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OBJECTIVE To determine the surveillance impact of utilizing a discrete field in structured radiology reports in patients with incidental pancreatic findings. METHODS We implemented a dictation template containing a discrete structured field element to auto-trigger listing of patients with incidental pancreatic findings on a pancreas clinic registry in the electronic health record. We isolated CT and MRI reports with incidental pancreatic findings over a 24-month period. We stratified patients by presence or absence of the discrete field element in reports (flagged versus unflagged) and evaluated the impact of report flagging on likelihood of clinic follow-up, follow-up imaging, endoscopic ultrasound, surgical intervention, genetics referral, obtaining pathologic diagnosis, and time interval between index imaging to various outcomes. RESULTS Patients with flagged reports were more likely to be seen or discussed in a pancreas clinic compared with those with unflagged reports (189 of 376, 50.3% versus 79 of 474, 16.7%; P

Background The learning environment plays a critical role in learners' satisfaction and outcomes. However, we often lack insight into learners' perceptions and assessments of these environments. It can be difficult to discern learners' expectations, making their input critical. When medical students and surgery residents are asked to evaluate their teachers, what do they focus on? Materials and methods Open-ended comments from medical students' evaluations of residents and attending surgeons and from residents' evaluations of attendings during the 2016-2017 academic year were analyzed. Content analysis was used, and codes derived from the data. A matrix of theme by learner role was created to distinguish differences between medical student and resident learners. Subthemes were grouped based on similarity into high-order themes. Results Two overarching themes were Creating a positive environment for learning by modeling professional behaviors and Intentionally engaging learners in training and educational opportunities. Medical students and residents made similar comments for the subthemes of appropriate demeanor, tone and dialog, respect, effective direct instruction, feedback, debriefing, giving appropriate levels of autonomy, and their expectations as team members on a service. Differences existed in the subthemes of punctuality, using evidence, clinical knowledge, efficiency, direct interactions with patients, learning outcomes, and career decisions. Conclusions Faculty development efforts should target professional communication, execution of teaching skills, and relationships among surgeons, other providers, and patients. Attendings should make efforts to discuss their approach to clinical decision making and patient interactions and help residents and medical students voice their opinions and questions through trusting adult learner-teacher relationships.

Effective self-assessment is a cornerstone of lifelong professional development; however, evidence suggests physicians have a limited ability to self-assess. Novel strategies to improve the accuracy of learner self-assessment are needed. Our institution's surgical entrustable professional activity (EPA) implementation strategy incorporates resident self-assessment to address this issue. This study evaluates the accuracy of resident self-assessment versus faculty assessment across 5 EPAs in general surgery.Within a single academic general surgery residency program, assessment data for 5 surgery EPAs was prospectively collected using a mobile application. Matched assessments (resident and faculty assessments for the same clinical encounter) were identified and the remainder excluded. Assessment scores were compared using Welch's t test. Agreement was analyzed using Cohen's kappa with squared weights.One thousand eight hundred and fifty-seven EPA assessments were collected in 17 months following implementation. One thousand one hundred and fifty-five (62.2%) were matched pairs. Residents under-rated their own performance relative to faculty assessments (2.36 vs 2.65, p0.01). This pattern held true for all subsets except for Postgraduate Year (PGY)2 residents and Inguinal Hernia EPAs. There was at least moderate agreement between matched resident and faculty EPA assessment scores (κ = 0.57). This was consistent for all EPAs except Trauma evaluations, which were completed by faculty from 2 different departments. Surgery resident self-assessments more strongly agreed with Surgery faculty assessments than Emergency Medicine faculty assessments (κ = 0.58 vs 0.36).Resident EPA self-assessments are equivalent or slightly lower than faculty assessments across a wide breadth of clinical scenarios. Resident and faculty matched assessments demonstrate moderate agreement.

Background Automated data extraction from the electronic medical record is fast, scalable, and inexpensive compared with manual abstraction. However, concerns regarding data quality and control for underlying patient variation when performing retrospective analyses exist. This study assesses the ability of summary electronic medical record metrics to control for patient-level variation in cost outcomes in pancreaticoduodenectomy. Methods Patients that underwent pancreaticoduodenectomy from 2014 to 2018 at a single institution were identified within the electronic medical record and linked with the National Surgical Quality Improvement Program. Variables in both data sets were compared using interrater reliability. Logistic and linear regression modelling of complications and costs were performed using combinations of comorbidities/summary metrics. Models were compared using the adjusted R2 and Akaike information criterion. Results A total of 117 patients populated the final data set. A total of 31 (26.5%) patients experienced a complication identified by the National Surgical Quality Improvement Program. The median direct variable cost for the encounter was US$14,314. Agreement between variables present in the electronic medical record and the National Surgical Quality Improvement Program was excellent. Stepwise linear regression models of costs, using only electronic medical record–extractable variables, were non-inferior to those created with manually abstracted individual comorbidities (R2 = 0.67 vs 0.30, Akaike information criterion 2,095 vs 2,216). Model performance statistics were minimally impacted by the addition of comorbidities to models containing electronic medical record summary metrics (R2 = 0.67 vs 0.70, Akaike information criterion 2,095 vs 2,088). Conclusion Summary electronic medical record perioperative risk metrics predict patient-level cost variation as effectively as individual comorbidities in the pancreaticoduodenectomy population. Automated electronic medical record data extraction can expand the patient population available for retrospective analysis without the associated increase in human and fiscal resources that manual data abstraction requires.

