Faculty Bibliography

Hepatic artery injuries sustained as a result of blunt abdominal trauma are rare. This case represents the first reported hepatic artery transection and the second hepatic artery injury described in children. Hepatic artery injuries are associated with high mortality, and their management is complex and controversial

BACKGROUND: Effective use of ultrasonography (US) by surgeons was demonstrated a decade ago. Major surgical organizations now require its incorporation into surgical training and practice. But little information about the teaching of US to surgical residents exists. This study assesses the current status of US training in general surgery residency programs. STUDY DESIGN: A survey was mailed to the directors of 255 Accreditation Council for Graduate Medical Education-accredited general surgery residency programs. It questioned whether and how US was taught, who performed the examinations, and the types of US performed. Data were analyzed using chi-square tests comparing university versus community programs and training and practice in trauma US versus training in other US modalities. RESULTS: The response rate was 51% (130 of 255). Ninety-six percent of the programs responding taught US, with no differences between university- and community-based training programs in presence of training. Focused Assessment for the Sonography of Trauma (FAST) instruction was done by 79% (hands-on) and 68% (didactic) of programs that responded. Abdominal, laparoscopic, breast, endocrine, and vascular US were each taught less frequently (22% to 55%). Program directors at university programs reported that their attending surgeons performed FAST and abdominal US more often than their community counterparts (71% and 31% versus 47% and 14%). Program directors reported that university trainees performed laparoscopic, endocrine, and vascular US more often than community surgery residents (47%, 17%, 35% versus 29%, 3%, 19%). Program directors reported that surgery attendings or residents performed trauma and laparoscopic US more often than their radiology counterparts, and radiology attendings or residents performed more abdominal, breast, endocrine, and vascular US. CONCLUSIONS: The majority of general surgery residency programs whose directors responded to this survey are teaching US, but most of the training is in FAST. There is no difference in the reported presence of overall US training between university and community programs. But university programs report that their surgeons or residents performed more US in all areas (other than breast) than their community counterparts reported

In July 2003, work-hour restrictions were implemented by the Accreditation Council for Graduate Medical Education (ACGME) to limit resident duty hours. Attending surgeon work-hours have not been similarly reduced, and many trauma services have added emergency general surgery responsibilities. We hypothesized that trauma attending/resident work-hour disparity may disincentivize residents from selecting trauma careers and that trauma directors would view ACGME regulations negatively. We conducted a 6-month study of resident and in-house trauma attending self-reported hours at a level I trauma center and sent a questionnaire to 172 national level I trauma directors (TDs) regarding work-hours restrictions. TD survey response rate was 48 per cent; 100 per cent of 15 residents and 6 trauma faculty completed work-hour logs. Attending mean hours (87.1/ wk), monthly calls (5), and shifts > 30 hours exceeded that of all resident groups. Case volume was similar. Residents viewed their lifestyle more favorably than the lifestyle of the trauma attending (Likert score 3.6 +/- 0.5 vs Likert score 2.5 +/- 0.8, P = 0.0003). Seventy-one per cent cited attending work hours and lifestyle as a reason not to pursue a trauma career. Nationally, 80 per cent of trauma surgeons cover emergency general surgery; 40 per cent work greater than 80 hours weekly, compared with < 1 per cent of surgical trainees (P < 0.0001). Most TDs feel that residents do not spend more time reading (89%) or operating (96%); 68 per cent feel patient care has suffered as a result of duty-hours restrictions. Seventy-one per cent feel residents will not select trauma surgery as a career as a result of changes in duty hours. Perceived trauma attending/ resident work-hour disparity may disincentive trainees from trauma career selection. TDs view resident duty-hour restrictions negatively

Acid-base abnormalities are common in the critically ill. The traditional classification of acid-base abnormalities and a modern physico-chemical method of categorizing them will be explored. Specific disorders relating to mortality prediction in the intensive care unit are examined in detail. Lactic acidosis, base excess, and a strong ion gap are highlighted as markers for increased risk of death

BACKGROUND: Pulsatile pressure induced by the beating heart causes cyclic strain on arterial endothelial cells and smooth muscle cells (SMCs). This study examined whether Akt, a serine/threonine protein kinase known to promote cell survival by inhibiting apoptosis, is activated by cyclic strain in bovine aortic SMCs. METHODS: Bovine aortic SMCs were cultured on flexible-bottomed membranes and then serum-starved for 24 to 36 hours. The cells were then exposed to 150-mm Hg repetitive deformations, which created an average of 10% strain on the monolayer SMCs at a frequency of 60 cycles/minute for 0 (negative control) and 30 minutes. Platelet-derived growth factor (PDGF)--stimulated SMCs were used as positive controls. Phosphorylation of Akt was determined by means of Western blot analysis. An apoptosis assay (TUNEL) was also performed on SMCs exposed to cyclic strain. RESULTS: Akt phosphorylation was significantly increased over that of the negative control after 30 minutes of cyclic strain and in the PDGF group. Cyclic strain did not increase the prevalence of apoptosis in SMCs over the control. CONCLUSIONS: Cyclic strain activated the pro-survival Akt kinase. The pro-survival function was supported by the fact that cyclic strain did not increase apoptosis in bovine aortic SMCs. This experiment suggests that cyclic strain may induce arterial wall thickening by tipping the balance toward arterial SMC proliferation through the inhibition of apoptosis