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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priority for decades, exemplified initially through the Liaison Committee for Graduate Medical Education and then superseded by the Accreditation Council for Graduate Medical Education.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

Context: Helicopter emergency medical services and their possible effect on outcomes for traumatically injured patients remain a subject of debate. Because helicopter services are a limited and expensive resource, a methodologically rigorous investigation of its effectiveness compared with ground emergency medical services is warranted.Objective: To assess the association between the use of helicopter vs ground services and survival among adults with serious traumatic injuries.Design, Setting, and Participants: Retrospective cohort study involving 223,475 patients older than 15 years, having an injury severity score higher than 15, and sustaining blunt or penetrating trauma that required transport to US level I or II trauma centers and whose data were recorded in the 2007-2009 versions of the American College of Surgeons National Trauma Data Bank.Interventions: Transport by helicopter or ground emergency services to level I or level II trauma centers.Main Outcome Measures: Survival to hospital discharge and discharge disposition.Results: A total of 61,909 patients were transported by helicopter and 161,566 patients were transported by ground. Overall, 7813 patients (12.6%) transported by helicopter died compared with 17,775 patients (11%) transported by ground services. Before propensity score matching, patients transported by helicopter to level I and level II trauma centers had higher Injury Severity Scores. In the propensity score-matched multivariable regression model, for patients transported to level I trauma centers, helicopter transport was associated with an improved odds of survival compared with ground transport (odds ratio [OR], 1.16; 95% CI, 1.14-1.17; P < .001; absolute risk reduction [ARR], 1.5%). For patients transported to level II trauma centers, helicopter transport was associated with an improved odds of survival (OR, 1.15; 95% CI, 1.13-1.17; P < .001; ARR, 1.4%). A greater proportion (18.2%) of those transported to level I trauma centers by helicopter were discharged to rehabilitation compared with 12.7% transported by ground services (P < .001), and 9.3% transported by helicopter were discharged to intermediate facilities compared with 6.5% by ground services (P < .001). Fewer patients transported by helicopter left level II trauma centers against medical advice (0.5% vs 1.0%, P < .001).Conclusion: Among patients with major trauma admitted to level I or level II trauma centers, transport by helicopter compared with ground services was associated with improved survival to hospital discharge after controlling for multiple known confounders. [ABSTRACT FROM AUTHOR]

As college and university campuses re-open during the COVID-19 pandemic, there is increased concern for mental health crises. Current trends in campus mental health care emphasize providing quality care in a safe, non-judgmental, and non-punitive manner. Collegiate-based emergency medical services organizations are well-positioned to respond to acute mental health crises on college campuses. Campus health professionals and administrators seeking to promote a health-centered approach toward mental health crises should support the growth and development of collegiate-based emergency medical services organizations.

Objective: The objective of this study was to identify out-of-hospital cardiac arrest characteristics for patients treated by collegiate-based emergency medical services (CBEMS) organizations., Participants: CBEMS organizations provided data via the National Collegiate EMS Foundation Cardiac Arrest Data Registry., Methods: CBEMS organization details, patient demographics, cardiac arrest characteristics and treatments, and prehospital outcomes for cases spanning October 2007 to May 2020 were analyzed with descriptive statistics., Results: There were 65 OHCA entries. The majority were for male patients (82%) and a notable number of cases occurred in patients 45 years of age or younger (41%). Cases were frequently witnessed (71%) with high rates of bystander cardiopulmonary resuscitation (57%) and defibrillation (29%) prior to EMS arrival. Almost half of the patients (48%) had achieved return of spontaneous circulation until care was transferred to a provider of equal/higher level., Conclusions: CBEMS organizations may be well situated to respond rapidly to on-campus OHCAs.

