessitating RT in trauma patients. We performed a retrospective chart review of ICU RT from 2004 to 2008. Patient demographics, injuries and injury severity, reason for transfer, LOS, interventions, and outcomes data were collected. Overall, 158 patients required readmission to the ICU. Respiratory insufficiency/failure (48%) was the most common reason for RT followed by cardiac (16%) and neurological (13%) events. The most commonly associated injuries were traumatic brain injuries (TBIs) (32%), rib fractures (30%), and pulmonary contusions (20%). Initial ICU LOS was 6.6 ± 8 days (range, 1 to 44 days) with 4.4 ± 7.8 ventilator days. Mean floor time before ICU RT was 5.7 ± 6.3 days (range, 0 to 33 days). Forty-nine patients (31%) required intubation and mechanical ventilation on RT. ICU RT incurred an additional ICU LOS of 8 ± 8.5 days (range, 1 to 40 days) and 5.2 ± 7.5 ventilator days. Mortality after a single RT was 10 per cent (n = 16). RT to the ICU most often occurs as a result of respiratory compromise, and patients with TBI are particularly vulnerable. Trauma pulmonary hygiene practices should be evaluated to determine strategies that could decrease RT.

Failure of lorazepam to treat alprazolam withdrawal in a critically ill patient

Management of sedation in the critical care unit is an ongoing challenge. Benzodiazepines have been commonly used as sedatives in critically ill patients. The pharmacokinetic and pharmacodynamic properties that make benzodiazepines effective and safe in critical care sedation include rapid onset of action and decreased respiratory depression. Alprazolam is a commonly used benzodiazepine that is prescribed for anxiety and panic disorders. It is frequently prescribed in the outpatient setting. Its use has been reported to result in a relatively high rate of dependence and subsequent withdrawal symptoms. Symptoms of alprazolam withdrawal can be difficult to recognize and treat in the critical care setting. In addition, other benzodiazepines may also be ineffective in treating alprazolam withdrawal. We present a case of alprazolam withdrawal in a critically ill trauma patient who failed treatment with lorazepam and haloperidol. Subsequent replacement with alprazolam resulted in significant improvement in the patient’s medication use and clinical status.

Vancomycin intermittent dosing versus continuous infusion for treatment of ventilator-associated pneumonia in trauma patients

Current guidelines for the empiric treatment of ventilator-associated pneumonia (VAP) recommend that vancomycin is dosed 15 mg/kg and administered twice daily for a target trough level of 15 to 20 μg/mL. This study compared conventional intermittent vancomycin infusion (IVI) with continuous vancomycin infusion (CVI). Our prospective, randomized study compared CVI with IVI in trauma patients with suspected VAP. The primary outcome measure was a serum vancomycin level within the target level 48 hours after initiation of therapy. Treatment groups were compared using standard statistical methods. The study included 73 patients, 36 IVI and 37 CVI. Eighteen patients were withdrawn from the study as a result of discontinuation of the drug before 48 hours or failure to draw levels at the appropriate time, resulting in 27 IVI and 28 CVI study patients. There were no differences between treatment groups in gender (P = 0.97), Injury Severity Score (P = 0.70), total body weight (P = 0.36), or age (P = 0.81). The mean serum vancomycin level for the IVI group was 8.9 ± 3.9 μg/mL, and the CVI level was 19.8 ± 6.13 μg/mL (P < 0.0001). Two patients in the IVI group (7.4%) were in the therapeutic range compared with 16 (57.1%) in the CVI group (P < 0.0001). Six patients in the CVI group (21.4%) and none of the IVI patients had supratherapeutic levels. Four patients developed renal insufficiency, three IVI (11.1%) and one CVI (3.6%) (P = 0.36). The current American Trauma Society dosing recommendations for vancomycin for presumptive VAP treatment are inadequate. Continuous vancomycin infusion should be adopted as the standard dosing strategy.

