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Ehyal Shweiki,1 Niels D Martin,2 Alec C Beekley,1 Jay S Jenoff,1 George J Koenig,1 Kris R Kaulback,1 Gary A Lindenbaum,1 Pankaj H Patel,1 Matthew M Rosen,1 Michael S Weinstein,1 Muhammad H Zubair,2 Murray J Cohen1 1Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA; 2Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA Abstract: Medical resident education in the United States has been a matter of national priority for decades, exemplified initially through the Liaison Committee for Graduate Medical Education and then superseded by the Accreditation Council for Graduate Medical Education. A recent Special Report in the New England Journal of Medicine, however, has described resident educational programs to date as prescriptive, noting an absence of innovation in education. Current aims of contemporary medical resident education are thus being directed at ensuring quality in learning as well as in patient care. Achievement and work-motivation theories attempt to explain people's choice, performance, and persistence in tasks. Expectancy Theory as one such theory was reviewed in detail, appearing particularly applicable to surgical residency training. Correlations between Expectancy Theory as a work-motivation theory and residency education were explored. Understanding achievement and work-motivation theories affords an opportunity to gain insight into resident motivation in training. The application of Expectancy Theory in particular provides an innovative perspective into residency education. Afforded are opportunities to promote the development of programmatic methods facilitating surgical resident motivation in education. Keywords: learning, education, achievement

Abnormal fibrinolysis early after injury has been associated with increased mortality in trauma patients, but no studies have addressed patients with burn injury. This prospective cohort study aimed to characterize fibrinolytic phenotypes in burn patients and to see if they were associated with mortality. Patients presenting to a regional burn centre within 4 h of thermal injury were included. Blood was collected for sequential viscoelastic measurements using thromboelastography (RapidTEG™) over 12 h. The percentage decrease in clot strength 30 min after the time of maximal clot strength (LY30) was used to categorize patients into hypofibrinolytic/fibrinolytic shutdown (SD), physiological (PHYS) and hyperfibrinolytic (HF) phenotypes. Injury characteristics, demographics and outcomes were compared. Of 115 included patients, just over two thirds were male. Overall median age was 40 (i.q.r. 28-57) years and median total body surface area (TBSA) burn was 13 (i.q.r. 6-30) per cent. Some 42 (36.5 per cent) patients had severe burns affecting over 20 per cent TBSA. Overall mortality was 18.3 per cent. At admission 60.0 per cent were PHYS, 30.4 per cent were SD and 9.6 per cent HF. HF was associated with increased risk of mortality on admission (odds ratio 12.61 (95 per cent c.i. 1.12 to 142.57); P = 0.041) but not later during the admission when its incidence also decreased. Admission SD was not associated with mortality, but incidence increased and by 4 h and beyond, SD was associated with increased mortality, compared with PHYS (odds ratio 8.27 (95 per cent c.i. 1.16 to 58.95); P = 0.034). Early abnormal fibrinolytic function is associated with mortality in burn patients.

Spinal cord injury (SCI) is a devastating event with a limited hope for recovery and represents an enormous public health issue. It is crucial to understand the disturbances in the metabolic network after SCI to identify injury mechanisms and opportunities

Background: The rise of personalized medicine has reminded us that each patient must be treated as an individual. One factor in making treatment decisions is the physiological state of each patient, but definitions of relevant states and methods to visuali

The use of continuous performance tasks has been examined as a potential measure for clinical/laboratory identification of Attention-deficit/hyperactivity disorder. The present study compared the performance of 30 children, 26 boys and 4 girls ranging in age from 9-0 to 12-11 [sic], with central auditory processing disorders (CAPD) who did not meet criteria for coexisting ADHD with the performance of children with CAPD coexisting with ADHD (CAPD/ADHD) on the Auditory Continuous Performance Test (ACPT). In interpreting the results, the variability as well as the actual counts for correct responses and total errors were considered. Results indicated limited potential for the use of the ACPT in the differential diagnosis of ADHD. Implications of the results as well as considerations for future research are discussed. [ABSTRACT FROM AUTHOR]

The neuropsychological investigation of learning disabilities has contributed much toward a more complete understanding of how the hemispheres are functionally organized and how differences in this functional organization may affect differential patterns of learning and behavior. It has been suggested that right-hemisphere dysfunction increases the likelihood of difficulty with attention/concentration and of overactive behavior, and interferes with arithmetic calculation more readily than reading and spelling. The present study examined the influence of right-versus left-hemisphere neuropsychological dysfunction on academic achievement and attention using two groups of children with learning disabilities and a group of nondisabled children. Results provide limited support for the hypothesis that the right hemisphere subserves attention and concentration. No support was found for the hypothesis that right-hemisphere deficits are more frequently associated with deficient arithmetic calculation, as opposed to reading and spelling performance. Results are discussed in the context of previous research on right-hemisphere dysfunction and learning disabilities. [ABSTRACT FROM AUTHOR]

