Implementation of an academic half day in a vascular surgery residency program improves trainee and faculty satisfaction with surgical indications conference

Background

The Accreditation Council for Graduate Medical Education mandates scheduled didactics for residency programs but allows flexibility in implementation. Work-hour restrictions, patient care duties, and operative schedules create barriers to attendance for surgical trainees. We explored vascular surgery trainees and faculty perceptions on trainees operative preparation and participation, and overall fund of knowledge after implementing an academic half day conference (AHD) schedule.

Predicting ICU readmission among surgical ICU patients: Development and validation of a clinical nomogram

Background

Unplanned intensive care unit readmission within 72 hours is an established metric of hospital care quality. However, it is unclear what factors commonly increase the risk of intensive care unit readmission in surgical patients. The objective of this study was to evaluate predictors of readmission among a diverse sample of surgical patients and develop an accurate and clinically applicable nomogram for prospective risk prediction.

Major surgery in leukemia

Complications of leukemia that required surgery in twenty-five patients over a five year interval were reviewed. Sixteen patients with chronic leukemia underwent a total of twenty-one operations with one operative death. Nine patients with acute leukemia required ten operations, with two operative deaths. These patients tend to have specific types of complications that are particular to leukemic patients, and with proper support the majority of these patients can be benefited.     

Acute renal failure after abdominal surgery. The importance of sepsis

Twenty-six patients with acute renal failure associated with intra-abdominal disease were evaluated for the cause of renal failure. Sepsis accounted for renal failure in fourteen of the patients. Fifty per cent of the patients died and death was due to sepsis in 62 per cent.     

Gastric prostaglandin e output during basal and stimulated acid secretion in normal subjects and patients with duodenal ulcer

PGE output into the gastric lumen under basal conditions and after insulin hypoglycemia was studied in four normal subjects and eight patients with uncomplicated duodenal ulcers. In both groups, increased acid secretion following vagal stimulation was accompanied by a rise in PGE output. This observation, together with their known inhibitory effect on acid secretion, supports the concept that synthesis and local release of PGE may play a regulatory role. The fact that patients with ulcer disease have a slightly higher PGE output in gastric juice during basal and stimulated acid secretion does not support the hypothesis that PGE deficiency is an underlying mechanism in the pathogenesis of acid peptic disease.     

The Influence of IPPB,CPAP, and IPPB with CPAP during Cardiopulmonary Bypass on Postbypass and Postoperative Pulmonary Function

Pulmonary compliance and shunt (

_S/

_T) were employed to determine the optimal method for maintaining the lungs during cardiopulmonary bypass in 100 calves. The calves were divided into four groups with respect to pulmonary maintenance during bypass: nonventilation with the lungs collapsed (Group 1); nonventilation with the lungs exposed to 5 cm H₂O of continuous positive airway pressure (CPAP) (Group 2); intermittent positive-pressure breathing (IPPB) without CPAP (Group 3); and IPPB with 5 cm H₂O of CPAP (Group 4). All groups had similar compliance preoperatively and sustained significant decreases 30 minutes after bypass. Lung compliance returned to preoperative levels two hours postoperatively in Groups 1 and 2 but was still reduced in Groups 3 and 4. The

_S/

_T was markedly higher postoperatively in Groups 3 and 4 than in Groups 1 and 2.These data demonstrate that ventilation during bypass reduces early postoperative lung compliance and increases

_S/

_T and they suggest that static pulmonary inflation during bypass offers no advantages over allowing the lungs to remain collapsed.     

Comparative effectiveness of one-stage versus two-stage basilic vein transposition arteriovenous fistulas

Objective

Basilic vein transposition (BVT) fistulas may be performed as either a one-stage or two-stage operation, although there is debate as to which technique is superior. This study was designed to evaluate the comparative clinical efficacy and cost-effectiveness of one-stage vs two-stage BVT.

Failure to achieve success with remedial gastric surgery

Twenty-five patients underwent a variety of gastrointestinal operations in an attempt to gain relief from symptoms of recurrent ulcer and/or postgastrectomy syndromes excluding dumping. Only eleven obtained a satisfactory result. Conversion to a gastroduodenostomy provided the best relief for bilious vomiting.     

The role of biofeedback and relaxation therapy in arterial occlusive disease

Eleven patients with chronic arterial occlusive disease and intermittent claudication were treated with biofeedback-relaxation therapy in an attempt to increase walking time by improving peripheral blood flow. Criteria for admission to the study included (1) participation in an exercise program without improvement in symptoms (2) a maximal treadmill walking time (MWT) of <5 min and (3) an ankle blood pressure of <60 mm Hg immediately postexercise. Patients were randomized into two groups: Group I entered biofeedback training immediately, and Group II served as controls for 3 months prior to undergoing the same treatment protocol as Group I. Patients were taught EMG and skin temperature feedback during 30 1-h training sessions over a 13-week period. Following biofeedback therapy all patients in Group I significantly increased their MWT (P < 0.001) while patients in the control Group (II) showed minimal improvement in MWT. After undergoing biofeedback therapy, Group II also improved their MWT. At the completion of the study, 9 of 11 patients walked >8 min. The improved MWT was associated with a fall in resting (P < 0.05) and exercise (P < 0.01) arm systolic blood pressure. Both the exercise ankle blood pressure (P < 0.05) and exercise ankle/arm blood pressure ratio (P < 0.01) increased significantly following biofeedback therapy, suggesting a reduction in resistance around the site of occlusion. Our findings indicate that biofeedback training may be an effective nonoperative treatment for selected patients with arterial occlusive disease and intermittent claudication.     

