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BACKGROUND: Professionalism in academia requires surgical faculty to establish a safe clinical learning environment based on respectful behaviors that span the training and patient interface. National data reporting trainee mistreatment suggest that there are significant gaps between resident and medical student perceptions of attending behavior. It is unknown whether patient perceptions mirror those of surgical trainees. HYPOTHESIS: Based on triangulated ratings, patients, surgical residents, and medical students have similar perceptions of a surgeons' respectful behaviors. METHODS: Respect scores from end-of-rotation evaluations by surgical residents and rotating medical students were compared for 50 academic surgeons over the period of 2014 to 2018. Clinician and Group Consumer Assessment surveys were collected from patients of 36 of these surgeons and mined for respect and listening behavior ratings. Data were triangulated and analyzed for correlation and variability across the trainee and patient experiences. RESULTS: Resident respect ratings of faculty were consistently higher than those from medical students. Despite a wider variability, medical students still rated their surgical faculty as being respectful to themselves and others most often, almost always, and always 95% of the time. Patient scores were generally lower than trainee scores for an individual surgeon, particularly regarding listening skills. Triangulation of trainee data with patient data identified surgeons demonstrating strong respectful behaviors across the clinical environment as well as those with gaps in behavior toward trainees and patients. CONCLUSION: Triangulation of feedback from trainees and patients provides a unique opportunity to target interventions in professionalism across the clinical learning environment.
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Cirugía General , Internado y Residencia , Estudiantes de Medicina , Cirujanos , Competencia Clínica , Cirugía General/educación , Humanos , Aprendizaje , Proyectos de Investigación , RespetoRESUMEN
BACKGROUND: The worldwide spread of SARS-CoV-2, the coronavirus that causes the syndrome designated COVID-19, presents a challenge for emergency operative management. The transmission and virulence of this new pathogen has raised concern for how best to protect operating room staff while effectively providing care to the infected patient requiring urgent or emergent surgery. OBSERVATIONS: Establishment of a clear protocol that adheres to rigorous infection control measures while providing a safe system for interfacility transport and operative care is vital to a successful surgical pandemic response. While emergency protocols must be rapidly developed, they should be collaboratively improved and incorporate new knowledge as and when it becomes available. These measures combined with practice drills to keep operating room personnel ready and able should help construct processes that are useful, easy to follow, and tailored to the unique local environment of each health care setting. CONCLUSIONS: After the initial apprehensions and struggles during our confrontation with the COVID-19 crisis, it is our hope that the experience we share will be helpful to surgical staff at other institutions grappling with the challenges of operative care in the pandemic environment. While this protocol focuses on the current COVID-19 pandemic, these recommendations serve as a template for surgical preparedness that can be readily adapted to infectious disease crisis that unfortunately might emerge in the future.
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OBJECTIVES: In this study, we tested whether iodide would reduce heart damage in rat and pig models of acute myocardial infarction as a risk analysis for a human trial. DESIGN: Prospective blinded and randomized laboratory animal investigation. SETTING: Animal research laboratories. SUBJECTS: Sexually mature rats and pigs. INTERVENTIONS: Acute myocardial infarction was induced by temporary ligation of the coronary artery followed by reperfusion. Iodide was administered orally in rats or IV in rats and pigs just prior to reperfusion. MEASUREMENTS AND MAIN RESULTS: Damage was assessed by blood cardiac troponin and infarct size; heart function was determined by echocardiography. Blood peroxide scavenging activity was measured enzymatically, and blood thyroid hormone was determined using radioimmune assay. Iodide administration preserved heart function and reduced blood cardiac troponin and infarct size by approximately 45% in pigs and approximately 60% in rats. Iodide administration also increased blood peroxide scavenging activity and maintained thyroid hormone levels. CONCLUSIONS: Iodide administration improved the structure and function of the heart after acute myocardial infarction in rats and pigs.