Endovascular graft repair for blunt traumatic disruption of the thoracic aorta: experience at a nonuniversity hospital

Blunt thoracic aortic injury (BAI) represents the second leading cause of death from blunt trauma. Admission rates for BAI are extremely low because instant fatality occurs in nearly 75 per cent of patients. Management strategies have transitioned from the more invasive immediate thoracotomy to delayed endograft repair with strict hemodynamic management. In this study, we assess outcomes and complications of open versus endograft repair for BAI at a nonuniversity hospital. Retrospective chart review was conducted on 49 patients admitted to a Level I trauma center who incurred BAI from 2004 to 2011. Collected data points included demographics, mortality, complication rates, and intensive care unit and hospital length of stay (LOS). Twenty-one patients underwent open thoracotomy (OPEN), whereas 28 patients were managed with thoracic endovascular aortic repair (TEVAR). The overall 30-day mortality rate was significantly lower comparing TEVAR to OPEN (7.1 vs 50%, P = 0.028); seven deaths occurred in the OPEN group versus two with TEVAR. Overall complications, including mortality, acute respiratory distress syndrome, renal failure, pneumonia, pulmonary embolism, and cardiac arrest, were fewer after TEVAR (32.1 vs 81.0%, P < 0.001) despite similar injury severity. Survivor hospital LOS (26.0 ± 15.3 vs 27.7 ± 18.7 days, P = 0.79), intensive care unit LOS (13.5 ± 10.9 vs 12.7 ± 8.8 days, P = 0.94), and ventilator days (11.4 ± 13.4 vs 16.4 ± 14.5 days, P = 0.25) were similar. Early nonoperative management with TEVAR for BAIs is a feasible and effective management strategy. Improved patient outcomes over traditional open thoracotomy in the presence of similar injury severity can be seen after TEVAR in the nonuniversity hospital setting.

Breakdown of the Consent Process at a Quaternary Medical Center: Our Full Disclosure

Circumstances may arise in the intensive care unit (ICU) when the physician is unable to obtain informed consent. We undertook this study to determine the variations in the consent process. An anonymous survey was distributed to all critical care nurses (RN), resident physicians (RES), advanced practitioners (AP), and attending physicians (ATT). Participants were asked to describe the risks of nine common ICU procedures (central venous line, peripherally inserted central catheter, bronchoscopy, tube thoracostomy, tracheostomy, vena cava filter, angioembolization, image-guided drainage, and percutaneous endoscopic gastrostomy tube). Participants were also asked which member of the healthcare team should obtain consent. All groups were compared with ATT responses and RN responses were compared with the remaining groups. The response rate was 134 of 610 participants (22%) with 51 per cent RN (n = 68), 17 per cent RES (n = 23), 7 per cent AP (n = 9), and 25 per cent ATT (n = 34). Compared with ATT, RN assessment of important risks varied significantly for eight of nine procedures. RES responses varied in three procedures. A minority believed that nurses should obtain consent. However, many physicians (34% ATT and 27% RES) denied having informed consent discussions with 50 per cent or more of their patients. This study has exposed a wide variation in consent practices. Future efforts to standardize consent processes are needed to protect patients and physicians.

Breakdown of the consent process at a quaternary medical center: our full disclosure

Circumstances may arise in the intensive care unit (ICU) when the physician is unable to obtain informed consent. We undertook this study to determine the variations in the consent process. An anonymous survey was distributed to all critical care nurses (RN), resident physicians (RES), advanced practitioners (AP), and attending physicians (ATT). Participants were asked to describe the risks of nine common ICU procedures (central venous line, peripherally inserted central catheter, bronchoscopy, tube thoracostomy, tracheostomy, vena cava filter, angioembolization, image-guided drainage, and percutaneous endoscopic gastrostomy tube). Participants were also asked which member of the healthcare team should obtain consent. All groups were compared with ATT responses and RN responses were compared with the remaining groups. The response rate was 134 of 610 participants (22%) with 51 per cent RN (n = 68), 17 per cent RES (n = 23), 7 per cent AP (n = 9), and 25 per cent ATT (n = 34). Compared with ATT, RN assessment of important risks varied significantly for eight of nine procedures. RES responses varied in three procedures. A minority believed that nurses should obtain consent. However, many physicians (34% ATT and 27% RES) denied having informed consent discussions with 50 per cent or more of their patients. This study has exposed a wide variation in consent practices. Future efforts to standardize consent processes are needed to protect patients and physicians.

