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Background:  At the onset of the coronavirus disease 2019 (COVID-19) pandemic, anesthesiology residency programs were impacted differently due to various factors such as the local severity of COVID-19, exposure to patient suffering, and inability to complete rotations. We sought to investigate the impact of local-level pandemic severity on the well-being of anesthesiology residents., Methods:  This multi-site study surveyed postgraduate year two residents from 15 United States (US) anesthesiology programs using the Perceived Stress Scale, Mini-Z, Patient Health Questionnaire-9,WHO-5 Well-Being Index,and the Multidimensional Scale of Perceived Social Support before the pandemic (baseline survey) and during the first COVID-19 surge (post survey)., Results:  A total of 144 (65%) residents responded to the initial baseline survey; 73 (33%) responded to the post survey, and 49 (22%) completed both surveys. There was not a statistically significant difference in any well-being outcomes of participants between the surveys, nor was there a significant difference based on the severity of COVID-19 impact at the program's hospital. Male participants had higher perceived stress scores (β = 4.05, 95%CI: 0.42, 7.67, P = 0.03) and lower social support from family (β = -6.57, 95%CI: -11.64, -1.51, P = 0.01) at the post survey compared to female participants after controlling for baseline scores. Additionally, married participants or those with domestic partners reported higher perceived social support in the post survey (β = 5.79, 95%CI: -0.65, 12.23, P = 0.03)., Conclusion:  The local COVID-19 severity at a residency program did not disproportionately impact well-being scores among anesthesiology residents. Those most vulnerable to diminished well-being appeared to be male and single participants. As a result, targeted well-being interventions, including those aiming to increase social support, to higher-risk resident groups may be indicated. Future work is needed to assess the longstanding COVID-19 pandemic impacts on resident well-being., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Chen et al.)

Background: The COVID-19 pandemic caused a rapid pivot from in-person to virtual residency interviews across the United States. We present a survey we conducted about the attitudes and opinions of anesthesiology program directors with regard to the 2021 virtual interview process., Methods: This was a 13-question online survey disseminated to 142 anesthesiology residency program directors in February 2021, asking them to compare the most recent interview cycle to their experience with prior cycles., Results: There were 46 (37%) respondents. Generally, respondents saw an increase in applicants and reported perceiving worse interpersonal relationships with applicants, significantly so in programs with small resident classes., Conclusions: Past research has focused on the benefits of virtual interviews for the applicant, but these should be evaluated in tandem with increased difficulties for the interviewers., Competing Interests: Conflicts of interest: The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The authors received no external funding for the research, authorship, and/or publication of this article., (© 2021 Society for Education in Anesthesia.)

Background: Most postgraduate medical education occurs in hospitals in an apprenticeship model with actual patients. Creating a work shift schedule must account for complex factors, including hospital needs, work-hour restrictions, trainee qualifications, and case distribution in order to fairly allocate the resident workload. In this study, we report the first successful implementation of an equitable, computer-generated scheduling system for anesthesiology residents., Methods: A total of 24 residents at a single, urban training program were surveyed in 2015 to rank work shift difficulty. Shifts were categorized and translated into a weighted point system by program leadership based on the survey results. An automated and modifiable scheduling system was created to incorporate rule-based assignment of prerequisites and evenly distribute points throughout the academic year. Point values were retrospectively calculated in 2014, and prospectively calculated from 2015 to 2018. The equality of variance test was used to evaluate the variation of the SD of monthly average point distributions year-over-year and within each class of trainees., Results: Year-over-year analysis revealed that post-point system implementation, call point distribution trended toward reduced variance in all 4 years, with significant reductions of 63% in 2016 (SD 4.9, P < .01), and 57% in 2017 (SD 5.8, P < .01). Analyzed by class, first-year trainees' SD decreased by 73% in 2016 (SD 2.5, P < .01), by 67% in 2017 (SD 3.1, P < .04), and 65% in 2018 (SD 3.3, P < .02) compared with the pre-point system year in 2014. The second year clinical anesthesia resident class SD decreased by 56% in 2015 (SD 5.9, P < .01), 41% in 2016 (SD 7.9, P < .02), and 49% in 2017 (SD 6.9, P < .01)., Conclusion: The computerized point system improved work distribution equity year-over-year and within trainee cohort groups., Competing Interests: Disclosures: The authors report no external funding for this study. The authors declare no conflicts of interest., (© 2021 Society for Education in Anesthesia.)

