Inferior Pancreaticoduodenal Artery Aneurysms in Association with Celiac Stenosis/Occlusion

Inferior pancreaticoduodenal artery aneurysms in association with celiac stenosis or occlusion are well described in the literature. These aneurysms are true aneurysms and develop as a result of increased flow through the pancreaticoduodenal arcades in the presence of hemodynamically significant stenosis of the celiac axis or common hepatic artery. Aneurysms may be multiple and rarely associated with aneurysms in other collateral pathways—such as the dorsal pancreatic artery or the arc of Buhler. These aneurysms may be incidentally detected or patients may present with abdominal pain or shock secondary to rupture of the aneurysms. Treatment options include surgical resection and transcatheter embolization; current literature favors the latter option. Treatment of celiac axis stenosis may be recommended in addition to treating the aneurysms; however, no formal guidelines exist on this recommendation

“Back in the Day”… What Are Surgeon Bloggers Saying About Their Careers?

The projected shortage of general surgeons is owing to an increased demand for surgical services and a declining pool of practicing general surgeons. Burnout and attrition of residents from surgical residencies contribute to the latter. Attrition may be caused by the choice of a career in surgery without an understanding of the realities; subsequent recognition of the realities may cause residents to reexamine the opportunity costs of a career in the field. Because weblogs (blogs) are often used for reflection, qualitative analysis of the content of blogs authored by general surgeons may provide insight into the positive and negative realities of a surgical career. These insights may be informative to students as they consider a surgical career, may better prepare residents for the reality of what is to come, and identify targets for improving the culture of surgery and mitigating sources of career dissatisfaction. This is a qualitative analysis of entries on blogs authored by practicing general surgeons. A systematic approach was used to identify a sample of blog posts. These posts were analyzed using a constant comparative analysis method associated with constructivist grounded theory. Thirty-five posts drawn from 9 blogs were analyzed. Five main themes were identified in the reviewed blogs. Overall, 104 comments were positive in tone, 74 were neutral, and 147 were negative. There were 96 comments that focused on the rewards of being a surgeon, 88 concerning the practice environment, 57 about the educational environment, 54 about the toll of being a surgeon, and 30 pertaining to nostalgia. The most commonly identified subthemes focused on the training experience (38 comments), a surgical career providing personal fulfillment (35 comments), the impact of the culture of surgery (33 comments), and financial concerns (30 comments). A conceptual framework focused on balance was used to explain how the themes relate to each other. Themes identified are consistent with prior studies about surgeon career satisfaction. The considerable rewards of being a surgeon were outweighed by the challenges encountered in day-to-day practice. Meeting societal needs for more general surgeons would require efforts to minimize the tolls, to the extent possible, while encouraging individuals drawn to the rewarding work of being a surgeon

A Survey of Study Habits of General Surgery Residents

To understand the study habits of general surgery residents as well as their motivating factors for study. A survey was mailed to general surgical residents. Performance on the American Board of Surgery In-Training Examination (ABSITE) was correlated with reported study habits using the Pearson's correlation coefficient. Massachusetts General Hospital and Brigham and Women's Hospital, 2 urban tertiary referral academic training institutions in Boston, Massachusetts. Fifty-eight general surgical residents of all training levels (including research). On average, surgical residents studied for 3 ± 1 days per week, the average duration of each study session being 1.3 ± 0.6 hours. The average total number of study hours per week was 3.4 ± 2.3. There were strong positive correlations between increased study frequency and high overall ABSITE score (Pearson's r = 0.339; p = 0.02) and between the total number of study hours per week and high overall ABSITE score (Pearson's r = 0.423; p < 0.005). Only 10% and 3% reported complete satisfaction with current study materials and routine, respectively. Most residents (96%) reported a willingness to try a new type of study method and 75% were willing to enroll in a trial comparing study methods. Increased study frequency and overall increased study duration are positively correlated with ABSITE performance. Dissatisfaction with current study materials and study routine is high, as is willingness to adopt new methods and enroll in investigational trials comparing study methods

Multi-institutional analysis of neutrophil-to-lymphocyte ratio (NLR) in patients with severe hemorrhage: A new mortality predictor value

BACKGROUND: The neutrophil/lymphocyte ratio (NLR) has been associated as a predictor for increased mortality in critically ill patients. We sought to determine the relationship between NLR and outcomes in adult trauma patients with severe hemorrhage requiring the initiation of massive transfusion protocol (MTP). We hypothesized that the NLR would be a prognostic indicator of mortality in this population. METHODS: This was a multi-institutional retrospective cohort study of adult trauma patients (≥18 years) with severe hemorrhage who received MTP between November 2014 and November 2015. Differentiated blood cell counts obtained at days 3 and 10 were used to obtain NLR. Receiver operating characteristic (ROC) curve analysis assessed the predictive capacity of NLR on mortality. To identify the effect of NLR on survival, Kaplan-Meier (KM) survival analysis and Cox regression models were used. RESULTS: A total of 285 patients with severe hemorrhage managed with MTP were analyzed from six participating institutions. Most (80%) were men, 57.2% suffered blunt trauma. Median (IQR) age, Injury Severity Score, and Glasgow Coma Scale were 35 (25-47), 25 (16-36), and 9 (3-15), respectively. Using ROC curve analysis, optimal NLR cutoff values of 8.81 at day 3 and 13.68 at day 10 were calculated by maximizing the Youden index. KM curves at day 3 (p = 0.05) and day 10 (p = 0.02) revealed an NLR greater than or equal to these cutoff values as a marker for increased in-hospital mortality. Cox regression models failed to demonstrate an NLR over 8.81 as predictive of in-hospital mortality at day 3 (p = 0.056) but was predictive for mortality if NLR was greater than 13.68 at day 10 (p = 0.036). CONCLUSIONS: NLR is strongly associated with early mortality in patients with severe hemorrhage managed with MTP. Further research is needed to focus on factors that can ameliorate NLR in this patient population. LEVEL OF EVIDENCE: Prognostic study, level III