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Modelos Animales de Enfermedad , Yoduros/administración & dosificación , Daño por Reperfusión Miocárdica/diagnóstico por imagen , Daño por Reperfusión Miocárdica/prevención & control , Animales , Vasos Coronarios/efectos de los fármacos , Ecocardiografía , Estudios Prospectivos , Distribución Aleatoria , Ratas , Porcinos , Glándula Tiroides/efectos de los fármacosAsunto(s)
Choque/metabolismo , Choque/patología , Animales , Cardiopatías/tratamiento farmacológico , Cardiopatías/metabolismo , Cardiopatías/patología , Humanos , Modelos Logísticos , Norepinefrina/administración & dosificación , Norepinefrina/uso terapéutico , Sepsis/tratamiento farmacológico , Sepsis/metabolismo , Sepsis/patología , Choque/tratamiento farmacológicoRESUMEN
BACKGROUND: We aimed to assess surgeons' access to and use of medical information, as well as their training and perceptions about evidence-based medicine (EBM), in order to identify priority areas for improvement. STUDY DESIGN: An anonymous survey conducted among surgeons from the USA, Ghana, Peru, and Thailand examined access to, and use and perception of, medical literature. RESULTS: Of 307 participants, 98% reported access to "OK" or "good" internet. Fifty-one percent reported that language was a barrier to accessing needed medical information; most frequently in Peru (73%) and Thailand (64%). Access to priced full-text journals was poorest in Peru, where 54% lacked access, followed by Ghana (42%) and Thailand (32%). US respondents scored highest on the EBM knowledge test (1.4, SD 0.8), followed by Thailand (1.3, SD 0.9), Ghana (1.1, SD 0.8), and Peru (0.9, SD 0.8) (p < 0.001). Adjusted analysis revealed Ghanaians and Peruvians spent 5% and 1% more on medical information, respectively, relative to country income, than persons from other countries (p < 0.01). After adjustment, employment in a large and/or urban hospital and history of EBM training were associated with better EBM test scores, while middle-income origin and public hospital employment were associated with worse scores (p < 0.05). CONCLUSION: Language, access to priced full-text journals, and training are significant barriers to surgeons' practice of EBM globally. The way forward involves collaboration among surgical societies, publishers, hospital employers, and international policymakers in providing surgeons from all country income levels with the access and training necessary to interpret and apply medical information.
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Acceso a la Información , Actitud del Personal de Salud , Medicina Basada en la Evidencia/educación , Cirujanos/psicología , Adulto , Estudios Transversales , Ghana , Humanos , Internet , Persona de Mediana Edad , Percepción , Perú , Encuestas y Cuestionarios , TailandiaRESUMEN
In the original article some funding information was inadvertently omitted. The complete funding information is as follows.
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Hepatic ischemia-reperfusion (IR) results in progressive injury; initiated by oxidative stress during ischemia and compounded by cytokine-mediated inflammation during reperfusion. Recovery requires strict regulation of these events. Recombinant human erythropoietin (rhEPO) is thought to mitigate hepatocellular IR injury by altering the nonparenchymal liver microenvironment. This study sought to identify additional mechanisms whereby rhEPO is protective after liver IR injury. Mice were treated with rhEPO (4 units/g s.c.) at the onset of partial liver ischemia and assessed for transaminase and histologic injury at intervals after reperfusion. Induction of cytokines, activation of signal transducers and activators of transcription (STATs), suppressors of cytokine signaling (Socs1, Socs3, Cis), caspase-3 activation, and heme oxygenase-1 (HO-1) expression were assessed in postischemic liver. Effects of rhEPO stimulation were further characterized in whole-liver lysates from mice undergoing rhEPO injection alone and in cultured AML-12 hepatocytes. Recombinant human erythropoietin treatment at the onset of severe (90 min) hepatic IR confirmed commensurate biochemical and histological protection without affecting tissue cytokine levels. Although Socs3 and STAT5 activation were induced in normal liver after in vivo rhEPO injection, this treatment did not augment expression beyond that seen with IR alone, and neither was induced in cultured hepatocytes treated with rhEPO. Recombinant human erythropoietin inhibited caspase-3 activation in nonparenchymal cells, whereas hepatocellular HO-1 was rapidly induced both in vivo and in vitro with rhEPO treatment. These data suggest HO-1 as a potent mechanism of rhEPO-mediated protection after liver IR, which involves both direct hepatocellular and nonparenchymal mechanisms.