Physicians routinely rely on nontechnical skills-including leadership ability, managerial skills and financial considerations-when delivering patient care. Efficient practice management is a commonplace expectation of attending anesthesiologists, but there is no uniform residency training to foster the expertise required to succeed in this endeavor. The purpose of this study is to evaluate a novel practice management course for anesthesiology residents., Methods: Senior anesthesiology residents (Clinical Anesthesia-3) at The George Washington University were eligible to participate in a 1-month Ambulatory Anesthesiology-Practice Management Rotation focusing on the acquisition of nontechnical skills and knowledge applicable to becoming an effective clinical leader. The rotation included 1-week service as operating room manager, completion of an online module, assigned readings with follow-up discussions, and completion of a billing and reimbursement exercise. The interventions, in aggregate, were measured with a preknowledge and a postknowledge test., Results: Twelve residents out of 14 (86%) completed the preknowledge and postknowledge tests. Residents scored significantly higher on the postcourse exam (61.49%, SD 18.65%) than the pretest (42.7%, SD 12.7%) (P < .004)., Conclusion: A curriculum designed to develop the practice management skills required of a physician anesthesiologist is feasible and effective at improving knowledge within a 1-month, senior resident rotation., Competing Interests: This work has not been published and is not under consideration for publication from any other journal. The authors all contributed to the submission and agree upon its contents. The authors have no conflicts of interest to report.

Background: Morbidly obese patients are at risk for nonalcoholic steatohepatitis (NASH) even in the absence of risk factors for liver disease. Unfortunately, NASH is usually not clinically evident, and a definitive, noninvasive test for NASH does not exist. Resistin, a cytokine originating from adipose tissue, is involved in insulin resistance and also initiates proinflammatory signaling from hepatic stellate cells. This study explores the relationship between resistin expression and liver pathology in bariatric surgery patients., Methods: Blood samples from 30 patients undergoing bariatric surgery were collected. Total RNA was extracted and cDNA was synthesized. Quantitative RT-PCR was used to quantify relative gene expression using 18s rRNA gene as an internal control. Wedge liver biopsies from these patients were sectioned and stained. Based on a previously published scoring method, biopsies were assigned an overall NASH severity score and subscores for steatosis, inflammation, and fibrosis. Results were analyzed by using Student's t test., Results: Resistin mRNA levels ranged from 0.5 to 9.7. A group of five patients with very high resistin expression (>4) was identified. These patients had a significantly higher average NASH score compared with the rest of the group (7.9 vs. 4.48, p = 0.019). Steatosis and inflammation scores were significantly higher in the high-resistin group (p < 0.05 for both comparisons). There also was a trend toward higher fibrosis score in this group, which approached statistical significance (p = 0.051)., Conclusions: In morbidly obese patients, high resistin expression in serum is associated with hepatic steatosis, inflammation, and fibrosis. The development of elevated resistin expression may represent a link between obesity and the onset of steatohepatitis.

Background: Type 2 diabetes (T2D) resolves rapidly after bariatric surgery, even before substantial weight is lost. However, the molecular pathways underlying this phenomenon remain unclear. Microarray data has shown that numerous genes are differentially expressed in blood after bariatric surgery, including resistin and leptin. Resistin and leptin are circulating hormones derived from adipose tissue, which are associated with obesity and insulin resistance. This study examined expression of these genes before and after bariatric surgery in diabetic and nondiabetic obese patients., Methods: The study included 16 obese patients who underwent bariatric surgery, either Roux-en-Y gastric bypass (RYGB) or adjustable gastric banding. Eight patients had T2D. Preoperative blood samples were collected in PAXgene tubes to stabilize mRNA. Postoperative samples were collected 3 months after surgery. Total RNA was isolated and cDNA was synthesized. Real-time quantitative PCR was used to quantify mRNA. Results were analyzed using Student's t test with a P<0.05 considered significant., Results: Postoperatively, five diabetic patients had discontinued hypoglycemic medications and one showed improved glycemic control. Both leptin and resistin mRNA levels were elevated in the diabetic group but decreased after surgery to levels near those of the nondiabetic group. Greater downregulation of resistin and leptin expression occurred in patients who lost more excess body weight (EBW), while patients who lost less than 10% EBW had a mean increase in expression of the two genes. Downregulation of both genes was more pronounced after RYGB compared to gastric banding., Conclusions: Downregulation of resistin and leptin gene expression after bariatric surgery may play a role in normalizing obesity-associated insulin resistance. Interestingly, downregulation is greater after RYGB and in patients who lose a greater proportion of EBW. Targeted therapies for obesity and diabetes may be developed by understanding the pathways by which these adipocytokines contribute to obesity and T2D.