The Reward is Worth the Wait: A Prospective Analysis of 100 Consecutive Organ Donors

Aggressive donor management protocols have evolved to maximize the number of procured organs. Our study assessed donor management time and the number and types of organs procured with the hypothesis that shorter management time yields increased organ procurement and transplant rates. We prospectively analyzed 100 donors managed by a regional organ procurement organization (OPO) during 2007 to 2008. Data included patient demographics, number and types of organs procured and transplanted, patient management time by the OPO, and achievement of donor pre-procurement goals. One hundred consecutive organ donors were managed with a mean age 41 ± 18 years and mean management time 23 ± 9 hours; 376 organs were procured and 327 successfully transplanted. Donors managed greater than 20 hours yielded significantly more heart (5 vs 26, P < 0.01) and lung (6 vs 40, P < 0.01) procurements, more organs procured per donor (3.2 ± 1.4 vs 4.2 ± 1.6, P < 0.01), and more organs transplanted per donor (2.6 ± 1.5 vs 3.7 ± 1.8, P < 0.01) than those managed 20 hours or less. No difference in the attainment of donor management goals was observed between these populations. Contrary to our initial hypothesis, donor management times greater than 20 hours yielded increased organ procurement and transplant rates, particularly for hearts and lungs, despite no differences in the achievement of donor preprocurement management goals.

The reward is worth the wait: a prospective analysis of 100 consecutive organ donors

Aggressive donor management protocols have evolved to maximize the number of procured organs. Our study assessed donor management time and the number and types of organs procured with the hypothesis that shorter management time yields increased organ procurement and transplant rates. We prospectively analyzed 100 donors managed by a regional organ procurement organization (OPO) during 2007 to 2008. Data included patient demographics, number and types of organs procured and transplanted, patient management time by the OPO, and achievement of donor preprocurement goals. One hundred consecutive organ donors were managed with a mean age 41 ± 18 years and mean management time 23 ± 9 hours; 376 organs were procured and 327 successfully transplanted. Donors managed greater than 20 hours yielded significantly more heart (5 vs 26, P < 0.01) and lung (6 vs 40, P < 0.01) procurements, more organs procured per donor (3.2 ± 1.4 vs 4.2 ± 1.6, P < 0.01), and more organs transplanted per donor (2.6 ± 1.5 vs 3.7 ± 1.8, P < 0.01) than those managed 20 hours or less. No difference in the attainment of donor management goals was observed between these populations. Contrary to our initial hypothesis, donor management times greater than 20 hours yielded increased organ procurement and transplant rates, particularly for hearts and lungs, despite no differences in the achievement of donor preprocurement management goals.

MOPEDS: Motorized Objects Propelling Ethanol Drinking Subjects

Mopeds are not subject to the same laws and jurisdiction as cars or motorcycles, including the requirement of a driver's license. We undertook this study to examine the influence of alcohol (ETOH) on moped crashes. We retrospectively reviewed adult moped injuries compared with motor vehicle crashes (MVCs) and motorcycle crashes (MCCs) from 1995 through 2006. Demographics, severity of injury, mortality, and serum ETOH levels were recorded. Data were analyzed using the Student t test for continuous data and the χ2 test for proportional data. Motor vehicle crashes accounted for 7186 admissions. MCC and moped crashes numbered 973 and 113, respectively. Although not statistically significant ( P = 0.064), moped crashes yielded the highest mortality (9.7%) compared with MCCs (8.5%) and MVCs (6.7%). An increased association of blood ETOH levels with moped crashes, however, was statistically significant ( P = 0.004). Serum ETOH levels above 0.05 g/dL were observed in 1681 MVCs (23.4%), 241 MCCs (24.8%), and 44 moped crashes (39%). In this study, we discovered that moped crashes demonstrate a significantly higher ETOH involvement than either MVCs or MCCs representing a previously unrecognized public safety risk.

MOPEDS: Motorized Objects Propelling Ethanol Drinking Subjects

Mopeds are not subject to the same laws and jurisdiction as cars or motorcycles, including the requirement of a driver's license. We undertook this study to examine the influence of alcohol (ETOH) on moped crashes. We retrospectively reviewed adult moped injuries compared with motor vehicle crashes (MVCs) and motorcycle crashes (MCCs) from 1995 through 2006. Demographics, severity of injury, mortality, and serum ETOH levels were recorded. Data were analyzed using the Student t test for continuous data and the χ² test for proportional data. Motor vehicle crashes accounted for 7186 admissions. MCC and moped crashes numbered 973 and 113, respectively. Although not statistically significant (P = 0.064), moped crashes yielded the highest mortality (9.7%) compared with MCCs (8.5%) and MVCs (6.7%). An increased association of blood ETOH levels with moped crashes, however, was statistically significant (P = 0.004). Serum ETOH levels above 0.05 g/dL were observed in 1681 MVCs (23.4%), 241 MCCs (24.8%), and 44 moped crashes (39%). In this study, we discovered that moped crashes demonstrate a significantly higher ETOH involvement than either MVCs or MCCs representing a previously unrecognized public safety risk.