Real-time sample entropy predicts life-saving interventions after the Boston Marathon bombing

Identifying patients in need of a life-saving intervention (LSI) during a mass casualty event is a priority. We hypothesized that real-time, instantaneous sample entropy (SampEn) could predict the need for LSI in the Boston Marathon bombing victims. Severely injured Boston Marathon bombing victims (n = 10) had sample entropy (SampEn) recorded upon presentation using a continuous 200-beat rolling average in real time. Treating clinicians were blinded to real-time results. The correlation between SampEn, injury severity, number, and type of LSI was examined. Victims were males (60%) with a mean age of 39.1 years. Injuries involved lower extremities (50.0%), head and neck (24.2%), or upper extremities (9.7%). Sample entropy negatively correlated with Injury Severity Score (r = −0.70; P = .023), number of injuries (r = −0.70; P = .026), and the number and need for LSI (r = −0.82; P = .004). Sample entropy was reduced under a variety of conditions.SampEn (mean ± SD)PAmputation, n = 50.7 ± 0.3No amputation, n = 51.9 ± 0.8.027Transfusion, n = 50.7 ± 0.3No transfusion, n = 51.9 ± 0.8.027Intubation, n = 60.8 ± 0.3No intubation, n = 42.1 ± 0.7.027Vasopressors, n = 70.8 ± 0.3No vasopressors, n = 32.4 ± 0.3.004 Sample entropy strongly correlates with injury severity and predicts LSI after blast injuries sustained in the Boston Marathon bombings. Sample entropy may be a useful triage tool after blast injury

Creation of the first Hartford Consensus compliant elementary school in the USA

Background: The Hartford Consensus established a framework for minimizing deaths due to mass shootings, specifically eliminating preventable deaths due to limb exsanguination. Two major principles defined within this framework are (1) redefining the first responder role and (2) the ubiquitous availability of proper training in application of hemorrhage control techniques, including tourniquets. We hypothesized that this hemorrhage control posture could be fully translated into an elementary school. Methods: Following institutional review board approval, all teachers at a prekindergarten through 8th grade elementary school underwent short, intensive instruction on their role as a first responder, as well as indications and proper technique for hemorrhage control and tourniquet application for limb exsanguination. All teachers self-reported their confidence in their role as a first responder as well as tourniquet application indications and technique before and after instruction. Following instruction, teachers were evaluated on proper tourniquet application technique on a simulated limb to assess competence. Results: 26 elementary school teachers and 2 administrative staff underwent training. All reported low confidence in their role as a first responder and in tourniquet application indication and technique before training. Following training, all teachers reported high confidence. Testing demonstrated all teachers were competent in the tourniquet application technique. Following training, each classroom was equipped with a purpose-made commercial tourniquet, and a dedicated hemorrhage control bag was placed in the school's central administrative office. Conclusions: All teachers were successfully trained to act as first responders and in correct hemorrhage control techniques, which was verified by testing. This is the first elementary school to universally adopt a hemorrhage control posture to eliminate preventable deaths from limb exsanguination advocated by the Hartford Consensus

Gangrenous cholecystitis: Deceiving ultrasounds, significant delay in surgical consult, and increased postoperative morbidity

Gangrenous cholecystitis (GC) is difficult to diagnose preoperatively in the patient with suspected acute cholecystitis. We sought to characterize preoperative risk factors and post-operative complications. Pathology reports of all patients undergoing cholecystectomy for suspected acute cholecystitis from June 2010 to January 2014 and admitted through the emergency department were examined. Patients with GC were compared with those with acute/chronic cholecystitis (AC/CC). Data collected included demographics, preoperative signs and symptoms, radiologic studies, operative details, and clinical outcomes. Thirty-eight cases of GC were identified and compared with 171 cases of AC/CC. Compared with AC/CC, GC patients were more likely to be older (57 years vs. 41 years, p < 0.001), of male sex (63% vs. 31%, p < 0.001), hypertensive (47% vs. 22%, p = 0.002), hyperlipidemic (29% vs. 14%, p = 0.026), and diabetic (24% vs. 8%, p = 0.006). GC patients were more likely to have a fever (29% vs. 12%, p = 0.007) and less likely to have nausea/vomiting (61% vs. 80%, p = 0.019) or an impacted gallstone on ultrasound (US) (8% vs. 26%, p = 0.017). Otherwise, there was no significant difference in clinical or US findings. Among GC patients, US findings were absent (8%, n = 3) or minimal (42%, n = 16). Median time from emergency department registration to US (3.3 hours vs. 2.8 hours, p = 0.28) was similar, but US to operation was longer (41.2 hours vs. 18.4 hours, p < 0.001), conversion to open cholecystectomy was more common (37% vs. 10%, p < 0.001), and hospital stay was longer (median, 4 days vs. 2 days, p < 0.0001). Delay in surgical consultation occurred in 16% of GC patients compared with 1% of AC patients (p < 0.001). Demographic features may be predictive of GC. Absent or minimal US signs occur in 50%, and delay in surgical consultation is common. Postoperative morbidity is greater for patients with GC compared with those with AC/CC. Epidemiologic study, level III; therapeutic study, level IV