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Eritropoyetina/uso terapéutico , Hemo-Oxigenasa 1/fisiología , Hígado/irrigación sanguínea , Proteínas de la Membrana/fisiología , Daño por Reperfusión/prevención & control , Animales , Apoptosis/efectos de los fármacos , Células Cultivadas , Citocinas/metabolismo , Eritropoyetina/farmacología , Hepatocitos/efectos de los fármacos , Mediadores de Inflamación/metabolismo , Hígado/metabolismo , Hígado/patología , Masculino , Ratones Endogámicos C57BL , Estrés Oxidativo/efectos de los fármacos , Proteínas Recombinantes/farmacología , Proteínas Recombinantes/uso terapéutico , Daño por Reperfusión/metabolismo , Daño por Reperfusión/patología , Factores de Transcripción STAT/metabolismo , Transducción de Señal/efectos de los fármacos , Proteínas Supresoras de la Señalización de Citocinas/metabolismoRESUMEN
BACKGROUND: The feasibility of video-assisted retroperitoneal debridement (VARD) for infected pancreatic walled-off necrosis is established. We provide prospective data on the safety and efficacy of VARD. DESIGN: Multicenter, prospective, single-arm phase 2 study. SETTING: Six academic medical centers. PATIENTS: We evaluated 40 patients with pancreatic necrosis who had infection determined using Gram stain or culture. INTERVENTIONS: Percutaneous drains were placed at enrollment, and computed tomographic scans were repeated at 10 days. Patients who had more than a 75% reduction in collection size were treated with drains. Other patients were treated with VARD. Crossover to open surgery was performed for technical reasons and/or according to surgeon judgment. MAIN OUTCOME MEASURES: Efficacy (ie, successful VARD treatment without crossover to open surgery or death) and safety (based on mortality and complication rates). Patients received follow-up care for 6 months. RESULTS: We enrolled 40 patients (24 men and 16 women) during a 51-month period. Median age was 53 years (range, 32-82 years). Mean (SD) Acute Physiology and Chronic Health Evaluation II score at enrollment was 8.0 (5.1), and median computed tomography severity index score was 8. Of the 40 patients, 24 (60%) were treated with minimally invasive intervention (drains with or without VARD). Nine patients (23%) did not require surgery (drains only). For 31 surgical patients, VARD was possible in 60% of patients. Most patients (81%) required 1 operation. In-hospital 30-day mortality was 2.5% (intent-to-treat). Bleeding complications occurred in 7.5% of patients; enteric fistulas occurred in 17.5%. CONCLUSIONS: This prospective cohort study supports the safety and efficacy of VARD for infected pancreatic walled-off necrosis. Of the patients, 85% were eligible for a minimally invasive approach. We were able to use VARD in 60% of surgical patients. The low mortality and complication rates compare favorably with open debridement. An unexpected finding was that a reduction in collection size of 75% according to the results of computed tomographic scans at 10 to 14 days predicted the success of percutaneous drainage alone.
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Desbridamiento/métodos , Pancreatitis Aguda Necrotizante/cirugía , Cirugía Asistida por Video , Adulto , Anciano , Anciano de 80 o más Años , Algoritmos , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Pancreatitis Aguda Necrotizante/diagnóstico por imagen , Pancreatitis Aguda Necrotizante/mortalidad , Estudios Prospectivos , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: The purpose of this analysis was to determine if the surgical clerkship model and site affect educational outcomes and student postclerkship perceptions. METHODS: Data from University of Washington students participating in surgical clerkships at traditional/academic or community/apprentice sites across Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) between 2005 and 2007 were gathered retrospectively. Comparisons of final examination scores as well as postclerkship student evaluations of the educational experience were made between traditional and community training sites. RESULTS: The mean final examination scores at WWAMI sites were significantly higher than those at traditional academic sites. Furthermore, WWAMI sites were rated higher with respect to time spent by faculty in direct observation, quality of the clerkship as a whole, and overall contribution to medical education. CONCLUSIONS: Community surgical clerkship sites remote from an academic institution can provide an excellent learning experience for students.