OBJECTIVE To obtain a legal understanding of the “key” or “critical” portions of an operation, pertaining to attending supervision, resident autonomy, and patient safety. DESIGN Snowball sampling, a subset of purposive sampling, was used to develop a population of 47 risk managers and legal counsel, who were given an online, qualitative questionnaire. Interpretive description was used to analyze qualitative data. Individual responses were coded with simultaneous categorization and assessment of underlying relationships. SETTING Online, qualitative questionnaire. PARTICIPANTS Hospital risk managers and legal counsel from across the United States. RESULTS Overall, 25 of 47 (53%) risk managers completed the survey. Qualitative responses could be organized into 3 major themes (1) variation in the definition of “key” or “critical” portions of an operation, (2) differing expectations of attending supervision and resident autonomy, and (3) the need for clear communication and trust among attendings, residents, and patients. CONCLUSIONS Among risk managers, the primary liaisons between surgeons and patients in malpractice litigation, there is widespread variation in understanding the “key” and “critical” portions of an operation and the dynamic between appropriate attending supervision and resident autonomy. Better collaboration and transparency between surgeons and legal experts are required to facilitate a shared mental model regarding attending supervision and resident autonomy.

Background Lack of transparency and meaningful assessment in surgical residency has led to inconsistent intraoperative entrustment and highly variable trainee competence at graduation. The relationship between faculty entrustment and resident entrustability on clinical competency remains unclear. We sought to evaluate the dynamic between entrustment/entrustability and clinical competency in general surgery residency. Methods Intraoperative observations were conducted across a 22-month period at an academic tertiary center. Entrustment/entrustability were measured using OpTrust. Clinical competencies were appraised via ACGME Milestones and Objective Structured Assessment of Technical Skill (OSATS) scores. Mixed effects linear regression was used to investigate the relationship among overall ACGME Milestone scores, OSATS domain scores, and overall OpTrust scores. Results Overall OpTrust scores significantly correlated with overall Milestone scores and multiple OSATS score domains. Conclusions OpTrust demonstrated a positive association between ACGME general surgery Milestones and OSATS scores. Overall, OpTrust may help optimize intraoperative faculty entrustment and resident entrustability, facilitating surgical trainee success during residency.

Entrustable Professional Activities are a holistic assessment framework developed in the Netherlands in 2005, which have recently been adopted in undergraduate medical education in the United States. As part of an increased focus on competency-based assessment, the specialty of pediatrics has led the way in incorporating them into graduate medical education. We describe the development and initial pilot process of implementation of EPAs into the assessment of General Surgery trainees.

Predictive models for nonhome discharge (NHD) have been proposed in major surgical specialties. The rates and risk factors associated with NHD and prolonged length of stay (PLOS) after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) have not been evaluated. The aim of this study is to identify risk factors for NHD and PLOS after CRS/HIPEC in a national cohort of patients.CRS/HIPEC cases were identified from the National Surgical Quality Improvement Program 2011-2012 data set. Patients with an NHD or PLOS (30 d) were compared with a group of patients discharged to home within 30 d. Univariate analysis was used to compare patient characteristics, operative variables, and postoperative complications among both groups. Multivariate regression analysis was used to identify independent predictors of NHD and PLOS.Five hundred fifty-six patients undergoing CRS/HIPEC were identified, of which 44 (7.9%) were not discharged to home within 30 d. The rate of NHD and PLOS in this cohort was 4.1% and 3.7%, respectively. Multivariate analysis identified age ≥65 y, pre-op albumin3.0 g/dL, and having a multivisceral resection as independent predictors of NHD/PLOS. If all three predictors are met preoperatively, the probability of NHD/PLOS was calculated to be 30.2%.The main risk factors for NHD/PLOS after CRS/HIPEC were advanced age, hypoalbuminemia, and multivisceral resection. Adequate identification of these risk factors may facilitate preoperative discussion with patients, and improve discharge planning and resource utilization.