Vena Cava Filter Insertion and the General Surgery Armamentarium: A 13-Year Experience

The prevention of pulmonary emboli has a long surgical history. Through the development of percutaneous technologies, vena cava filters (VCFs) are now commonly inserted by interventional radiologists. This study reviews our experience with VCFs inserted by general surgeons. We retrospectively reviewed data from our VCF performance improvement database, which is a prospective collection of the VCF experience of the Department of General Surgery from February 1996 to May 2009. Demographics, procedural information, and complications were recorded. Eight hundred fifty-five VCFs were inserted in 853 patients. The mean age was 42.0 years (range, 14 to 90 years). One hundred ninety-seven VCFs were placed in the operating room, and 658 were placed in the intensive care unit. Twelve VCFs were intentionally inserted in a suprarenal position, and four were placed in the superior vena cava. Two patients received both superior vena cava and inferior vena cava filters. Complications included deep vein thrombosis at the insertion site (n = 16), vena cava thrombosis (n = 9), post-VCF pulmonary embolism (n = 2), and a ventricle perforation requiring operative repair (n = 1). No deaths were attributed to the presence of a VCF. Overall insertion success was 99.8 per cent. In two patients, an inferior VCF could not be placed as a result of inferior vena cava occlusion with no safe “landing zone” for deployment. The placement of VCFs is a vital skill in the general surgery armamentarium. Our experience demonstrates that general surgeons can safely insert VCFs with minimal perioperative complications.

Vena cava filter insertion and the general surgery armamentarium: a 13-year experience

The prevention of pulmonary emboli has a long surgical history. Through the development of percutaneous technologies, vena cava filters (VCFs) are now commonly inserted by interventional radiologists. This study reviews our experience with VCFs inserted by general surgeons. We retrospectively reviewed data from our VCF performance improvement database, which is a prospective collection of the VCF experience of the Department of General Surgery from February 1996 to May 2009. Demographics, procedural information, and complications were recorded. Eight hundred fifty-five VCFs were inserted in 853 patients. The mean age was 42.0 years (range, 14 to 90 years). One hundred ninety-seven VCFs were placed in the operating room, and 658 were placed in the intensive care unit. Twelve VCFs were intentionally inserted in a suprarenal position, and four were placed in the superior vena cava. Two patients received both superior vena cava and inferior vena cava filters. Complications included deep vein thrombosis at the insertion site (n=16), vena cava thrombosis (n=9), post-VCF pulmonary embolism (n=2), and a ventricle perforation requiring operative repair (n=1). No deaths were attributed to the presence of a VCF. Overall insertion success was 99.8 per cent. In two patients, an inferior VCF could not be placed as a result of inferior vena cava occlusion with no safe "landing zone" for deployment. The placement of VCFs is a vital skill in the general surgery armamentarium. Our experience demonstrates that general surgeons can safely insert VCFs with minimal perioperative complications.

Operative Experience in the Era of Duty Hour Restrictions: Is Broad-Based General Surgery Training Coming to an End?

Since the institution of Accreditation Council for Graduate Medical Education (ACGME) resident work hour restrictions, conflicting evidence exists regarding the impact on resident case volume with most data from single-institution studies. We examined the effect of restrictions on national resident operative experience. After permission from the ACGME, we reviewed the publicly available national resident case log data (1999 through 2008) maintained on the ACGME web site ( www.acgme.org ), including total major cases with subanalysis of the ACGME-specified categories. The mean cases per resident were compared before (1999 to 2003) and after (2003 to 2008) restrictions. After the implementation of duty hour restrictions, the mean number of total cases per resident significantly decreased (949 ± 18 vs 911 ± 14, P = 0.004). Subanalysis showed a significant increase in alimentary tract (217 ± 7 vs 229 ± 3, P = 0.004), skin/soft tissue (31 ± 3 vs 36 ± 1, P = 0.01), and endocrine (26 ± 2 vs 31 ± 2, P = 0.006) cases. However, we observed a significant decrease in head and neck (21 ± 0.3 vs 20 ± 0.3, P = 0.01), vascular (164 ± 29 vs 126 ± 5, P = 0.01), pediatric (41 ± 1 vs 37 ± 2, P = 0.006), genitourinary (10 ± 2 vs 7 ± 1, P = 0.004), gynecologic surgery (5 ± 1 vs 3 ± 0.6, P = 0.002), plastics (16 ± 0.3 vs 15 ± 0.7, P = 0.03), and endoscopy (91 ± 3 vs 82 ± 2, P < 0.001) procedures. Analysis of the ACGME-compiled national data confirms that duty hour restrictions have significantly impacted resident operative experience. Importantly, experience in specialty areas, including vascular and endoscopy, appears to have been sacrificed for consolidation of resources into general surgery services as indicated by the increase in alimentary tract and endocrine cases. These findings raise the following question: Is the era of truly broad-based general surgery training coming to an end?

