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QS330. A Case of Right Middle Lobe Syndrome in Marfan’s Disease
398 ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS Most residents at present do not do the lectures. Improved monitoring and proactive approach with possible incentives will need to be developed to improve compliance with online education. QS329. A DECISION-DELPHI TO EVALUATE INJURY CONTROL CURRICULA IN CANADIAN HEALTH PROFESSIONAL SCHOOLS: OPINIONS OF TRAUMA EXPERTS. Shaifali Sandal1, Avery Nathens2, Najma Ahmed2; 1 St George University, St George’s, Grenada; 2University of Toronto, Toronto, ON, Canada Introduction: Injury constitutes a major public health problem responsible for about 5.8 million deaths worldwide. It is the leading cause of potential years of life lost between the ages of 1-44. In a landmark document in 1966, the American Association for the Surgery of Trauma reported that the vast majority of injuries were preventable. Recently, the American Association of Medical Colleges identified physicians as having a pivotal role in education about injury control; despite this, a review of literature shows that injury prevention is poorly covered in medical and nursing schools. The purpose of the present study was to create an instrument to capture the thoughts and experiences of trauma care providers and opinion leaders about the desired content, mode of delivery and evaluation of a standardized curriculum in injury control. Methodology and Results: A thorough review of the literature was used to create a preliminary instrument to capture quantitative and qualitative elements. Using feedback from the preliminary pilot testing phase, in conjunction with a review of the literature, we created a unique 8 page 31 item instrument. Readability, appropriateness of content, validity and reliability were informally tested with local experts. This instrument was mailed to 170 trauma specialists across Canada, including trauma physicians, surgeons, nurses, data analysts and clinical epidemiologists whose area of research is injury. Participants were also given the option of completing the instrument on-line. Quasianonymity was obtained by ensuring that consent for participation and all further communications with the experts was maintained by the research assistant. A Decision-Delphi methodology was used to determine the opinions of the Trauma Experts about curricula in three different areas; firstly, their educational background and experiences on injury control, secondly, their knowledge and opinions about the current curricular content in health professional schools, and finally, what the ideal injury control curriculum should include and how it should be delivered and evaluated. Conclusions: The quantitative analysis will help to understand what, when and how an injury control curriculum should be constructed. Iterative coding analysis of the qualitative comments will uncover themes, which will help deepen our understanding of why injury control subjects are under-represented in health professional curricula. The results of this study will also inform the design of a Test Question Analysis tool to assess the knowledge and capture the experiences of student bodies in the health professions. Collectively, this body of work will help create a standard inter-professional curriculum for injury control among the health professional schools in North America. QS330. A CASE OF RIGHT MIDDLE LOBE SYNDROME IN MARFAN’S DISEASE. Shirong Chang1, Hector Saucedo1, Kenneth Lloyd2, Matthisa Loebe1; 1Baylor College of Medicine, Houston, TX; 2The Methodist Hospital, Houston, TX Background: Right middle lobe syndrome (RMLS) is characterized by chronic or recurrent right middle lobe atelectasis that can lead to pulmonary infection. Pulmonary abnormalities have been report in patients with Marfan’s syndrome; however, the association with RMLS has never been documented. Case Report: A 68-year old male patient with a diagnosis of Marfan’s syndrome and history of a small right lung mass vs. scar tissue since child-
hood was admitted to the hospital after several weeks of productive cough and constitutional symptoms that were treated unsuccessfully with both intravenous and oral antibiotics. A computed tomography (CT) scan of the chest revealed a 9.7 ⫻ 6.7 cm right middle lung mass. A right lateral thoracotomy was performed which revealed a large abscess. The patient subsequently underwent a right middle lobe lobectomy that led to resolution of symptoms. Conclusion: Right middle lobe syndrome is chronic or recurrent collapse of right middle lobe due to extrinsic compression or intrinsic abnormalities of bronchus. In Marfan’s syndrome patients, the abnormal collagen cross-link caused by mutate fibrillin molecule produced a reduced tensile strength of pulmonary connective tissue. Therefore, Marfan’s syndrome patient has higher propensity for collapse of right middle lung that can lead to inflammation and pneumonia under certain insults. High level of suspicion with prompt diagnosis and aggressive treatment with antibiotics may be effective. However, surgical resection become necessary when medical management fails. QS331. MANAGEMENT OF VASCULAR INJURIES ASSOCIATED WITH KNEE DISLOCATIONS IN THE OBESE PATIENT. Jennifer Rogers1, David Han2; 1Penn State College of Medicine, Hershey, PA; 2Penn State Hershey Medical Center, Hershey, PA Introduction: The management of injuries to the popliteal artery that occur as a result of traumatic knee dislocation focuses on timely restoration of arterial flow and stabilization of the orthopedic injury. In some cases, determining the order of repair can be challenging, especially when complex vascular and/or orthopedic injuries exist. In the obese patient, repair can be more complex and time-consuming, which can increase the chance for subsequent complications. Case Report: A 40-year-old obese male presented with severe pain in the right knee after twisting it while exiting a golf cart. Orthopedic evaluation revealed a displaced tibial plateau fracture dislocation. Initial evaluation revealed a palpable right dorsalis pedis pulse, but over the ensuing hours the pulse could no