Background Optimizing intraoperative education is critical for development of autonomous residents. Faculty decisions concerning intraoperative entrustment determine the degree to which a resident gains intraoperative responsibility. Accordingly, residents exhibit entrustable behaviors that further faculty entrustment in the operating room. Little empiric evidence exists evaluating how the sex of a resident influences faculty-resident decisions of entrustment. Studies involving perception-based measurements of autonomy report inequities for women residents. We sought to assess faculty behaviors in entrustment in relation to resident sex using OpTrust, a third-party objective measurement tool. Methods From September 2015 to June 2017 at the University of Michigan, surgical cases were observed and entrustment behaviors were rated using OpTrust. Critical case sampling was used to generate variation in operation type, case difficulty, faculty-resident pairings, faculty experience, and the level of the resident's training. Independent sample t-tests were conducted to compare faculty entrustment scores, as well as resident entrustability scores. Results A total of 56 faculty and 73 residents were observed across 223 surgical cases from 4 surgical specialties: general, plastic, thoracic, and vascular. There was no difference in faculty entrustment or entrustability scores between women and men (2.54 vs 2.35, P = .117 and 2.32 vs 2.22, P = .393, respectively). Conclusion Using OpTrust scores, we found that a resident's sex does not appear to influence faculty entrustment in the OR. Faculty entrustment scores for women and men residents are similar across cases. This observation suggests that during the intraoperative interaction, faculty are not extending entrustment or opportunities for autonomy differently to women or men. Future research is needed to identify and measure perioperative elements that inform resident autonomy, which may contribute to inequities for women residents.

Background Changes in the surgical training landscape have sparked an interest in developing new educational models anchored on entrustment assessment. We sought to optimize the validated OpTrust entrustment assessment tool by comparing ratings from short-course video reviews to previously validated intraoperative assessments. Methods Entrustment assessment scores for video-based and 1-h (short-course) observations were compared to previously validated intraoperative assessment scores. Faculty and residents were surveyed for their perceptions related to operative observation. Results There was a strong association between entrustment scores when comparing in-person to video-based observations (R2 = 0.76–0.84, p 97%) felt observation did not negatively impact operative experience. Conclusions Assessment of entrustment behaviors using short-course video review provides a feasible approach to intraoperative assessment. This latest application of OpTrust allows for the tool to be incorporated into surgical training programs across a variety of environments.

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) can significantly improve the survival in selected patients with peritoneal carcinomatosis. This study aims to identify perioperative patient characteristics predictive of failure to rescue (FTR), mortality following postoperative complications from CRS/HIPEC.Patients suffering a complication following CRS/HIPEC between 2005 and 2013 were identified in the American College of Surgeons National Surgical Quality Improvement Program data set. FTR was defined as 30-d mortality in the setting of a complication. Patients who suffered FTR were compared against those who survived a complication (non-FTR). Predictors of FTR were identified using a multivariable logistic regression model.A total of 915 eligible CRS/HIPEC cases were identified. In all, 382 patients (42%) developed ≥1 postoperative complication, and 88 patients (10%) suffered ≥1 major complication. Seventeen patients died following a complication, amounting to an FTR rate of 4%. FTR patients were more likely than non-FTR patients to have dependent functional status (18% versus 2%, P = 0.01), have American Society of Anesthesiologists (ASA) class 4 status (29% versus 8%, P = 0.01), develop ≥3 complications (65% versus 24%, P 0.01), and suffer a major complication (94% versus 20%, P 0.01). The following were independently associated with FTR: ASA class 4 (odds ratio [OR]: 13.4, 95% confidence interval [CI], 1.2-146.8) and major complications (OR: 66.0, 95% CI, 8.4-516.6).ASA class 4, major morbidity, and likely dependent functional status are independent predictors of FTR following CRS/HIPEC to treat peritoneal carcinomatosis. Therefore, ASA class 4 and dependent functional status should be considered as contraindications for CRS/HIPEC and only offered in highly selective cases.