Background: Direct to operating room resuscitation (DOR) is used by some trauma centers for severely injured trauma patients as an approach to minimize time to hemorrhage control. It is unknown whether this strategy results in favorable outcomes. We hypothesized that utilization of an emergency department operating room (EDOR) for resuscitation of patients with abdominal trauma at an urban Level I trauma center would be associated with decreased time to laparotomy and improved outcomes., Methods: We included patients 15 years or older with abdominal trauma who underwent emergent laparotomy within 120 minutes of arrival both at our institution and within a National Trauma Data Bank sample between 2007 to 2019 and 2013 to 2016, respectively. Our institutional sample was matched 1:1 to an American College of Surgeons National Trauma Databank sample using propensity score matching based on age, sex, mechanism of injury, and abdominal Abbreviated Injury Scale score. The primary outcome was time to laparotomy incision. Secondary outcomes included blood transfusion requirement, intensive care unit (ICU) length of stay (LOS), ventilator days, hospital LOS, and in-hospital mortality., Results: Two hundred forty patients were included (120 institutional, 120 national). Both samples were well balanced, and 83.3% sustained penetrating trauma. There were 84.2% young adults between the ages of 15 and 47, 91.7% were male, 47.5% Black/African American, with a median Injury Severity Score of 14 (interquartile range [IQR], 8-29), Glasgow Coma Scale score of 15 (IQR, 13-15), 71.7% had an systolic blood pressure of >90 mm Hg, and had a shock index of 0.9 (IQR, 0.7-1.1) which did not differ between groups (p > 0.05). Treatment in the EDOR was associated with decreased time to incision (25.5 minutes vs. 40 minutes; p ≤ 0.001), ICU LOS (1 vs. 3.1 days; p < 0.001), transfusion requirement within 24 hours (3 units vs. 5.8 units packed red blood cells; p = 0.025), hospital LOS (5 days vs. 8.5 days, p = 0.014), and ventilator days (1 day vs. 2 days; p ≤ 0.001). There were no significant differences in in-hospital mortality (22.5% vs. 15.0%; p = 0.14) or outcome-free days (4.9 days vs. 4.5 days, p = 0.55)., Conclusion: The use of an EDOR is associated with decreased time to hemorrhage control as evidenced by the decreased time to incision, blood transfusion requirement, ICU LOS, hospital LOS, and ventilator days. These findings support DOR for patients sustaining operative abdominal trauma., Level of Evidence: Therapeutic/Care Management, Level III., (Copyright © 2022 American Association for the Surgery of Trauma.)

Background: The Surgeon General oversees the Commissioned Corps of the U.S. Public Health Service (USPHS) and is viewed as the "Nation's Doctor," responsible for providing the public with information on living healthier and safer lives. The Surgeon General's influence is seen through public health initiatives such as warning labels on tobacco and alcohol products. The objectives of this paper are to describe the tradition of the Office of the Surgeon General as created by Dr John M. Woodworth and to describe the careers of Dr C. Everett Koop and Dr Richard H. Carmona-the only 2 surgeons by training to hold the role., Methods: This is a historical literature review using a combination of primary and secondary sources., Results: Dr Woodworth set the priorities and responsibilities of the Surgeon General's Office: education, public service, sanitation, and public health. Dr Koop is widely regarded as the most influential Surgeon General of all time. He was both a pioneer in pediatric surgery and a highly influential public figure, issuing landmark reports on smoking, violence, and AIDS. Dr Carmona is a trauma surgeon by training and focused on the dangers of second-hand smoke as Surgeon General. Dr Carmona served in a more political role as Surgeon General, eventually running for Senate at the end of his term., Conclusion: This brief review of the history of the Surgeon General's Office highlights the contributions of the first Surgeon General and the only 2 surgeons who have held the position., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Synthetic materials currently used for arterial grafts can provoke serious complications such as infection, rejection, and incomplete reendothelialization. Porcine small intestinal submucosa (SIS) allografts (homografts) may not share these disadvantages yet still may provide an effective graft alternative. This study was designed to provide additional information concerning the performance of this material when used as an allo-patch graft. A porcine model was selected to enable hemodynamic comparisons to the adult human physiology. Slaughterhouse small intestine was used to prepare the SIS graft material. A well-vascularized section ofjejunum was resected, rinsed, and maintained in 0.9% NaCl solution containing 10% gentamicin. The graft was prepared by removing the serosal layer, inverting the material, and discarding the mucosal surface in a similar manner. The remaining submucosa and stratum compactum constituted the graft material and was subdivided into sizes from 1.5 to 3.0 cm2 tacked to foil for manageability, and was returned to the gentamicin solution. The surgery was initiated with a femoral arterial line in the anesthetized swine, followed by isolation and preparation of the infrarenal aorta for grafting. Cross-clamps were applied and a 1.0 x 1.5-cm section of aortic wall was resected. Two sides of allograft were freed from the foil and sewn into the aorta. Then the remaining sides were removed from the foil and final graft placement was completed. The graft was harvested at postoperative day 28 and presented for microscopic examination. Results confirmed that reendothelialization with neovascularization had occurred during this interval.

The objectives of the study were to evaluate age and teat order on a performance trait, average daily gain, and on physiological stress indicators, alpha1-acid glycoprotein (AGP), neutrophil-to-lymphocyte ratio (N:L), and cortisol in commercial growing pigs from weaning to market age. Pigs (n = 129) from five commercial California farms were weighed and blood-sampled at 28-d intervals from 28 to 168 d of age. Laboratory assays were performed from blood samples to quantify cortisol, AGP, and N:L. Age and facility effects (P<.001), but not teat order effects (P>.05), were found for all three physiological traits and ADG. Pigs that routinely suckled from teats 1, 4, or 6 (numbered from anterior to posterior on the upper teat bank) had similar (P>.05) ADG and BW throughout the production cycle. No correlation (P> .05) was found between cortisol, AGP, and N:L. The use of these physiological and production traits as stress and health indices of growing pigs in commercial facilities has limitations in comparing data between facilities or different ages of pigs.

