Associate Program Directors in Surgery: A Select Group of Surgical Educators.

Objective: The role of the Associate Program Director (APD) within surgical education is not clearly defined or regulated by the Accreditation Council for Graduate Medical Education, often leading to variations in the responsibilities among institutions. Required credentials are not specified and compensation and protected time are not regulated resulting in large discrepancies among institutions. APDs are brought into the fold of surgical education to parcel out the escalating responsibilities of program director (PD).

Gene expression in fetal murine keratinocytes and fibroblasts.

Background: Early fetuses heal wounds without the formation of a scar. Many studies have attempted to explain this remarkable phenomenon. However, the exact mechanism remains unknown.

Brain-type natriuretic peptide and right ventricular end-diastolic volume index measurements are imprecise estimates of circulating blood volume in critically ill subjects.

Background: Surrogate indicators have often been used to estimate intravascular volume to guide fluid management. Brain-type natriuretic peptide (BNP) has been used as a noninvasive adjunct in the diagnosis of fluid overload and as a marker of response to therapy, especially in individuals with congestive heart failure. Similarly, right ventricular end-diastolic volume index (RVEDVI) measurements represent another parameter used to guide fluid resuscitation.

Effect of the 16-hour work limit on general surgery intern operative case volume: a multi-institutional study.

Importance: The 80-hour work-week limit for all residents was instituted in 2003 and studies looking at its effect have been mixed. Since the advent of the 16-hour mandate for postgraduate year 1 residents in July 2011, no data have been published regarding the effect of this additional work-hour restriction.

Objective: To determine whether the 16-hour intern work limit, implemented in July 2011, has adversely affected operative experience.

Type IV Ehlers-Danlos Syndrome: A Surgical Emergency? A Case of Massive Retroperitoneal Hemorrhage.

Retroperitoneal hemorrhagic bleeding is a known manifestation of Type-IV Ehlers-Danlos Syndrome that is caused by loss-of-function mutations of the pro-alpha-1 chains of type III pro-collagen (COL3A1) resulting in vascular fragility. A number of previous reports describe futile surgical intervention for retroperitoneal bleeding in Type-IV Ehlers-Danlos Syndrome with high post-operative mortality, although the rarity of retroperitoneal bleeding associated with Type-IV Ehlers-Danlos Syndrome precludes an evidence-based approach to clinical management. We report a 23-year-old male with history of Type-IV Ehlers-Danlos Syndrome who presented with severe abdominal pain and tachycardia following an episode of vomiting.

A prospective randomized trial using blood volume analysis in addition to pulmonary artery catheter, compared with pulmonary artery catheter alone, to guide shock resuscitation in critically ill surgical patients.

Measurement of blood volume (BV) may guide fluid and red blood cell management in critically ill patients when capillary leak from shock and fluid resuscitation makes assessment of intravascular volume difficult. This is a prospective randomized trial of critically ill surgical patients with septic shock, severe sepsis, severe respiratory failure, and/or cardiovascular collapse. The control group received fluid management based on pulmonary artery catheter parameters and red blood cell transfusions based on hematocrit values.

Predicting performance on the American Board of Surgery qualifying and certifying examinations: a multi-institutional study.

Background: We sought to determine whether US Medical Licensing Examination (USMLE) Step 1 score, American Board of Surgery (ABS) In-Training Examination (ABSITE) score, and other variables are associated with failing the ABS qualifying and certifying examinations. Identifying such factors may assist in the early implementation of an academic intervention for at-risk residents.

Design: Retrospective review.

The need for a standardized evaluation method to assess efficacy of cultural competence initiatives in medical education and residency programs.

Cultural competence education is relatively new in the United States, particularly in the area of graduate and post-graduate medical education. There is, however, wide acceptance that an understanding of the role culture plays in the treatment and care of patients is critical. Numerous studies and a variety of commentaries document this importance, but valid, uniform evaluation methods for assessing the efficacy of these efforts is lacking.

The availability of circulating blood volume values alters fluid management in critically ill surgical patients.

Background: This study evaluated whether commercially available blood volume measurements in critically ill surgical patients altered fluid management.

Methods: Patients admitted to the surgical intensive care unit of a tertiary care teaching hospital were prospectively evaluated. The frequency of changes in fluid management when results of blood volume measurements were available was determined.

Using transcutaneous oxygen pressure measurements as selection criteria for activated protein C use.

Background: Limited resources and the expense of Activated Protein C (APC) (drotrecogin alfa) may contribute to the reluctance to utilize this drug in sepsis. Employing the PROWESS criteria resulted in absolute reduction in 28-day mortality of 6.1%, representing a relative risk reduction of 19.

Twenty-eight-day mortality in critically ill surgical patients is an imprecise temporal end-point measure for in-hospital mortality.

Background: The purpose of this study was to determine the incidence of deaths occurring beyond 28 days in critically ill surgical patients and to identify the proportion of these deaths attributable to the original disease process.

Methods: Analysis of 1,360 subjects admitted to a surgical intensive care unit during a 2 year period. Demographics, indication(s) for admission, comorbidities, mortality rate, multiorgan failure development, and cause of death was obtained.

Peripheral blood hematocrit in critically ill surgical patients: an imprecise surrogate of true red blood cell volume.

Background: Peripheral blood hematocrit (red blood cell volume/total blood volume) is conventionally used to determine the need for blood transfusions. In critically ill surgical patients, this variable may not accurately approximate true red blood cell volume. We compared peripheral blood hematocrit to (1) plasma volume, (2) estimated circulating blood volume, and (3) a normalized hematocrit to clarify their relationships.

Circulating blood volume measurements correlate poorly with pulmonary artery catheter measurements.

Background: Determination of the intravascular volume status of a critically ill surgical patient is paramount for appropriate fluid and cardiovascular management. Many clinical parameters have been utilized to estimate intravascular volume but none are precise indicators of circulating blood volume. The purpose of this observational pilot study was to compare measured blood volume with hemodynamic parameters obtained from the pulmonary artery catheter and to determine if incorporation of these measurements altered treatment decisions in critically ill surgical patients.

Traumatic brain injury: outcomes from rural and urban locations over a 5-year period (Part 1).

The national death rates from rural trauma are disproportionately higher compared to urban areas. Traumatic brain injury is a major cause of hospital admissions in Hawai'i. This is the first in a two part series to explore this significant public health concern.

Determination of reference ranges for transcutaneous oxygen and carbon dioxide tension and the oxygen challenge test in healthy and morbidly obese subjects.

Background: Transcutaneous monitoring of oxygen and carbon dioxide tension emerged decades ago as reliable, indirect measurements of arterial pressure of oxygen and carbon dioxide in neonates. Investigators have since found other valuable roles for this modality, particularly in critically ill adults. This investigation was undertaken to further characterize these measurements in normal and in obese adults, who are contributing to a rising proportion of intensive care unit admissions.