There has been a proliferation of gastrointestinal surgical fellowships; however, little is known regarding their association with surgical volume and management approaches.Surveys were distributed to members of GI surgical societies. Responses were evaluated to define relationships between fellowship training and surgical practice with pancreatoduodenectomy (PD).Surveys were completed by 889 surgeons, 84.1% of whom had completed fellowship training. Fellowship completion was associated with a primarily HPB or surgical oncology-focused practice (p 0.001), and greater median annual PD volume (p = 0.030). Transplant and HPB fellowship-trained respondents were more likely to have high-volume (≥20) annual practice (p = 0.005 and 0.029, respectively). Regarding putative fistula mitigation strategies, HPB-trained surgeons were more likely to use stents, biologic sealants, and autologous tissue patches (p = 0.007,0.001 and 0.001, respectively). Surgical oncology trainees reported greater autologous patch use (p = 0.003). HPB fellowship-trained surgeons were less likely to routinely use intraperitoneal drainage (p = 0.036) but more likely to utilize early (POD ≤ 3) drain amylase values to guide removal (p 0.001). Finally, HPB fellowship-trained surgeons were more likely to use the Fistula Risk Score in their practice (29 vs. 21%, p = 0.008).Fellowship training correlated with significant differences in surgeon experience, operative approach, and use of available fistula mitigation strategies for PD.

Background The advancement of surgical science relies on educating new generations of surgeon-scientists. Career development awards (K Awards) from the National Institutes of Health, often considered a marker of early academic success, are one way physician-scientists may foster skills through a mentored research experience. This study aimed to develop a conceptual framework to understand institutional support and other factors leading to a K Award. Methods A national, qualitative study was conducted with academic surgeons. Participants included 15 K Awardees and 12 surgery department Chairs. Purposive sampling ensured a diverse range of experiences. Semistructured, in-depth telephone interviews were conducted. Interviews were audio recorded and transcribed verbatim, and 2 reviewers analyzed the transcripts using Grounded Theory methodology. Results Participants described individual and institutional factors contributing to success. K Awardees cited personal factors such as perseverance and team leadership skills. Chairs described the K Awardee as an institutional “investment” requiring protected time for research, financial support, and mentorship. Both K Awardees and Chairs identified a number of challenges unique to the surgeon-scientist, including financial strains and competing clinical demands. Conclusion Institutional support for surgeons pursuing K Awards is a complex investment with significant initial costs to the department. Chairs act as stewards of institutional resources and support those surgeon-scientists most likely to be successful. Although the K Award pathway is one way to develop surgeon-scientists, financial burdens and challenges may limit its usefulness. These findings, however, may better prepare young surgeons to develop career plans and identify new mechanisms for academic productivity.

Background Increasing focus on more granular assessment in medical education has led to more lengthy instruments, with concern that the increased complexity undermines the utility of these tools. This study evaluated the relative contribution of individual questions in an assessment of resident performance and a faculty performance evaluation by residents. Methods The authors performed factor analysis on the individual items in the resident assessment instrument (3,009 assessments of 71 residents) and faculty evaluations (7,328 evaluations of 61 faculty) collected from 2006 to 2012. Results Factor analysis of the resident assessment tool revealed that 1 component was responsible for 96.6% of the variance. This component encompassed each question from the assessment form, and could also be termed "overall resident competency." Factor analysis of the attending evaluation form revealed 2 unique components, representing "clinical care" and "interpersonal skills," which accounted for 89.9% of variance. Conclusions Three components accounted for 90% to 97% of the observed variance in our analysis. Factor analysis represents a useful strategy for analyzing the utility of data obtained from individual items in the assessment and evaluation instruments.

This review outlines the current state of undergraduate medical education for the surgeon in training, and highlights ongoing efforts to improve the preparation of graduating students entering surgical residency. Possible models for improved integration of specialty specific training in medical school are explored, and future directions in undergraduate surgical education are considered in the context of ongoing curricular initiatives in medical schools within North America.

BackgroundHepatopancreatobiliary (HPB) surgery fellowship training has multiple paths. Prospective trainees and employers must understand the differences between training pathways. This study examines self-reported fellowship experiences and current scope of practice across three pathways.MethodsAn online survey was disseminated to 654 surgeons. These included active Americas Hepato-Pancreato-Biliary Association (AHPBA) members and recent graduates of HPB, transplant–HPB and HPB–heavy surgical oncology fellowships.ResultsA total of 416 (64%) surgeons responded. Most respondents were male (89%) and most were practising in an academic setting (83%). 290 (70%) respondents underwent formal fellowship training. Although fellowship experiences varied, current practice was largely similar. Minimally invasive surgery (MIS) and ultrasound were the most commonly identified areas of training deficiencies and were, respectively, cited as such by 47% and 34% of HPB-, 49% and 50% of transplant-, and 52% and 25% of surgical oncology-trained respondents. Non-HPB cases performed in current practice included gastrointestinal (GI) and general surgery cases (56% and 49%, respectively) for HPB-trained respondents, transplant and general surgery cases (87% and 21%, respectively) for transplant-trained respondents, and GI surgery and non-HPB surgical oncology cases (70% and 28%, respectively) for surgical oncology-trained respondents.ConclusionsFellowship training in HPB surgery varies by training pathway. Training in MIS and ultrasound is deficient in each pathway. The ultimate scope of non-transplant HPB practice appears similar across training pathways. Thus, training pathway choice is best guided by the training experience desired and non-HPB components of anticipated practice.

