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Objective: As part of the Blue Ribbon Committee II, review current goals, structure and financing of surgical training in Graduate Medical Education (GME) and recommend needed changes., Background: Surgical training has continually undergone major transitions with the 80-hour work week, earlier specialization (vascular, plastics, and cardiovascular), and now entrustable professional activities as part of competency-based medical education (CBME). Changes are needed to ensure the efficiencies of CBME are utilized, that stable graduate medical education funding is secured, and that support for surgeons who teach is made available., Methods: Convened subcommittee discussions to determine the needed focus for recommendations., Results: Five recommendations are offered for changes to GME financing, incorporation of CBME, and support for educators, students, and residents in training., Conclusions: Changes in surgical training related to CBME offer opportunities for change and innovation. Our subcommittee has laid out a potential path forward for improvements in GME funding, training structure, compensation of surgical educators, and support of students and residents in training., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Bronchiolitis obliterans syndrome (BOS) is a severe complication following hemopoietic stem cell transplantation (HSCT) and is often undetected until there is significant deterioration in pulmonary function. Lung clearance index (LCI 2.5 ) derived from the nitrogen multiple breath washout (N 2 MBW) test may be more feasible and sensitive than spirometry, which is currently used for surveillance and detection of BOS. We aimed to examine the feasibility of performing surveillance N 2 MBW in children post-HSCT, and in an exploratory analysis, determine if LCI 2.5 led to earlier detection of BOS when compared to spirometric indices. Participants aged 5 to 17 years were recruited prior to receiving HSCT into a prospective, single-center, feasibility study at the Royal Children's Hospital, Melbourne. N 2 MBW and spirometry were performed within the month prior to transplant and repeated at 3, 6, 9, and 12 months post-transplant. Data were also collected on the presence of graft-versus-host (GVHD) disease in any organ, including the lungs. Twenty-one (12 male) children with a mean age of 13.4 (range 9.2 to 17.1) years at recruitment participated in this study. Prior to HSCT, all participants had normal LCI 2.5 , while 16 (76%) demonstrated normal forced expiratory volume in 1 second (FEV 1 ). Ninety-nine percent of N 2 MBW tests were technically acceptable, compared with 66% of spirometry tests. Three participants developed BOS, while 2 participants died of other respiratory complications. At 6 and 12 months post-transplant, the BOS group had increases in LCI 2.5 ranging from 3 to 5 units and mean reductions in FEV 1 % predicted of 40% to 53% relative to pre HSCT values, respectively. In those who developed BOS, post-HSCT LCI 2.5 values were significantly worse when compared with the no BOS group (P < .001). Relative changes in LCI 2.5 and FEV 1 were both predictive of BOS at 6 months post HSCT. This study demonstrates that N 2 MBW is a more feasible test compared with spirometry in children post HSCT. However, in an exploratory analysis, LCI 2.5 did not lead to earlier detection of BOS, when compared to spirometry., (Copyright © 2024 The American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the validity and reliability of the modified shuttle 25-level test (MST-25) in children with cystic fibrosis (CF)., Methods: A prospective single center study in clinically stable children with CF. Participants undertook two testing conditions on different days: (1) 2xMST-25 tests; (2) cardiopulmonary exercise test (CPET). Test order was randomized. Nadir oxygen saturation (SpO 2 ), peak heart rate (HR), breathlessness (modified Borg), rate of perceived exertion (RPE), energy expenditure (EE) and metabolic equivalents (MET) from the MST-25 and CPET were compared to assess validity, while outcomes from 2xMST-25 tests were compared for reliability. CPET was performed using breath-by-breath analysis and EE from the MST-25 obtained using the SenseWear Armband., Results: Strong correlations were found between MST-25 distance and peak oxygen uptake, peak work and minute ventilation on CPET (all r > 0.7, p < 0.01). Moderate correlations were found between MST-25 distance and CPET for METs (r = 0.5) and HR (r = 0.6). Weak associations between tests were evident for nadir SpO 2 (r = 0.1), modified Borg (r s  = 0.2) and RPE (r s  = 0.2). Test-retest reliability was excellent for MST-25 distance (ICC 0.91), peak EE (ICC 0.99) and peak METs (ICC 0.90). Good reliability was achieved for HR (ICC 0.84) and modified Borg score (ICC 0.77), while moderate reliability for nadir SpO 2 (ICC 0.64) and RPE (ICC 0.68) was observed., Conclusion: The MST-25 is a valid and reliable field test for the assessment of exercise capacity in children with CF. The MST-25 can be used to accurately monitor exercise capacity and prescribe exercise training, particularly when CPET is not available., (© 2023 The Authors. Pediatric Pulmonology published by Wiley Periodicals LLC.)