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Prácticas Clínicas , Cirugía General/educación , Alaska , Análisis de Varianza , Evaluación Educacional , Humanos , Modelos Educacionales , Montana , Estudios Retrospectivos , Estadísticas no Paramétricas , Washingtón , WyomingRESUMEN
BACKGROUND/AIMS: Preservation of function requires tight regulation of the cellular events initiated when hepatic ischemia is followed by reperfusion (IR). One important mechanism modulating the cytokine-directed response to injury is Suppressors of Cytokine Signaling. SOCS1 and SOCS3 ensure appropriate intensity and duration of cytokine signaling through negative feedback on JAK-STAT signaling. The contribution of SOCS1 and SOCS3-mediated regulation to the evolution of hepatic IR injury is unknown. METHODS: C57Blk6 mice were subjected to mild (20 min) or severe (90 min) hepatic ischemia. Liver was analyzed for cytokine and SOCS1/3 induction as well as JAK-STAT activation at intervals after reperfusion. RESULTS: Tnf, Il-1beta, and Il-6 expression paralleled increasing injury severity. Despite early phosphorylation of both STAT1 and STAT3 after severe injury, only nuclear translocation of activated STAT3, suggesting that the induction of target genes through JAK-STAT after IR is predominantly via STAT3. Socs3 was expressed across the injury spectrum while Socs1 was induced only in the face of severe IR injury. Severe IR in Il-6 deficient mice confirmed that Il-6, acting via STAT3, serves as a primary inducer of both regulatory mechanisms. CONCLUSIONS: Under the influence of IL-6-mediated STAT3 signaling, Socs1 serves as a complimentary regulatory mechanism when Socs3 is insufficient to limit cytokine-mediated inflammation after hepatic IR.
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Hepatopatías/metabolismo , Daño por Reperfusión/metabolismo , Transducción de Señal/inmunología , Proteínas Supresoras de la Señalización de Citocinas/metabolismo , Animales , Perfilación de la Expresión Génica , Interleucina-1beta/genética , Interleucina-1beta/metabolismo , Interleucina-6/genética , Interleucina-6/metabolismo , Hígado/inmunología , Hígado/metabolismo , Hígado/patología , Hepatopatías/inmunología , Hepatopatías/patología , Masculino , Ratones , Ratones Endogámicos C57BL , Ratones Noqueados , Daño por Reperfusión/inmunología , Daño por Reperfusión/patología , Factor de Transcripción STAT1/metabolismo , Factor de Transcripción STAT3/metabolismo , Índice de Severidad de la Enfermedad , Proteína 1 Supresora de la Señalización de Citocinas , Proteína 3 Supresora de la Señalización de Citocinas , Factor de Necrosis Tumoral alfa/genética , Factor de Necrosis Tumoral alfa/metabolismoRESUMEN
BACKGROUND: The aims of this study were to assess the clinical utility of the practice of routine preoperative CT scanning and to determine its cost-effectiveness in colon cancer patients. METHODS: A 6-year database of colon cancer patients treated at a veterans affairs medical was reviewed to determine the influence of preoperative CT scanning on clinical management. Cost analysis involved comparison of the institutional cost of CT scanning with the cost savings provided by avoiding nontherapeutic operations. RESULTS: CT scans were obtained in 130 consecutive patients. CT scans provided information that was used in treatment planning in 43 (33%) patients and definitively altered the mode of treatment in 21 (16%) patients. The practice saved the institution $24,018 over 6 years. CONCLUSION: Routine preoperative CT scanning definitively alters treatment in a small number of cases and is cost-effective.