Background Hepatopancreatobiliary fellowship programmes have recently undergone significant changes with regards to training standards, case‐volume thresholds and multimodality educational platforms. The goals of this study were to compare the perspectives of fellows and programme directors (PDs) on perceptions of readiness to enter practice and identify core Hepato‐Pancreato‐Biliary (HPB) procedures that require increased emphasis during training. Methods This survey targeted PDs and trainees participating in the Fellowship Council/AHPBA pathway. Data related to demographics, education and career plans were collected. Analysis of PD and fellow opinions regarding their confidence to perform core HPB procedures was completed. Results The response rate was 88% for both fellows (21/24) and PDs (23/26). There was good agreement between PDs and fellows in the perception of case volumes. Select differences where PDs ranked higher perceptions included major hepatectomies (PDs: 87% versus fellows: 57%, P= 0.04), pancreaticoduodenectomies (100% versus 81%, P = 0.04) and laparoscopic distal pancreatectomies (78% versus 43%, P = 0.03). ‘Good or excellent’ case volumes translated into increased fellow readiness, except for some pancreatitis procedures, laparoscopic distal pancreatectomies and potentially major hepatectomies. Conclusions This study provides insight into content domains that may require additional attention to achieve an appropriate level of proficiency and confidence upon completion of training.

BackgroundThe Americas Hepato-Pancreato-Biliary Association (AHPBA) and the Australian and New Zealand Hepatic, Pancreatic and Biliary Association (ANZHPBA) are developing an online distance learning curriculum to facilitate an interactive didactic experience for hepatopancreatobiliary (HPB) fellows in the operationalization of existing HPB fellow curricula. Two needs assessment surveys were carried out to identify the optimal structure and process for deployment in fellow education.MethodsA 22-question survey querying fellows' learning styles and current and anticipated use of learning tools was disseminated electronically to 38 North American and Australasian HPB fellows. A follow-up 20-question survey was administered to assess fellows' feelings regarding online content.ResultsResponse rates were 55% (n = 21) for the first survey and 42% for the second (n = 16). In the first survey, 67% of respondents claimed familiarity with the required HPB curriculum, and 43% indicated dissatisfaction with current personal study strategies. A total of 62% (n = 13) reported studying with focused clinical relevance versus using a prescribed curriculum (n = 1, 5%). Fellows anticipated participating using online tools once (n = 10, 48%) or two or three times (n = 5, 24%) per week. Most respondents (n = 18, 86%) would meaningfully follow one or two discussions per month. The second survey identified themes for improvement such as discussion topics of interest, avoidance of holiday timing and mandatory participation.ConclusionsAn international online distance learning format is an appealing mechanism for improved dissemination and operationalization of the established HPB fellow curricula. Fellows will engage in interactive discussions monthly. Controversial topics or those requiring complex decision making are best suited to this learning format.

The reported influence of Accreditation Council for Graduate Medical Education resident duty hour limitations on operative case volume has been mixed. Additional restrictions instituted in July 2011 further limited the work hours of postgraduate year 1 (PGY-1) residents, threatening to reduce availability for educational and operative activities. In this study, we evaluate our novel intern call schedule, which we hypothesized would preserve operative experience despite these increased restrictions.A retrospective analysis of PGY-1 operative reports was conducted. Operations outside of major case categories were excluded. Operative case volumes in the Section of General Surgery for the same period were analyzed, as were average duty hours for each resident. Comparative statistics were generated using Wilcoxon rank sum tests.Single-institution study conducted at the University of Michigan, a tertiary-care academic hospital.Overall, 50 categorical general surgery residents from 2005 to present were included. Three residents were subsequently excluded as they were preliminary interns rather than categorical; 2 residents were excluded having completed their intern years at other institutions.The median number of major cases done during the PGY-1 for all evaluated residents was 89 (interquartile range [IQR]: 72-101). For interns between the years 2005 and 2011, the median number of major cases was 87 (IQR: 73-101), whereas interns in the 2011 to 2013 academic years performed 91.5 (IQR: 69.5-101.5, p = 0.91). Although case volume varied between intern classes, no significant differences were observed between any 2 individual classes in the study. Analysis of annual case volumes among each PGY revealed a relative increase of 29% (p0.001) among PGY-2 residents, and 20% (p = 0.02) by PGY-3 residents. Relative increases among senior residents (8% for both PGY-4 and PGY-5) did not reach statistical significance.Our novel call schedule attempts to minimize prolonged night-float coverage responsibilities for interns in hopes of preserving their operative experience. In spite of increased duty hour restrictions, PGY-1 operative volume has not decreased significantly at our institution. However, in the same time period, PGY-2 and PGY-3 case volume has increased. Our findings highlight the challenges faced by surgical residencies in light of these new restrictions, particularly the 16-hour limit. Additional rigorously designed prospective studies should be conducted to better understand the influence of the most recent Accreditation Council for Graduate Medical Education work hour limitations on the subjective and objective experiences of surgical residents.

