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Immediate breast reconstruction (IBR) rates continue to rise, yet recent patterns based on race, age, and patient comorbidities have not been adequately assessed. Women undergoing mastectomy only or mastectomy with IBR from 2005 to 2011 were identified in the American College of Surgeons–National Surgical Quality Improvement (NSQIP) data sets. A multivariate logistic regression was performed to determine factors independently associated with receipt of IBR. Thirty-day surgical complication rates after IBR were also assessed. Rates of IBR increased significantly over the study period from 26% of patients in 2005 to 40% in 2011. Non-Caucasian race, older age (≥45 years), obesity, and presence of comorbid conditions including diabetes mellitus, current smoking, and cardiovascular disease were all negatively associated with receipt of IBR. Surgical complication rates after IBR were not predicted by non-Caucasian race, older age, or presence of diabetes mellitus. This current assessment of IBR using the American College of Surgeons–National Surgical Quality Improvement data sets demonstrates that non-Caucasian and older women (≥45 years) continue to receive IBR at lower rates despite the lack of association of added risk of surgical morbidity.

1. Gene flow from transgenic crops to feral populations and naturalized compatible relatives has been raised as one of the main issues for the deregulation of transgenic events. Creeping bentgrass, Agrostis stolonifera L., is a perennial, outcrossing grass that propagates by seeds and stolons. Transgenic Roundup Ready® glyphosate-resistant creeping bentgrass (GRCB), which is currently under USDA-APHIS regulated status, was planted in 2002 on 162 ha within a production control area in Oregon, USA. 2. We conducted a study to assess transgene flow from the GRCB fields. A survey within and around the production control area was performed during the year when the GRCB fields produced seed and for 3 years after the fields were taken out of production. Transgene flow was determined by testing creeping bentgrass and its relatives for expression of the glyphosate resistance transgene. 3. While GRCB seed-production practices were strictly regulated, evidence of transgene flow was found in all years. In 2006, 3 years after the transgene source fields were taken out of production and a mitigation programme was initiated, 62% of the 585 creeping bentgrass plants tested in situ were glyphosate-resistant (GR). Our results document not only the movement of the glyphosate resistance transgene from the fields, but also the establishment and persistence of high frequencies of GR plants in the area, confirming that it was unrealistic to think that containment or eradication of GRCB could be accomplished. 4. Synthesis and applications: These findings highlight the potential for transgene escape and gene flow at a landscape level. The survey provides empirical frequencies that can be used to design monitoring and management methods for genetically engineered (GE) varieties of outcrossing, wind-pollinated, perennial grasses and to evaluate the potential for coexistence of GE and non-GE grass seed crops. Such information should also be used in the decision-making process for authorization of field trials and deregulation of genetic engineering events.

Disparities along racial and ethnic lines exist in breast cancer treatment and reconstruction. This study compares preoperative characteristics among female breast cancer patients who received autologous breast reconstruction to determine if race affects clinical outcomes. Women receiving autologous breast reconstruction at a single institution from 2005 to 2011 were identified within a prospectively maintained database. Preoperative risk factors and rates of postoperative morbidity and mortality were assessed with respect to race. African-American patients had significantly higher rates of preoperative comorbidities than Caucasian patients. Despite the heightened preoperative risk factors, postoperative complications did not significantly differ between racial categories. As the alleviation of healthcare disparities remains a focus of healthcare reform, these findings are beneficial in further educating African-American breast cancer patients and their providers of the safe and viable option of autologous tissue transfer for breast reconstruction.