Methods: We retrospectively reviewed TBI patients ≥ 18 years of age treated with VV-ECMO. The primary outcome was survival to discharge. Secondary outcomes included progression of intracranial hemorrhage, bleeding complications, and episodes of oxygenator thrombosis requiring exchange. Medians and interquartile ranges were reported where appropriate., Results: 13 TBI patients received VV-ECMO support during the study period. The median age was 28 years (Interquartile range (IQR) 25-37.5) and 85% were men. Median admission Glasgow coma scale was 5 (IQR 3-13.5). Median injury severity score (ISS) was 48 (IQR 33.5-66). Median pre-ECMO PaO2:FiO2 ratio was 58 (IQR 47-74.5). Five (38.4%) patients survived to discharge. Six patients (46%) received systemic A/C while on ECMO. No patient had worsening of intracranial hemorrhage on computed tomography imaging. There were two bleeding complications in patients on A/C, neither was related to TBI. Four patients required an oxygenator change; 2 in patients on A/C., Conclusion: VV-ECMO appears safe with TBI. We have demonstrated that A/C can be withheld without increased complications. Traumatic brain injury should not be considered an absolute contraindication to the use of VV-ECMO for severe respiratory failure and should be decided on a case by case basis. Additional research is needed to confirm these preliminary findings.

This study evaluated the safety of early anti-factor Xa assay-guided enoxaparin dosing for chemoprophylaxis in patients with TBI. We hypothesized that assay-guided chemoprophylaxis would be comparable in the risk of intracranial hemorrhage (ICH) progression to fixed dosing. An observational analysis of adult patients with blunt traumatic brain injury (TBI) was performed at a Level I trauma center from August 2016 to September 2017. Patients in the assay-guided group were treated with an initial enoxaparin dose of 0.5 mg/kg, with peak anti-factor Xa activity measured four hours after the third dose. Prophylactic range was defined as 0.2 to 0.5 IU/mL with a dose adjustment of ± 10 mg based on the assay result. The assay-guided group was compared with historical fixed-dose controls and to a TBI cohort from the most recent Trauma Quality Improvement Project dataset. Of 179 patients included in the study, 85 were in the assay-guided group and 94 were in the fixed-dose group. Compared with the fixed-dose group, the assay-guided group had a lower Glasgow Coma Score and higher Injury Severity Score. The proportion of severe (Abbreviated Injury Score, head ≥3) TBI, ICH progression, and venous thromboembolism rates were similar between all groups. The assay-guided and fixed-dose groups had chemoprophylaxis initiated earlier than the Trauma Quality Improvement Project group. The assay-guided group had the highest percentage of low molecular weight heparin use. Early initiation of enoxaparin anti-factor Xa assay-guided venous thromboembolism chemoprophylaxis has a comparable risk of ICH progression to fixed dosing in patients with TBI. These findings should be validated prospectively in a multicenter study.

The Hospital Outpatient Prospective Payment System has matured into a complex diagnosis-related group-like payment system over the past 18 years and has continued to become more prospective in paying for services that are bundled, packaged, and grouped into episodes of care. This payment system has become the basis by which payments for services in other payment systems, such as the ambulatory surgery centers and the Medicare Physician Fee Schedule, are made. The quality of hospital data has a greater effect on reimbursement of services than ever anticipated when this payment system was developed. Also, CMS methodological changes further distort reported hospital data, which often results in lowered payment levels for diagnostic imaging., (Copyright © 2019 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: Elderly patients with Traumatic Brain Injury (TBI) are frequently transferred to designated Trauma Centers (TC). We hypothesized that TC transfer is associated with improved outcomes., Methods: Retrospective study utilizing the National Trauma Databank. Demographics, injury and outcomes data were abstracted. Patients were dichotomized by transfer to a designated level I/II TC vs. not. Multivariate regression was used to derive the adjusted primary outcome, mortality, and secondary outcomes, complications and discharge disposition., Results: 19,664 patients were included, with a mean age of 78.1 years. 70% were transferred to a level I/II TC. Transferred patients had a higher ISS (12 vs. 10, p < 0.001). Mortality was significantly lower in patients transferred to level I/II TCs (5.6% vs. 6.2%, Adjusted Odds Ratio (AOR) 0.84, p = 0.011), as was the likelihood of discharge to skilled nursing facilities (26.4% vs. 30.2%, AOR 0.80, p < 0.001)., Conclusions: Elderly patients with mild TBI transferred to level I/II TCs have improved outcomes. Which patients with mild TBI require level I/II TC care should be examined prospectively., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Early thoracotomy (ET) is a procedure performed on patients in extremis. Identifying factors associated with ET survival may allow for optimization of guidelines and improved patient selection., Objectives: The objective of this study was to assess whether ETs performed at Level I trauma centers (TC) are associated with improved survival., Methods: This was a retrospective study utilizing the National Trauma Databank 2014-2015. We included all thoracotomies performed within 1 h of hospital arrival. Patients were stratified according to TC designation level. Patient demographics, outcomes, and center characteristics were compared. We conducted multivariable regression with survival as the outcome., Results: There were 3183 ETs included in this study; 2131 (66.9%) were performed at Level I TCs. Patients treated at Level I and non-Level I TCs had similar median injury severity scores, as well as signs of life and systolic blood pressures on admission. Patients treated at Level I TCs had significantly higher survival rates (21.6% vs. 16.3%, p < 0.001), with 40% greater odds of survival after controlling for injury-specific factors and emergency medical services transportation time (adjusted odds ratio 1.40, 95% confidence interval 1.04-1.89, p = 0.03). Penetrating injuries had 23.1% survival after ET vs. 12.9% for blunt injuries (adjusted odds ratio 1.86, 95% confidence interval 1.37-2.53, p < 0.001)., Conclusions: ETs performed at Level I TCs were associated with 40% greater odds of survival compared with ETs at non-Level I TCs. This demonstrates that factors extrinsic to the patient may play a role in survival of severely injured patients., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Coccidioidal meningitis is a lethal disease, and current therapy is not curative or is burdened with serious toxicities and logistic difficulties. In a patient with refractory disease, continuous infusion amphotericin B therapy was given via a programmable implanted pump into the cisternal subarachnoid space. The patient progressively responded, evidenced clinically and by laboratory studies. Drug delivery issues were addressed during this course that could guide future use of this modality, which is a promising novel avenue of therapy for chronic meningitis.