Surgical simulation has evolved considerably over the past two decades and now plays a major role in training efforts designed to foster the acquisition of new skills and knowledge outside of the clinical environment. Numerous driving forces have fueled this fundamental change in educational methods, including concerns over patient safety and the need to maximize efficiency within the context of limited work hours and clinical exposure. The importance of simulation has been recognized by the major stake-holders in surgical education, and the Residency Review Committee has mandated that all programs implement skills training curricula in 2008. Numerous issues now face educators who must use these novel training methods. It is important that these individuals have a solid understanding of content, development, research, and implementation aspects regarding simulation. This paper highlights presentations about these topics from a panel of experts convened at the 2008 Academic Surgical Congress.

Background The present study was undertaken to determine if psychomotor and visual-spatial abilities improve as a result of surgical training or are enhanced at baseline in those individuals choosing a surgical career. Methods Medical students entering a surgical field and practicing surgeons performed a series of neuropsychologic tests. Performance was compared between surgeon groups, as well as with normative aged-matched controls. Results An age-related decline was noted in the performance of all exercises, with the medical student group outperforming the midcareer surgeons, who in turn outperformed the senior surgeons. Interestingly, however, all 3 groups significantly outperformed their normative control groups on some or all tasks. Conclusions Improved visual memory and psychomotor performance compared with normative controls appears to be present at baseline rather than resulting from surgical training. Decline in performance with age is observed, however, and this should be considered when an older surgeon is learning new visually complex procedures.

Background Although the inflammatory response is a prerequisite for wound healing, excessive activation of the innate immune system can induce epithelial cell damage and apoptosis, which may further compromise dermal integrity. In a noninfectious burn wound model, we previously demonstrated that topical inhibition of p38 MAPK, an important inflammatory signaling pathway, attenuated epithelial cell damage and apoptosis. We now question whether attenuating local inflammation would weaken bacterial wound resistance and compromise host defense. Methods Rats received 30% total body surface area burn, and the wound was treated with topical application of a p38 MAPK inhibitor or vehicle. At 24 hours after injury, burn wounds were inoculated with Pseudomonas aeruginosa . At 48 hours postinjury, animals were sacrificed, and the burn wound was analyzed. Results Inoculating burn wounds induced significant bacterial growth. Dermal inflammatory changes were markedly accentuated in the inoculated animals. Topical p38 MAPK inhibition reduced the proinflammatory cytokine expression in the burn wounds and neutrophil sequestration with or without bacterial inoculation. Interestingly, the bacterial wound growth was significantly attenuated in animals treated with topical p38 MAPK inhibitor. Conclusions Topical p38 MAPK inhibition attenuated wound inflammation without interfering with bacterial host defense. Attenuation of excessive burn wound inflammatory signaling may prevent secondary damage of the dermal barrier and reduce the growth of opportunistic pathogens.

Background Computer-aided simulators may increase the safety and efficiency of training in laparoscopic surgery. Before implementation of the Immersion LapSim (Gaithersburg, MD) simulator in our training curriculum, we wished to determine its construct validity (ie, whether the simulator could differentiate laparoscopic novices from trainees with greater experience). Methods Subjects were medical students (MS), residents (RES), and laparoscopic faculty (FAC). Subjects performed 10 repetitions of 6 LapSim tasks. The LapSim measured performance in 6 to 10 parameters per task, and performance was compared between groups. Post hoc t tests were used to make pair-wise comparisons among the 3 groups using the Bonferroni technique. Statistical significance was set at P Results The degree of prior laparoscopic experience was reflected in performance on at least 1 parameter for each task. Several patterns of performance between MS, RES, and FAC were observed. Conclusions The LapSim has performance parameters that reliably differentiate between subjects with varying laparoscopic experience. However, some performance parameters do not differentiate between groups. To accurately measure a trainee's skill level, only parameters that sensitively measure the true level of performance should be used.