Little is known about intraoperative adverse events (iAEs) in emergency surgery (ES). We sought to describe iAEs in ES and to investigate their clinical and financial impact. The 2007 to 2012 administrative and American College of Surgeons-National Surgical Quality Improvement Program databases at our tertiary academic center were: (1) linked, (2) queried for all ES procedures, and then (3) screened for iAEs using the ICD-9-CM–based Patient Safety Indicator “accidental puncture/laceration”. Flagged cases were systematically reviewed to: (1) confirm or exclude the occurrence of iAEs (defined as inadvertent injuries during the operation) and (2) extract additional variables such as procedure type, approach, complexity (measured by relative value units), need for adhesiolysis, and extent of repair. Univariate and multivariate analyses were performed to assess the independent impact of iAEs on 30-day morbidity, mortality, and hospital charges. Of a total of 9,288 patients, 1,284 (13.8%) patients underwent ES, of which 23 had iAEs (1.8%); 18 of 23 (78.3%) of the iAEs involved the small bowel or spleen, 10 of 23 (43.5%) required suture repair, and 8 of 23 (34.8%) required tissue or organ resection. Compared with those without iAEs, patients with iAEs were older (median age 62 vs 50; P = .04); their procedures were more complex (total relative value unit 46.7, interquartile range [27.5 to 52.6] vs 14.5 [.5 to 30.2]; P < .001), longer in duration (>3 hours: 52% vs 8%; P < .001), and more often required adhesiolysis (39.1% vs 13.5% P = .001). Patients with iAEs had increased total charges ($31,080 vs $11,330, P < .001), direct charges ($20,030 vs $7,387, P < .001), and indirect charges ($11,460 vs $4,088, P < .001). On multivariable analyses, iAEs were independently associated with increased 30-day morbidity (odds ratio, 3.56 [CI, 1.10 to 11.54]; P = .03) and prolonged postoperative length of stay (LOS; LOS >7 days; odds ratio, 5.60 [1.54 to 20.35]; P = .01]. A trend toward increased mortality did not reach statistical significance. In ES, iAEs are independently associated with significantly higher postoperative morbidity and prolonged LOS. •We described the nature and patterns of intraoperative adverse events (iAEs) in emergency surgery (ES) and investigated independent impact on 30-day morbidity, mortality, and hospital charges.•iAEs were detected and confirmed through screening of the linked institutional administrative and databases at a tertiary academic center.•Multivariable analyses were performed to study the independent impact of iAEs on 30-day morbidity, mortality, and hospital charges.•In ES, iAEs are independently associated with increased postoperative morbidity and length of hospital stay.

Patient instability and limited radiology staffing may compel surgeons to make clinical decisions based on their independent interpretations of imaging studies. Despite potential implications for patients, no research to date has assessed the need for a diagnostic radiology curriculum in general surgery residency. We performed a cross-sectional study of surgery faculty and residents at 13 teaching hospitals across the United States. Survey responses were summarized using frequency and percentage, and analyzed by chi-square, Mantel-Haenszel chi-square, and McNemar tests. Surveys were distributed to 465 faculty and 520 residents, with response rates of 26% and 30%, respectively. Most respondents reported making decisions based on their independent imaging interpretation at least sometimes, with higher frequency in acute scenarios. The majority voiced a need for a dedicated radiology curriculum, with teaching in chest x-rays, abdominal x-rays, abdominal computed tomography, chest computed tomography, and focused assessment with sonography in trauma examinations. Surgeons and surgical residents enact treatment plans based on their independent interpretation of imaging studies, especially during acute patient scenarios. Further curricular development efforts are warranted to ensure trainee accuracy in radiologic interpretation. •No study to date has evaluated independent imaging interpretation among surgeons.•This study evaluated patterns in radiologic interpretation among surgeons and residents.•Both cohorts enact care plans based on their interpretations of imaging studies.•Participants denied formal training in radiology. Residents cited their colleagues as teachers.•Our data support a curriculum in diagnostic radiology for general surgery residents.

Blunt hollow viscus injury (BHVI) is challenging to diagnose. The purpose of this study was to determine the reliability of physical exam and the role of computed tomography (CT) in the diagnosis of BHVI. All blunt abdominal trauma (BAT) admissions to a level 1 trauma center from January 2009 through December 2011 were identified through the trauma registry. Data collected included demographics and findings on CT and physical exam. Of 2,912 patients with blunt trauma, 340 had BAT, and 30 (9%) had BHVIs. The sensitivity and specificity of CT were 86% and 88%, respectively, whereas the sensitivity and specificity of clinical exam were 53% and 69%. Twenty-seven percent of patients with BAT and bladder injuries had concomitant BHVIs. This is the largest single series of BHVI after BAT. CT is superior to clinical exam in establishing the diagnosis of BHVI. Although associated injuries are common, bladder injury may be an important marker for BHVI.