The objectives of this study were to investigate the determinants of the anion gap (AG) in cattle and to evaluate the utility of AG in detecting hyperlactatemia in sick neonatal calves and adult cattle. The AG was calculated as AG = ([Na+] + [K+])-([Cl-] + [HCO-3]), with all values in mEq/L. The AG of healthy neonatal calves (n = 16) was 29.6 +/- 6.2 mEq/L (mean +/- SD), and the blood L-lactate concentration ranged from 0.5 to 1.2 mM/L. The AG was significantly (P < .05) correlated with serum phosphate (r = .66) and creatinine (r = .51) concentrations. The AG of neonatal calves with experimentally induced diarrhea (n = 16) was 28.6 +/- 5.6 mEq/L, and the blood L-lactate concentration ranged from 1.1 to 2.9 mM/L. The AG was significantly correlated with blood L-lactate concentration (r = .67), serum phosphate concentration (r = .63), creatinine concentration (r = .76), and blood pH (r = -.61). The AG of adult cattle with abomasal volvulus (n = 41) was 20.5 +/- 7.8 mEq/L, and the blood L-lactate concentration ranged from 0.6 to 15.6 mM/L. The AG was significantly correlated with blood L-lactate concentration (r = .60), serum phosphate concentration (r = .71), creatinine concentration (r = .65), albumin concentration (r = .47), total protein concentration (r = .54), blood pyruvate concentration (r = .67), and blood pH (r = -.41) but not plasma beta-OH butyrate concentration. The results indicate that the AG in cattle is only moderately correlated with blood L-lactate concentration and is similarly correlated with serum phosphate and creatinine concentrations in neonatal calves and adult cattle, as well as with serum albumin and total protein concentrations in adult cattle. Anion gap determination is of limited usefulness in predicting blood L-lactate concentration in sick cattle, whereas the correlation between AG and serum creatinine concentration in sick cattle suggests that an increased AG should alert the clinician to the potential presence of uremic anions.

Seven mature dairy cows from 6 herds were obtained with history, clinical signs of disease, and laboratory findings suggestive of advanced paratuberculosis. A surgically implanted collection chamber was used to obtain peripheral tissue fluid. Blood, mammary gland flush fluid, and collection chamber flush fluid (CCFF) samples were obtained 6 times over a 2-week period from each cow. Mononuclear cell-rich portions of these fluids obtained by gradient centrifugation were submitted for bacteriologic culture of Mycobacterium paratuberculosis and for total and differential cell counts. Bacteriologic culture of feces for M paratuberculosis and complete necropsy performed on each cow at the conclusion of the study confirmed the diagnosis of paratuberculosis. Numbers of tissue macrophages obtained from CCFF samples were lower than expected. Mean (+/- SD) differential count of tissue macrophages collected from CCFF was 65.57 (+/- 23.39). Mean calculated tissue macrophages (total cell count x differential count) collected from CCFF samples was 623.1 (+/- 784.55) cells/microliters. Mycobacterium paratuberculosis was isolated from 1 of 42 (2.4%) collections of mononuclear cell-rich portions of plasma and from 2 of 42 (4.8%) CCFF samples. Mycobacterium paratuberculosis was not isolated from any collections of mammary gland flush fluid. The collection and processing techniques used in this study did not enhance detection of M paratuberculosis infection in cows with advanced paratuberculosis, beyond that of ileocecal lymph node biopsy or fecal culture.

A mixed population of 11 cattle (7 dairy, 4 beef; 9 male, 2 female) were examined because of acute onset of non-weightbearing hind limb lameness. Radiography revealed slipped capital femoral epiphyseal fracture in all cattle, with the exception of one large bull. Ten of the 11 cattle were treated with open reduction and internal fixation, using intramedullary pins. Cattle affected with slipped capital femoral epiphyseal fracture in previous reports typically have been calves that required forced extraction during dystocia. Cattle in this report were in the following 2 age groups in which trauma was the likely cause: 3 to 5 months and 1.5 to 2.3 years. Follow-up information was provided for 7 of the 10 cattle. Four of the 7 were functional and had no clinical signs of arthritis, abnormal gait, atrophy, scarring, contralateral compensation, breakdown, or other difficulty 6 months after surgical correction. If early diagnosis is achieved, it appears that reduction with intramedullary pinning can provide a good long-term prognosis in cattle when function as breeding animals is important to their future value.