Introduction. Overexpression of the anti-inflammatory cytokine interleukin-10 (IL-10) blocks atherosclerotic events in vivo, and IL-10 has been recently hailed as an “immunologic scalpel” for atherosclerosis. Alternatively, mice lacking IL-10 receiving atherogenic diets have increased occlusive lesions. It remains unclear whether such IL-10 modulation broadly applies to other forms of occlusive arterial remodeling. We hypothesized that lack of IL-10 would exacerbate, and exogenous or overexpression of IL-10 would abrogate low shear stress–induced neointimal hyperplasia (NIH). Methods. Wild-type (WT) and IL-10-deficient (IL-10−/−) mice underwent unilateral common carotid artery (CCA) ligation. Low shear stress in the patent ligated artery results in remodeling and formation of neointima containing BrdU and SMC α-actin-positive cells. Additional groups of WT mice underwent CCA ligation and were treated daily with intraperitoneal saline or 1 μg of human IL-10. Chronic delivery gene therapy approaches were also utilized to define the role of IL-10 signaling. WT mice were treated adventitially with 1 × 10 10 adenovirus/green fluorescent protein (Ad/gfp) and an Ad/empty control to confirm the veracity of adventitial delivery. Then, Ad viral IL-10 (vIL-10), Ad/empty, and virus buffer alone were applied directly to the adventitia of the CAA immediately following ligation. In separate experiments, 1 × 10 10 Ad/empty or Ad/vIL-10 was injected intramuscularly. CCAs were perfusion fixed 28 days postligation, the time at which NIH is near maximum. Results. IL-10−/− mice developed identical NIH areas compared to WT controls. Mice receiving IL-10 demonstrated NIH equivalent to saline controls. Mice receiving intramuscular or adventitial Ad/IL-10 developed high serum levels of IL-10 yet formed NIH areas similar to those of controls. Serum IL-10 levels were significantly higher ( P = 0.04) with adventitial delivery. Mice treated adventitially with Ad/gfp showed reliable transfection of cells within the adventitia of CAA. No antibody to human IL-10 was found in the sera of intraperitoneal IL-10-treated mice, which failed to attenuate NIH. Conclusion. Under the conditions of this experiment, lack of IL-10 does not exacerbate low shear stress–induced NIH, nor does exogenous administration or overexpression of IL-10 attenuate it. Despite high serum levels of vIL-10 in mice treated with ad/vIL-10 adventitially, there appears to be no therapeutic effect despite the confirmed transfection of adventitial cells. Discrepancies between these findings and previous research may be related to IL-10 dosing, inflammation induced by the adenoviral vector, or disparities between the NIH models.

Several groups have developed clinical guidelines for the management of breast cancer, yet little data exist regarding their validation. Therefore, we examined the effect of published National Comprehensive Cancer Network (NCCN) guidelines for invasive breast cancer on survival, quality of life (QOL), and hospital cost. From 260 consecutive breast cancer patients, 129 patients were identified for analysis: 93 patients (72%) were treated according to the guidelines (NCCN+), while the treatment of 36 patients (28%), with a similar stage distribution, deviated from the guidelines (NCCN-). Patients were excluded from analysis with a diagnosis of carcinoma in situ, inflammatory cancer, stage IV disease, and comorbid conditions that affected treatment. The 5-year survival was 87.6% for the NCCN+ patients versus 83.3% for NCCN- patients (P = 0.319 by Kaplan-Meier). Twelve QOL parameters were evaluated using a Likert-type scale (1 = severe and 5 = none). NCCN+ patients had a cumulative QOL score of 4.18 +/- 0.08 versus 4.24 +/- 0.14 for NCCN- patients (P = 0.745). Treatment-related costs were $20,300 +/- 1800 for NCCN+ patients versus $59,700 +/- 25,200 for NCCN- patients (P = 0.016 by t test). Although deviation from NCCN breast cancer guidelines had no effect on perceived quality of life or survival, there was a significant decrease in cost in the NCCN+ group. These findings suggest that adherence to NCCN guidelines can significantly reduce the cost of breast cancer care without adversely affecting either survival or quality of life.

Treatment of sepsis and septic shock remains a clinical conundrum. Recent prospective trials with anti-cytokine and anti-inflammatory therapies have shown only modest clinical benefit. The successful treatment of the patient with sepsis syndrome will likely require multi-modal therapies aimed at several of the immunological and physiological disturbances which are occurring simultaneously. Recent studies in experimental animals and critically ill patients have suggested that increased apoptosis of lymphoid organs and some parenchymal tissues may contribute to the immune suppression, anergy and organ system dysfunction. Therapies aimed at inhibiting lymphoid cell apoptosis may contribute to improved outcome, and should be considered in the treatment of hospitalized patients with sepsis syndromes. Although clinical trials with anti-apoptotic agents remain distant due in large part to technical difficulties associated with their administration and tissue targeting, inhibition of lymphocyte apoptosis may be an appropriate therapeutic target for the septic patient.