By the principles of Tactical Combat Casualty Care, battlefield casualties are preferentially triaged on the basis of pulse character and mental status. A weak or absent palpable pulse correlates with a systolic blood pressure (SBP) of ≤100 mm Hg. Furthermore, the motor component of the Glasgow Coma Scale (GCS-M) has been shown to correlate with outcomes. In a previous study, the authors developed a simple triage tool, the field triage score (FTS), on the basis of pulse character and GCS-M status, which provided a quick and effective means of predicting injury survival in the civilian trauma environment. The purpose of this analysis was to validate the predictive utility of the FTS in the battlefield trauma environment. The Joint Theater Trauma Registry was used to identify 4,988 battlefield casualties from Iraq and Afghanistan from January 2002 to September 2008 with requisite admission data elements of SBP, GCS-M status, and survival. SBP was stratified as ≤100 mm Hg, consistent with weak or absent pulse character, or >100 mm Hg, consistent with a normal pulse character. GCS-M status was stratified as either abnormal (<6) or normal (6). Casualties with presenting SBPs of 0 mm Hg were excluded from the analysis. As in the civilian trauma triage study, the FTS was derived by assigning a component value of 0 for weak or absent pulse or abnormal GCS-M status and a component value of 1 for either a normal pulse or normal GCS-M status. Adding the scores resulted in an aggregate FTS value of 0, 1, or 2. For the overall population of 4,988 casualties, 87.5% (n = 4,366) had FTS of 2, with overall mortality of .1% (5 of 4,366). From the battlefield, 10.8% of patients (n = 540) presenting with FTS of 1 had a mortality rate that increased to 6.1% (33 of 540). In contrast, combat casualties presenting with FTS of 0 had a significantly higher mortality of 41.4% (34 of 82). The calculated lengths of stay were 6.1 (FTS 2), 9.2 (FTS 1), and 17.7 (FTS 0) days. This study has validated the utility of the FTS as a simple and practical triage instrument for use in the battlefield environment. Using the FTS, medics and medical providers will have a quick and effective measure to predict high-acuity combat casualties to triage evacuation and medical resources in austere military environments. This technique may have potential implications for domestic or foreign disaster or mass casualty situations in which supplies, medical resources, and facilities are limited.

Despite the critical importance of cricothyroidotomy (CCT) for patient in extremis, clinical experience with CCT is infrequent, and current training tools are inadequate. The long-term goal is to develop a virtual airway skills trainer that requires a thorough task analysis to determine the critical procedural steps, learning metrics, and parameters for assessment. Hierarchical task analysis is performed to describe major tasks and subtasks for CCT. A rubric for performance scoring for each task was derived, and possible operative errors were identified. Time series analyses for 7 CCT videos were performed with 3 different observers. According to Pearson's correlation tests, 3 of the 7 major tasks had a strong correlation between their task times and performance scores. The task analysis forms the core of a proposed virtual CCT simulator, and highlights links between performance time and accuracy when teaching individual surgical steps of the procedure. •We conducted a hierarchical task analysis for cricothyroidotomy procedure.•Five main steps with substeps are defined along for the procedure.•Learning objectives and rubric for task performance assessment are derived.•Video analysis indicated strong relation between time and scores for 3 tasks.

Ethical and scientifically sound research requires that any sample population represent the population as a whole. African-Americans suffer disproportionately from cancer, hypertension, and heart failure compared with whites, but they are commonly underrepresented in clinical trials of these diseases. Failure to include African-American subjects in clinical trials prevents generalizability of the results to this population. African-Americans are often underrepresented in clinical research for numerous historic, societal, educational, and economic reasons. Efforts to improve enrollment of African-American subjects requires recognition of the problem, planning, educational efforts, and investigator training. The incidence of heart disease and prostrate cancer in African-Americans dictates that these patients be targeted for clinical trials of surgical research. The research team must appreciate the importance of community involvement and support in recruiting African-Americans participants. Additionally, the continued effort to recruit and train African-American investigators must be a priority

Functional outcomes can improve with early intensive care unit (ICU) mobilization programs but require additional resources. Details regarding resource allotment and methods to deliver therapy are lacking. We describe an effective team-based, resource-efficient mobility program (REMP). Consecutive admissions (November 2009 to March 2010) underwent an evaluation by a physical therapist and participation in the REMP. Sitting balance (SB), transfer from bed to chair, and ambulation were assessed on the initial evaluation and compared with ICU and hospital discharge using the Functional Independence Measure scale. Twenty-eight patients entered the REMP, and 31 patients served as controls. There were no differences in baseline characteristics or initial Functional Independence Measure scores for ambulation or SB. Bed-to-chair evaluation was higher in the controls (P < .024). Both groups improved across the 3 time periods on all measures; however, more REMP patients had a significantly improved SB at ICU and hospital discharge. A team-based, resource-efficient approach to early mobilization is feasible and effective in the ICU.