Operative experience in the era of duty hour restrictions: is broad-based general surgery training coming to an end?

Since the institution of Accreditation Council for Graduate Medical Education (ACGME) resident work hour restrictions, conflicting evidence exists regarding the impact on resident case volume with most data from single-institution studies. We examined the effect of restrictions on national resident operative experience. After permission from the ACGME, we reviewed the publicly available national resident case log data (1999 through 2008) maintained on the ACGME web site (www.acgme.org), including total major cases with subanalysis of the ACGME-specified categories. The mean cases per resident were compared before (1999 to 2003) and after (2003 to 2008) restrictions. After the implementation of duty hour restrictions, the mean number of total cases per resident significantly decreased (949 +/- 18 vs 911 +/- 14, P = 0.004). Subanalysis showed a significant increase in alimentary tract (217 +/- 7 vs 229 +/- 3, P = 0.004), skin/soft tissue (31 +/- 3 vs 36 +/- 1, P = 0.01), and endocrine (26 +/- 2 vs 31 +/- 2, P = 0.006) cases. However, we observed a significant decrease in head and neck (21 +/- 0.3 vs 20 +/- 0.3, P = 0.01), vascular (164 +/- 29 vs 126 +/- 5, P = 0.01), pediatric (41 +/- 1 vs 37 +/- 2, P = 0.006), genitourinary (10 +/- 2 vs 7 +/- 1, P = 0.004), gynecologic surgery (5 +/- 1 vs 3 +/- 0.6, P = 0.002), plastics (16 +/- 0.3 vs 15 +/- 0.7, P = 0.03), and endoscopy (91 +/- 3 vs 82 +/- 2, P < 0.001) procedures. Analysis of the ACGME-compiled national data confirms that duty hour restrictions have significantly impacted resident operative experience. Importantly, experience in specialty areas, including vascular and endoscopy, appears to have been sacrificed for consolidation of resources into general surgery services as indicated by the increase in alimentary tract and endocrine cases. These findings raise the following question: Is the era of truly broad-based general surgery training coming to an end?

Removal of erythropoietin from anaemia trauma practice guideline does not increase red blood cell transfusions and decreases hospital utilization costs

INTRODUCTION

We previously demonstrated that utilization of erythropoietin (r-EPO) did not significantly reduce blood utilization in trauma patients. We undertook this study to analyze blood utilization 1 year after r-EPO removal from our trauma service anaemia practice management guideline.

METHODS

Electronic records of patients admitted to the trauma service were retrospectively reviewed for units of packed red blood cells (pRBCs) transfused and for units of r-EPO administered 12 months before the initiation of an anaemia practice guideline (PRE), 12 months during the use of an anaemia guideline (GUIDE), and 12 months following removal of r-EPO from the guideline (POST). Hospital acquisition cost was also reviewed for the respective time periods. Nominal data were analyzed using chi-squared or Fisher's exact tests, and interval data were compared using ANOVA followed by Tukey's test where appropriate. Results were considered significant for P<0.05.

RESULTS

Over the 3-year study period, 4881 patients were admitted to the trauma service and included in this study. The hospital length of stay, intensive care unit length of stay, and units of pRBC transfused were similar among all three groups. Group I (PRE) received a total of 228 doses of r-EPO at a cost of $102,600. Group II (GUIDE) received a total of 410 doses at a cost of $184,500. Group III (POST) received 28 doses of r-EPO at a cost of $12,600.

CONCLUSION

Removal of erythropoietin from our trauma service anaemia practice management guideline did not result in increased blood utilization. However, it yielded a hospital acquisition cost savings of $171,900.