Background: Recurrent and complex bilateral inguinal hernias are associated with a high recurrence rate. This study evaluates prospectively the efficacy and safety of giant prosthetic reinforcement of the visceral sac (GPRVS) in a group of patients at high risk for recurrence. Methods: Sixty-four patients with 124 inguinal hernias (60 bilateral and 4 unilateral) underwent repair using a large polyester mesh based on Stoppa’s preperitoneal technique. Mean age was 61 years (63 men and 1 woman), and 69% had one or more comorbid medical conditions. Results: Factors predicating a high risk for recurrence included large hernia size (≥5 cm; 31%, 20 of 64), failure of one or more previous repairs (39%, 25 of 64), and chronic obstructive pulmonary disease (28%, 18 of 64). Mean operative time was 115 minutes (range 45 to 235). Mean length of stay was 3 ± 3 days. There were 2 major and 15 minor complications, no mesh infections, and no death. Follow-up was obtained in 95% (61 of 64). After a mean follow-up of 24 months, the recurrence rate was 1% (1 of 124) per inguinal hernia repaired or 2% (1 of 64) per patient. Conclusion: GPRVS is a safe and effective addition to the surgeon’s armamentarium to treat selected patients with recurrent or complex bilateral inguinal hernias.

The management of patients with mammographic abnormalities is rapidly shifting from needle-localized surgical biopsy (NLB) to stereotactic core biopsy (SCB). The precise role of SCB in the management of nonpalpable breast cancer remains to be defined. The purpose of this study was to compare SCB to NLB in the diagnosis of mammographically detected breast cancer in women who underwent breast-conserving surgery. The records of all patients with nonpalpable breast cancer who underwent breast-conserving surgery from 1/1/95 to 6/1/97 were analyzed with respect to method of diagnosis, time interval from detection to diagnosis and breast-conserving surgery, volume of breast tissue excised, margin status and reexcision rate, number of surgical procedures, and total charges and costs per patient. During a 30-month period, 117 patients with nonpalpable breast cancer underwent breast-conserving surgery. The diagnosis was made by NLB in 69 patients and SCB in 48 patients. The time from detection to diagnosis and breast-conserving surgery was 1.7 +/- 0.5 and 8.1 +/- 1.2 days for SCB patients and 6. 8 +/- 1.3 and 16.9 +/- 2.3 days for NLB patients (P0.01). The volume of breast tissue removed was 117.9 +/- 5.6 cm3 for SCB patients versus 75.2 +/- 2.9 cm3 for NLB patients (P0.01). Three SCB patients (6%) had positive margins, while 38 NLB patients (55%) had positive margins (P0.01). Only 1 SCB patient (2%) was reexcised, while 34 NLB patients (50%) were reexcised (P0.01). Eighty-nine percent of SCB patients had a single surgical procedure compared to 39% of NLB patients (P0.001). Patients who underwent SCB had reduced total charges and total costs per patient compared to NLB patients ($11,700 +/- $554 and $3537 +/- $167 per SCB patient versus $15,654 +/- $706 and $4853 +/- $198 per NLB patient, P0. 0001). Stereotactic core biopsy shortens the time from detection at mammography to diagnosis and breast-conserving therapy, permits appropriate discussion of treatment alternatives, reduces the positive margin rate and reexcision rate, and may represent a significant cost savings in the management of nonpalpable breast cancer.

HER1 26.2 [5.1, 70.3] 52 [8.5, 88.5] 25.2 [5.1, 70.3] 28.9 [3, 67.4] HER2 10.6 [1.2, 83.3] 4.5 [1, 17.5] 17 [2, 276.2] 10.4 [1, 32.6] HER3 476 [300, 928.6] 300 [300, 645.1] 496.1 [300, 995.9] 497.1 [300, 791.8] cMET 30 [27.6, 30] 30 [30, 30] 30 [18.9, 30] 30 [30, 30] IGFR 272.7 [100, 790.3] 292.6 [100, 884.7] 315 [100, 790.3] 243.4 [100, 520.9] PI3K 609.1 [100, 1237.4] 609.1 [100, 1618.4] 630.1 [100, 1224.9] 569.3 [100, 1138.9] SHC 100 [100, 209.4] 74 [41.6, 100] 118.6 [100, 215.1] 100 [100, 176.4] Total CK 797.2 [200.4, 1745.9] 200.4 [91, 1339.7] 949.7 [276.1, 1745.9] 522.5 [30, 1822.7]