Introduction: Several lines of evidence point to an important role for BP1, an isoform of DLX4 homeobox gene, in breast carcinogenesis and progression. BRCA1 is a well-known player in the etiology of breast cancer. While familial breast cancer is often marked by BRCA1 mutation and subsequent loss of heterozygosity, sporadic breast cancers exhibit reduced expression of wild type BRCA1, and loss of BRCA1 expression may result in tumor development and progression., Methods: The Cister algorithm and Genomatix program were used to identify potential BP1 binding sites in BRCA1 gene. Real-time PCR, Western blot and immunohistochemistry analysis were performed to verify the expression of BRCA1 and BP1 in cell lines and breast cancer tissues. Double-stranded siRNA transfection was carried out for silencing BP1 expression. ChIP and EMSA were used to confirm that BP1 specifically binds to BRCA1., Results: A putative BP1 binding site was identified in the first intron of BRCA1, which was confirmed by chromatin immunoprecipiation and electrophoresis mobility shift assay. BP1 and BRCA1 expression were inversely correlated in breast cancer cell lines and tissues, suggesting that BP1 may suppress BRCA1 transcription through consensus sequence binding., Conclusions: BP1 homeoprotein represses BRCA1 expression through direct binding to its first intron, which is consistent with a previous study which identified a novel transcriptional repressor element located more than 500 base pairs into the first intron of BRCA1, suggesting that the first intron plays an important role in the negative regulation of BRCA1. Although further functional studies are necessary to confirm its repressor activity towards BRCA1, the elucidation of the role of BP1 in breast tumorigenesis holds great promise in establishing BP1 as a novel target for drug therapy.

Background: Pathologic changes in the liver are common in morbidly obese patients, and insulin resistance may potentiate the progression of nonalcoholic steatohepatitis to fibrosis and cirrhosis. This study investigates the impact of leptin and adiponectin in morbidly obese diabetic and nondiabetic patients with regard to histopathologic changes in the liver., Methods: Thirty-seven morbidly obese patients who underwent bariatric surgery with liver biopsies were enrolled in the study. Fourteen were diabetic and 23 were nondiabetic. Intraoperative liver tissue was sent for histopathologic analysis and extraneous intraoperative tissue was snap-frozen in liquid nitrogen. Total RNA was extracted and RNA was reverse transcribed to cDNA. Real-time quantitative PCR was performed to determine relative gene expression levels. The data were analyzed using a logarithmic transformation and normalized by 18S ribosome expression. Student's t test was used for statistical analysis with p < or = 0.05 as significant., Results: Adiponectin expression was downregulated 4.4-fold (p < or = 0.05) in liver samples with evidence of inflammation on pathology. When hepatic inflammation was evaluated separately, there were no statistically significant differences in adiponectin levels between the diabetic and nondiabetic patients. However, overall adiponectin levels in hepatic samples of diabetic patients were 3.8-fold higher than those of nondiabetic patients (p < or = 0.05). There were no significant differences in leptin levels regardless of hepatic pathology or diabetic status., Conclusions: This study illustrates that there is a downregulation of adiponectin in morbidly obese patients with inflammatory infiltrates in the liver. Variations in adiponectin levels could be an indicator of disease progression since inflammatory infiltrates are commonly associated with nonalcoholic steatohepatitis (NASH) in morbidly obese patients. Currently, we are using human myofibroblasts derived from livers of morbidly obese people to further investigate the molecular mechanisms involved in the progression of fatty liver to fibrosis and cirrhosis.