Motor behavior and sensorimotor activation of the cerebrum and cerebellum were measured before and after motor imagery-based mental practice (MP) and physical practice (PP) of a sequential motor task. Two-button-press sequences (A, B) were performed outside a magnetic resonance imaging scanner and at 2 Hz inside the scanner during a pretest. Participants (n = 39) completed PP, MP, or no practice (NP) of Sequence A for 1 week and were posttested. Sequence A performance improved 121%, 86%, and 4% for the PP, MP, and NP groups respectively (p < 0.05), while Sequence B improved 56%, 40%, and 38% (p > 0.05). PP improvements were accompanied by increased striatal and decreased cerebellar activation, while MP improvements were accompanied by increased cerebellar, premotor, and striatal activation. The efficacy of MP for activating cerebral and cerebellar sensorimotor networks suggests that MP might be an effective substitute or complement to PP to activate compensatory networks for motor rehabilitation. [ABSTRACT FROM AUTHOR]

Peroxisome biogenesis disorders-Zellweger spectrum disorder (PBD-ZSD) is a rare genetic disease caused by mutations in the genes involved in peroxisome biogenesis. PBD-ZSD presentations vary in severity, and treatment of PBD-ZSD remains supportive focused on specific complications. A few reported cases of the use of liver transplantation to treat either neurological symptoms or liver dysfunction and cirrhosis in PBD-ZSD have been published. In this case report, we document the course of a 16-year-old boy diagnosed with PBD-ZSD and a delayed and unexpected neuropathy that developed after undergoing orthotopic liver transplantation (OLT) for which the indication was liver cirrhosis. Following OLT, the patient's gamma-glutamyl transferase (GGT), aspartate aminotransferase (AST), alanine transaminase (ALT), and albumin normalized; however, he developed a polyneuropathy, the cause of which was investigated with conditions such as inflammatory neuropathies (Guillain Barré syndrome: GBS/chronic inflammatory demyelinating polyneuropathy: CIDP), drug effect, or underlying complication of PBD-ZSD all considered possible. His neuropathic symptoms improved and therefore this case represents an exploration of an apparent delayed and resolving subacute neuropathy in PBD-ZSD after OLT., (© 2024 Wiley Periodicals LLC.)

Background: The risks associated with blood product administration and venous thromboembolic events remains unclear. We sought to determine which blood products were associated with the development of deep vein thrombosis (DVT) and pulmonary embolism (PE)., Methods: We analyzed data from patients ≥18 years of age in the Trauma Quality Improvement Program (TQIP) database that received ≥1 blood product and survived ≥24 ​h., Results: There were 42,399 that met inclusion, of whom, 2086 had at least one VTE event. In our multivariable logistic regression model, we found that WB had a unit odds ratio (uOR) of 1.05 (95 ​% CI 1.02-1.08) for DVT and 1.08 (1.05-1.12) for PE. Compared to WB, platelets had a higher uOR for DVT of 1.09 (1.04-1.13) but similar uOR for PE of 1.08 (1.03-1.14)., Conclusions: We found an association of both DVT and PE with early whole blood and platelets., Competing Interests: Declaration of competing interest SGS, MDA, ADF, FLW, MJC, TMG, and JAR have all received support from the Department of Defense in the form of grant funds to their institution. FLW, MJC, and TMG have received salary support from the Department of Defense in the form of grants. JMW has received travel funding support from the Society of Critical Care Medicine as part of her committee duties. MJC has received support from the National Institutes of Health in the form of grants. We have no commercial funds to report., (Published by Elsevier Inc.)