longer be felt. Motor and sensory examination were limited due to pain, but were grossly unremarkable. The ankle-brachial index was 0.54. Preoperative arteriography demonstrated occlusion of the popliteal artery at the knee joint, with reconstitution of the tibial vessels and patent runoff beyond the ankle. In the operating room, the knee dislocation was reduced, and the joint stabilized with an external fixator. During this time, the greater saphenous vein was harvested from the left thigh. The patient was then placed prone, and through a posterior approach, the popliteal artery injury was repaired with an interposition graft of saphenous vein. Completion arteriography showed a patent repair with three vessel runoff. The patient had a subsequent uneventful recovery. Discussion: Because different degrees of severity of ischemia occur, popliteal artery injuries can be difficult to diagnosis as well as variable in the urgency of repair. Various algorithms exist for the role of arteriography, but in many cases, the level of ischemia is severe and revascularization should proceed without delay. In determining the sequence of repair, consideration must be given to the severity of each injury. In cases where vascular repair is performed first, the graft may be in jeopardy during orthopedic manipulation. When the orthopedic stabilization is performed first, the external hardware can impair the ability to adequately expose the vessels, especially in the obese patient. A posterior approach to the arterial injury can allow optimal timing of both repairs. Harvesting the vein during orthopedic stabilization addresses the difficulty of harvesting vein with the patient prone during a posterior approach. Additionally, the posterior approach is typically away from the placement of the external fixator, and technically easier in the obese patient. Conclusion: This case suggests an approach that can provide optimal timing of concomitant orthopedic and vascular repair of popliteal artery injuries that result from traumatic knee
hood was admitted to the hospital after several weeks of productive cough and constitutional symptoms that were treated unsuccessfully with both intravenous and oral antibiotics. A computed tomography (CT) scan of the chest revealed a 9.7 ⫻ 6.7 cm right middle lung mass. A right lateral thoracotomy was performed which revealed a large abscess. The patient subsequently underwent a right middle lobe lobectomy that led to resolution of symptoms. Conclusion: Right middle lobe syndrome is chronic or recurrent collapse of right middle lobe due to extrinsic compression or intrinsic abnormalities of bronchus. In Marfan’s syndrome patients, the abnormal collagen cross-link caused by mutate fibrillin molecule produced a reduced tensile strength of pulmonary connective tissue. Therefore, Marfan’s syndrome patient has higher propensity for collapse of right middle lung that can lead to inflammation and pneumonia under certain insults. High level of suspicion with prompt diagnosis and aggressive treatment with antibiotics may be effective. However, surgical resection become necessary when medical management fails. QS331. MANAGEMENT OF VASCULAR INJURIES ASSOCIATED WITH KNEE DISLOCATIONS IN THE OBESE PATIENT. Jennifer Rogers1, David Han2; 1Penn State College of Medicine, Hershey, PA; 2Penn State Hershey Medical Center, Hershey, PA Introduction: The management of injuries to the popliteal artery that occur as a result of traumatic knee dislocation focuses on timely restoration of arterial flow and stabilization of the orthopedic injury. In some cases, determining the order of repair can be challenging, especially when complex vascular and/or orthopedic injuries exist. In the obese patient, repair can be more complex and time-consuming, which can increase the chance for subsequent complications. Case Report: A 40-year-old obese male presented with severe pain in the right knee after twisting it while exiting a golf cart. Orthopedic evaluation revealed a displaced tibial plateau fracture dislocation. Initial evaluation revealed a palpable right dorsalis pedis pulse, but over the ensuing hours the pulse could no longer be felt. Motor and sensory examination were limited due to pain, but were grossly unremarkable. The ankle-brachial index was 0.54. Preoperative arteriography demonstrated occlusion of the popliteal artery at the knee joint, with reconstitution of the tibial vessels and patent runoff beyond the ankle. In the operating room, the knee dislocation was reduced, and the joint stabilized with an external fixator. During this time, the greater saphenous vein was harvested from the left thigh. The patient was then placed prone, and through a posterior approach, the popliteal artery injury was repaired with an interposition graft of saphenous vein. Completion arteriography showed a patent repair with three vessel runoff. The patient had a subsequent uneventful recovery. Discussion: Because different degrees of severity of ischemia occur, popliteal artery injuries can be difficult to diagnosis as well as variable in the urgency of repair. Various algorithms exist for the role of arteriography, but in many cases, the level of ischemia is severe and revascularization should proceed without delay. In determining the sequence of repair, consideration must be given to the severity of each injury. In cases where vascular repair is performed first, the graft may be in jeopardy during orthopedic manipulation. When the orthopedic stabilization is performed first, the external hardware can impair the ability to adequately expose the vessels, especially in the obese patient. A posterior approach to the arterial injury can allow optimal timing of both repairs. Harvesting the vein during orthopedic stabilization addresses the difficulty of harvesting vein with the patient prone during a posterior approach. Additionally, the posterior approach is typically away from the placement of the external fixator, and technically easier in the obese patient. Conclusion: This case suggests an approach that can provide optimal timing of concomitant orthopedic and vascular repair of popliteal artery injuries that result from traumatic knee