We used repetitive transcranial magnetic stimulation (rTMS) to study visual naming in 14 patients with temporal lobe epilepsy. Ten had left hemisphere language by Wada testing and all experienced speech arrest with rTMS of the motor speech area in the left frontal lobe. One left-hander had speech arrest with stimulation of sites on both sides. Subjects were asked to name pictures or read words presented on a computer monitor. rTMS was delivered on half of the trials. Stimulation sites were the motor speech area in the left frontal lobe, the mirror site on the right, and the left and right mid superior and posterior temporal lobes. rTMS at left hemisphere sites caused more naming errors than did right hemisphere rTMS. All individual subjects, except two who had temporal lobe resections and the one with bilateral speech arrest, produced more naming errors with rTMS of left hemisphere sites. There was no significant effect on word reading. rTMS at the left hemisphere and right frontal sites produced reductions in reaction time for picture naming, but not for word reading. This was observed for both correct and incorrect responses. This study shows that left hemisphere rTMS can disrupt visual naming selectively.

The clinical significance of the fastidious organism DF-3 isolated from stool cultures is unclear. We sought to improve our understanding of this organism and to further define its association with human disease. Stool cultures for DF-3 were obtained from three sources: an ongoing study of enteric pathogens in patients infected with the human immunodeficiency virus, a screening procedure in which all stool samples submitted for Clostridium difficile toxin assay were cultured for DF-3, and stool samples submitted specifically for DF-3 culture. Retrospective clinical data were obtained from chart reviews of patients with positive cultures. Antimicrobial susceptibility testing and cell wall fatty acid analysis were performed for each DF-3 isolated. Eight isolates of DF-3 were obtained over a period of 8 months. All patients either had severe underlying disease or were immunocompromised, including three patients coinfected with human immunodeficiency virus and two patients with inflammatory bowel disease. The spectrum of clinical disease ranged from chronic diarrhea with a well-defined response to therapy for DF-3 to an asymptomatic carrier state. Cell wall fatty acid analysis of these isolates demonstrated a consistent pattern with a large peak of 12-methyltetradecanoate. DF-3, a fastidious gram-negative coccobacillus, can be recovered from stool cultures of immunocompromised patients by using selective media. The presence of 12-methyltetradecanoate in cell wall fatty acid analysis assists in identification. The increased use of a selective medium-(cefoperazone-vancomycin-amphotericin B) in the evaluation of diarrhea in immunocompromised hosts, including persons with inflammatory bowel disease, may better define the association of DF-3 with human gastrointestinal disease.

Since January 1979, the Joint Commission on Accreditation of Hospitals has accepted the CAP Inspection and Accreditation Program as evidence of compliance with the newly revised JCAH standard for Pathology and Medical Laboratory Services. In this article, the authors recall the events that led up to the Joint Commission's acceptance of CAP accreditation, and they explain how an inspection conducted by the CAP differs from that conducted by the JCAH.

Hypoglycaemia, defined as a plasma glucose concentration below 2.2 mmol/l, developed in 15 of 47 prospectively studied Gambian children with severe chloroquine-sensitive falciparum malaria. 5 of these hypoglycaemic children died compared with 1 in the normoglycaemic group (p = 0.02). In contrast to previous observations in quinine-treated adults, in whom hypoglycaemia was associated with hyperinsulinaemia, plasma concentrations of insulin were appropriately low and plasma ketones were high. Raised plasma concentrations of lactate and alanine suggested impairment of hepatic gluconeogenesis. In African children, hypoglycaemia is an important and treatable manifestation of severe malaria and is unrelated to antimalarial treatment.