Importance: Antiseizure medications (ASMs) are potential teratogens commonly prescribed for multiple indications. ASM fetal exposure can impair neurodevelopment. Folate improves pregnancy outcomes, but higher doses may pose risks., Objectives: To compare the outcomes of 6-year-old children of women with epilepsy (WWE) vs those of healthy women (HW), and assess the association of outcomes to third-trimester ASM exposures., Design, Setting, and Participants: After informed consent, pregnant WWE and HW were enrolled from 2012 through 2016 in this prospective, multicenter, nonrandomized clinical trial. Children were assessed at 6 years of age (2019-2022). Participants were recruited from 20 US epilepsy centers. Study data were analyzed from August 2023 to August 2024., Exposures: Fetal ASM exposures., Main Outcomes and Measures: The a priori main neurodevelopmental outcome was the blindly assessed Verbal Index Score in 6-year-old children. The Verbal Index Score is calculated as the mean of the scores from the Word Definitions and Verbal Similarities subtests from the Differential Ability Scales, Expressive One-Word Picture Vocabulary Test, Phonological Processing, Comprehension of Instructions, and Sentence Repetition subtests from the Neuropsychological Assessment and Peabody Picture Vocabulary Test. The 2 primary analyses (1) compared children of WWE and HW using linear regression and (2) examined the outcomes of fetal exposure via ASM blood concentrations. Analyses were adjusted for multiple potential confounding factors. Other outcomes and folate exposure-related outcomes were assessed., Results: A total of 1123 pregnant women were screened, and 456 were enrolled (426 did not meet criteria, and 241 chose not to participate). A total of 298 children of WWE (mean [SD] age, 6.4 [4.2] years; 158 female [53.0%]; 140 male [47.0%]) vs 89 children of HW (mean [SD] age, 6.4 [4.2] years; 41 female [46.1%]; 48 male [53.9%]) did not differ on Verbal Index Score (parameter estimate, -0.6; 95% CI, -3.2 to 1.9; P = .64). Exposure-dependent outcomes differed across ASMs. Assessment of other ASMs was limited because 232 of 298 WWE (78%) were taking lamotrigine or levetiracetam alone or in combination. Folate supplementation during the first 12 weeks of pregnancy had positive associations with cognition and behavior with no signal for risks at higher folate doses., Conclusions and Relevance: Results of this prospective nonrandomized clinical trial suggest that verbal abilities in children of WWE vs HW did not differ. Exposure-dependent outcomes of ASMs highlight the importance of dosing high enough to protect the mother and fetus from seizures but low enough to protect the fetus. Folate supplementation early in pregnancy including higher doses was associated with improved cognitive and behavioral outcomes. Additional research is needed for ASMs with inadequate information on fetal exposure risks., Trial Registration: ClinicalTrials.gov Identifier: NCT01730170.

Background: Patients with type O blood may have an increased risk of hemorrhagic complications because of lower baseline levels of von Willebrand factor and factor VIII, but the transition to a mortality difference in trauma is less clear. We hypothesized that type O trauma patients will have differential proteomic and metabolomic signatures in response to trauma beyond von Willebrand factor and factor VIII alone., Methods: Patients meeting the highest level of trauma activation criteria were prospectively enrolled. Blood samples were collected upon arrival to the emergency department. Proteomic and metabolomic (multiomics) analyses of these samples were performed using liquid chromatography-mass spectrometry. Demographic, clinical, and multiomics data were compared between patients with type O blood versus all other patients., Results: There were 288 patients with multiomics data; 146 (51%) had type O blood. Demographics, injury patterns, and initial vital signs and laboratory measurements were not different between groups. Type O patients had increased lengths of stay (7 vs. 6 days, p = 0.041) and a trend toward decreased mortality secondary to traumatic brain injury compared with other causes (traumatic brain injury, 44.4% vs. 87.5%; p = 0.055). Type O patients had decreased levels of mannose-binding lectin and mannose-binding lectin-associated serine proteases 1 and 2, which are required for the initiation of the lectin pathway of complement activation. Type O patients also had metabolite differences signifying energy metabolism and mitochondrial dysfunction., Conclusion: Blood type O patients have a unique multiomics signature, including decreased levels of proteins required to activate the lectin complement pathway. This may lead to overall decreased levels of complement activation and decreased systemic inflammation in the acute phase, possibly leading to a survival advantage, especially in traumatic brain injury. However, this may later impair healing. Future work will need to confirm these associations, and animal studies are needed to test therapeutic targets., Level of Evidence: Prognostic and Epidemiological; Level IV., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Hemorrhage is a leading cause of death. Blood products are used for the treatment of hemorrhagic shock. The use of low titer group O whole blood (LTOWB) has become more common., Methods: Data from patients ≥15 years of age in the Trauma Quality Improvement Program (TQIP) database that received ≥10 units of packed red cells and/or LTOWB within the first 4-h of hospital arrival were included. The proportion of LTWOB of total blood products administered was correlated to 6- and 24-h mortality., Results: 12,763 met inclusion, 3827 (30 %) received LTOWB. On multivariable logistic regression (MVLR), there was no difference in survival at 6 h with a LTOWB. When assessing 24-h survival, there was improved survival with LTOWB ≥10 % (OR 1.18, 1.08-1.28)., Conclusions: In this analysis of TQIP data, patients receiving ≥10 units of PRBC or LTOWB, we found that higher proportions of LTOWB transfusion relative to the total volume of blood products transfused during the first 4 h were associated with improved 24-h, but not 6-h survival., Competing Interests: Declaration of competing interest ADF, MDA, FLW, MJC, TMG, and SGS have all received funding from the Department of Defense in the form of grants to their institution. We have no other conflicts of interest to report., (Published by Elsevier Inc.)