Direct effects of endotoxin on canine gastric mucosal permeability and morphology.

The effects of endotoxin on gastric mucosal permeability and morphology were studied by intra-arterial infusion of sublethal doses of endotoxin into a single artery perfusing an exteriorized segment of canine stomach. Endotoxin infusion produced a profound change in mucosal appearance from bright, uniform red to mottled, palewhite discoloration when exposed to acid or mannitol. Gross erosions occurred in four of 13 mucosae bathed with 0.15 N HCl within 1 hr of infusion of endotoxin in the absence of arterial hypotension. Histological changes seen in most experiments include release of mucus from surface epithelial cells and elevation of the epithelium from the basement membrane. In more advanced lesions, severe injury extended into the gastric glands and surrounding connective tissue with cellular necrosis. In spite of gross and microscopic gastric mucosal injury, no significant change was seen in hydrogen ion back diffusion or sodium efflux. These observations suggest that gastric mucosal injuries can occur in endotoxemia without systemic arterial hypotension and that anatomical mucosal injuries are not associated with the destruction of the hydrogen-sodium permeability barrier.     

The effect of low-dose heparin therapy on serum platelet and transaminase levels

Review of recent literature permits characterization of a thrombocytopenic syndrome associated with full- or low-dose heparin therapy, the incidence, severity, and etiology of which remain controversial. This study was undertaken to determine the occurrence of thrombocytopenia accompanying subcutaneous heparin administration to healthy volunteers. Thirty-nine subjects received a regimen of 5000 USP units of heparin injected every 12 hr for 10 days. Serum liver enzymes were also monitored in a subgroup of the population. Two available heparin preparations, hog mucosa and beef lung extracts, were compared for the occurrence of these associated abnormalities. There was no thrombocytopenia observed in any person. However, as a group there was a significant (P = 0.01) downward linear trend in the mean platelet count during heparin administration, with a marked increase after cessation of the drug. Significant elevations of transaminase (SGOT and SGPT) levels occurred in 62% of the subjects, also returning to normal after heparin was discontinued. The enzyme pattern was characteristic of hepatocellular damage. The incidence of this finding was higher in subjects receiving hog mucosal heparin (93%) than in those receiving bovine heparin (37%, P < 0.05). Though not exhibiting thrombocytopenia, the subjects did have a decrease in mean platelet count. The etiology of the hypertransaminasemia is unknown, though the temporal correlation with the decrease in platelets suggests that the two are related, possibly through an immunologic mechanism. The enzyme elevations could result in inaccurate diagnosis based on these enzymes or pose potential danger to patients with marginal liver function. Patients receiving heparin should have liver enzymes as well as platelet counts followed regularly.     

Skin fluorescence,a method to predict amputation site healing

Although skin blood flow is an important determinant of amputation site healing, most techniques to evaluate it are cumbersome and indirect. We have prospectively compared a new, simple and direct technique, skin fluorescence (SF), with a more established indirect method, segmental limb blood pressures (BP), to determine the value of each in predicting amputation healing of an ischemic extremity. Twenty-six consecutive patients with ischemic tissue loss were studied prior to amputation. Thigh, calf, and ankle BP were measured; then SF was determined by injecting 10–15 mg/kg of fluorescein intravenously and examining the limb with uv light. BP of > 50 mm Hg was considered adequate for amputation wound healing; yellow SF indicated adequate skin blood flow. In each case, the most distal site predicted to heal by either method was selected for amputation. Thirty amputations were performed (6 digital, 3 transmetatarsal, 11 below knee, and 10 above knee) with an 80% healing rate. When SF and BP disagreed on the level of amputation, fluorescein always predicted a more distal site. SF accurately predicted amputation healing in 80% of cases. In the remaining 20%, amputation failures were due to infection in two and deep tissue necrosis in four. BP was accurate and useful in 47% of cases. In 14 patients BP indicated the need for a higher level of amputation than was successfully performed. In two patients BP measurement was indeterminate due to “stiff arteries.” Furthermore, in two patients amputations failed despite BP > 50 mm Hg. We conclude that SF helps the surgeon select a more distal level of amputation than segmental limb pressures, and one that has a high likelihood of healing.     

Jaundice in patients with acute cholecystitis: Its validity as an indication for common bile duct exploration

Our study demonstrates that (1) mild to moderate jaundice is frequently seen in patients with acute cholecystitis; (2) severe degrees of jaundice were seen in two patients without the presence of common duct stone or recognizable obstruction of the common bile duct; (3) only one of forty-one patients with acute cholecystitis had common bile duct stone; (4) jaundice does not appear to be a compelling reason for choledochotomy; and (5) less invasive technics such as intravenous and intraoperative cholangiography should suffice to exclude the possibility of common bile duct stone in patients with acute cholecystitis.