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Neoplasias del Colon/diagnóstico por imagen , Tomografía Computarizada por Rayos X/economía , Anciano , Neoplasias del Colon/patología , Neoplasias del Colon/cirugía , Medios de Contraste , Análisis Costo-Beneficio , Femenino , Humanos , Masculino , Estadificación de Neoplasias , Planificación de Atención al Paciente , Cuidados Preoperatorios , VeteranosRESUMEN
Liver ischemia-reperfusion injury (IR) would be expected to alter the capacity of previously ischemic as well as continuously perfused segments that are exposed to circulating inflammatory mediators to respond to a subsequent infectious insult. IR is reported to induce tolerance to subsequent endotoxin stimulation if the lipopolysaccharide (LPS) challenge is delayed until the late, neutrophil-mediated phase of reperfusion. Whether ischemic or perfused liver is differentially affected and whether LPS-tolerance may be overcome by increasing exposure is unknown. We hypothesized that late tolerance after IR reflects a refractory state in which the liver's expression of pro-inflammatory mediators in response to secondary LPS is limited. Precision-cut tissue culture methodology was used to investigate the capacity of rabbit liver to respond to a spectrum of LPS stimulation 24 h after partial IR. Slices from normal liver showed a dose-dependent response to LPS for tumor necrosis factor (TNF-alpha) expression. Slices from both previously ischemic and continuously perfused lobes retained dose responsiveness for TNF-alpha, although TNF-alpha was significantly decreased at high LPS concentrations compared with normal liver. Ischemic liver sustained this blunted response despite extended exposure to LPS, whereas perfused slices recovered responsiveness to high dose LPS with prolonged stimulation. IR induced interleukin-8 in both ischemic and perfused liver, but secondary LPS stimulation did not augment interleukin-8 expression. Hepatic IR induces a late tolerance to secondary LPS challenge in locally ischemic tissue that cannot be overcome by increasing LPS exposure. Nonischemic liver exposed to the systemic effects of IR injury, however, retains a capacity to respond to LPS with sufficient stimulation.
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Lipopolisacáridos/toxicidad , Hígado/irrigación sanguínea , Daño por Reperfusión/prevención & control , Animales , Isquemia/prevención & control , L-Lactato Deshidrogenasa/análisis , Circulación Hepática/efectos de los fármacos , Técnicas de Cultivo de Órganos , ConejosRESUMEN
PURPOSE: Changes in graduate medical education associated with full implementation of the Balanced Budget Act of 1997 have required medical schools to review and revise their curricula. As limited funding increases pressures to streamline training, residencies will potentially expect an entry level of skill and competence that is greater than that which schools are currently providing. To determine whether medical school curricular requirements correlate with residency needs, this multidisciplinary pilot study investigated expectations and prerequisites for postgraduate specialty training. METHOD: A questionnaire about 100 skills and competencies expected of new first-year residents was sent to 50 U.S. residency directors from surgery, internal medicine, family medicine, pediatrics, and obstetrics-gynecology programs. Each director was asked to state expectations of a first-year resident's competence in each skill at entry to residency and after three months of training. Skills deemed most appropriately acquired in residency were also identified. Competencies included diagnosis, management, triage, interpretation of data, informatics and technology, record keeping, interpersonal communications, and manual skills. RESULTS: A total of 39 residency directors responded, including seven surgery, nine medicine, seven family medicine, eight pediatrics, and eight obstetrics-gynecology. In addition to physical examination skills, 13 competencies achieved more than 70% agreement as being entry-level skills. There was wide variability as to the relative importance of the remaining skills, with residency directors expecting to devote significant resources and time in early training to ensure competence. CONCLUSIONS: Medical schools should consider the expectations of their students' future residency directors when developing new curricula. Assuring students' competencies through focused curricular change should save both time and resources during residency.
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Centros Médicos Académicos/normas , Competencia Clínica , Educación de Pregrado en Medicina/normas , Internado y Residencia , Curriculum , Humanos , Medicina , Especialización , Encuestas y Cuestionarios , Estados UnidosRESUMEN
BACKGROUND: The aim of this study is to assess the clinical utility of routine preoperative computed tomography (CT) scanning in patients with cancer of the intraperitoneal colon. METHODS: From November 1997 to June 2001, all patients at VA Puget Sound Healthcare System with a diagnosis of colon cancer were referred for a preoperative CT scan. Medical records and operative notes were reviewed to determine the influence of preoperative CT on clinical management. RESULTS: Seventy patients received a CT per protocol. Preoperative CT provided information that was used in treatment planning and management in 26 (37%) cases. However, if preoperative scans had not been performed, the clinical management would have been definitively altered in only 13 (19%) patients. CONCLUSIONS: Although these data suggest potential benefit for routine preoperative CT scanning, we believe additional study, including cost analysis, should precede the adoption of CT scanning as a routine preoperative study in patients with colon cancer.