Baylor University Medical Center Proceedings January 2014, Volume 27, Number 1 | Page 78

Background: Symptoms identical to posttraumatic stress disorder (PTSD)
have been shown to occur in caregivers of trauma patients. Secondary
traumatic stress (STS) characterizes those who exhibit PTSD symptoms
related to indirect exposure to a stressor. We hypothesized that caring for
trauma patients is associated with symptoms of PTSD/STS.

Survival differences were assessed with proportional hazard models,
adjusted for a comprehensive array of clinical and nonclinical risk
factors. Interaction between treatment and AAA size was added to
the model to assess whether the effect of immediate open repair vs
surveillance varied by AAA size.

Methods: Surgeons in various specialties (n = 133) were surveyed from
January to May 2012 at two regional surgical conferences. Symptoms
of PTSD were identified using the Secondary Traumatic Stress Scale
(STSS) using specific diagnostic criteria to measure the psychological
impact of exposure to trauma patients. Resilience was measured using
the Connor-Davidson Resilience Scale 10 items. The amount of time
caring for trauma patients was used as a measure of risk exposure. The
relationship between STSS, resilience, and exposure to trauma patients
was measured with P < 0.05 considered significant.

Results: The adjusted analysis revealed no statistically significant survival difference between immediate open repair and surveillance patients (hazard ratio [HR], 0.99; 95% CI, 0.83–1.18; mean follow-up
time, 1921 days for both study groups). This lack of treatment effect
persisted when men (HR, 1.01; 95% CI, 0.84–1.21) and women (HR,
0.96; 95% CI, 0.49–1.86) were examined separately and did not vary
by AAA size (P = .39 for the entire cohort and P = .24 for women).

Results: Twenty-eight surgeons (22%) met diagnostic symptom criteria
for PTSD as measured by the STSS. Approximately two thirds of
the surgeons (86 of 133, 65%) exhibited at least one symptom of
STS. However, the magnitude of exposure to trauma patients was
similar between surgeons with and without PTSD symptoms (P =
0.2177). Higher resilience scores were associated with lower STS scores
(r = –0.369, P < 0.0001). Most importantly, surgeons who met
symptom criteria for PTSD exhibited significantly lower resilience
scores (31 [3.4] vs. 34 [3.9], P < 0.0001).
Conclusion: Symptoms of PTSD as measured by the STSS were reported in two thirds of study participants but did not correlate with time
spent for caring for trauma patients. One in five reported symptoms
consistent with a PTSD. Lower resilience scores correlated with risk
of symptoms and may be used to identify those surgeons most at risk.
Efforts to better identify, address, and moderate these psychological
consequences of surgical care may improve both the emotional wellbeing and the vocational performance of surgeons.

MAYO CLINIC PROCEEDINGS
Immediate open repair vs surveillance in patients with
small abdominal aortic aneurysms: survival differences by
aneurysm size
Filardo G, Lederle FA, Ballard DJ, Hamilton C, da Graca B, Herrin J,
Harbor J, Vanbuskirk JB, Johnson GR, Powell JT
Mayo Clin Proc 2013;88(9):910–919. Reprinted with permission from
Elsevier.
Objective: To assess whether survival differences exist between patients
undergoing immediate open repair vs surveillance with selective repair
for 4.0- to 5.4-cm abdominal aortic aneurysms (AAAs) and whether
these differences vary by diameter, within sexes, or overall.
Patients and methods: The study cohort included 2226 patients randomized to immediate repair or surveillance for the UK Small Aneurysm Trial (September 1, 1991, through July 31, 1998; follow-up,
2.6–6.9 years) or the Aneurysm Detection and Management trial
(August 1, 1992, through July 31, 2000; follow-up, 3.5–8.0 years).

Conclusion: Immediate open repair offered no significant survival benefit, even in patients with the largest AAAs and highest risk of rupture.
Because recent trials failed to find a survival benefit of immediate
endovascular repair over surveillance for small asymptomatic AAAs,
our findings suggest that the gray area of first-line management for
these patients should be resolved in favor of surveillance.

NUTRITION IN CLINICAL PRACTICE
Improving patient outcomes through registered dietitian order writing
Roberts SR
Nutr Clin Pract 2013;28(5):556–565. Reprinted with permission from
Sage Publications.
Traditionally, registered dietitians (RD) have not had order writing
privileges in most patient-care facilities and rely on physicians to
implement their recommendations. Research has demonstrated that
this model results in a high percentage of RD recommendations not
being ordered. Timely nutrition interventions are important due to the
prevalence of malnutrition in the hospital setting and when RD recommendations are implemented, important outcomes are improved.
In addition, several studies have demonstrated that when RDs have
order writing privileges, which allows more assurance that an intervention will occur and timely interventions, improved outcomes, such
as improved nutrition status, better management of electrolytes and
glycemic control, reaching goal calories sooner, reduction in inappropriate parenteral nutrition use, cost savings, and less error with electronic order entry. The process for implementation and outcomes of
an RD order writing program at 1 large, urban, tertiary medical center
is described. The program has been successful, but the implementation
process required multiple years and ongoing monitoring through data
collection to ensure success. RDs interested in order writing privileges
must consider federal and stat H