Tumor invasion and metastasis remain a major cause of mortality in breast cancer patients. It was reported that BP1, a homeobox isoform of DLX4, is overexpressed in 80% of breast cancer patients and in 100% of estrogen receptor negative (ER-) tumors. The prevalence of BP1 positive cells and the intensity of BP1 immunoreactivity increased with the extent of ductal proliferation and tumorigenesis. These findings imply that BP1 may play an important role in ER- breast cancer. We sought to determine the effects and mechanisms of BP1 on cell proliferation and metastasis using ER- Hs578T cells as a model. Cells were transfected with either pcDNA3.2 plasmid containing BP1 gene, or pcDNA3.2 vector, then selected and cloned. Overexpression of BP1 increased cell proliferation rate by 2-5 fold (p<0.005), and enhanced the in vitro invasive activity by 25-65 fold (p<0.001). Microarray experiments were performed to identify differentially expressed genes when BP1 is overexpressed. The gene expression profile of the transfected cell lines were compared, resulting in 71 differentially expressed genes with a fold-change of >=2.0. Of those genes, 49 were up-regulated and 22 were down-regulated. Significant pathways were identified involving cell proliferation and metastasis. These data demonstrated that overexpression of BP1 significantly enhanced cell proliferation and metastatic potential in ER- Hs578T cells. Further analysis with more ER- cell lines and patient samples is warranted to establish BP1 as a therapeutic target for ER- breast cancer.

Background: The metabolic syndrome describes the association between obesity and co-morbidities including insulin resistance, hypertension, dyslipidemia, and cardiovascular (CV) disease. Adipokines produced from omentum contribute to the risk of CV disease and increase the inflammatory state. This study examines the gene expression differences in the omental tissue of morbidly obese diabetic and non-diabetic patients., Methods: Twenty morbidly obese patients undergoing bariatric surgery were included. Ten patients were diabetic and 10 were non-diabetic. Omental samples were collected intraoperatively and snap frozen. Total RNA was extracted using the Trizol reagent and purified with the RNeasy kit (Qiagen). Microarray experiments were performed using the Affymetrix Gene 1.0 ST array and data was analyzed with the Partek 6.3 program using an unpaired t-test (P<0.05). The gene expression profiles of the diabetic group were compared with the non-diabetic group. Using the Ingenuity program, the gene list generated from the microarray analysis was evaluated and real-time quantitative PCR (qPCR) was used to validate the array data., Results: Compared with the non-diabetic group, the diabetic obese patients showed 79 upregulated genes and 4 downregulated genes with >1.4-fold difference in expression. Ingenuity analysis showed numerous dysregulated genes associated with CV disease including leptin, Von Willebrand factor, P-selectin, angiopoietin-1 (ANGPT1), phospholipase A2 (group VII), and periostin osteoblast specific factor. Microarray results for the earlier mentioned genes were confirmed with qPCR. The results were analyzed with respect to the presence or absence of hyperlipidemia, hypertension, and coronary artery disease. In patients with hyperlipidemia, ANGPT1 and P-selectin were upregulated 1.9- and 2.9-fold, respectively., Conclusions: This microarray analysis of omental tissue from morbidly obese diabetic patients documents a host of upregulated genes related to CV disease. This study provides further evidence that diabetic status predisposes obese patients to a higher risk of developing CV disease.

Background: Bariatric surgery can resolve type 2 diabetes in morbidly obese patients. However, the underlying mechanism is unknown. This study aimed to identify potential biomarkers or molecular pathways that are altered after bariatric surgery in diabetic and nondiabetic patients., Methods: The study enrolled 17 morbidly obese patients undergoing bariatric surgery. Eight of the patients were diabetic, and nine were nondiabetic. In addition, a control group of four nonobese, nondiabetic volunteers was included. Patient blood samples were drawn before and after the operation. All blood samples were stabilized in Paxgene tubes (PreAnalytix). Total RNA was extracted and purified using the Paxgene Blood RNA Kit. For each sample, 100 ng of total RNA was amplified and labeled using the Ovation RNA Amplification System V2 with the Ovation Whole Blood reagent before hybridization to an Affymetrix Focus array containing more than 8,500 verified genes. Microarray results were analyzed with the GeneSpring GX 10.0 program, which uses an analysis of variance (ANOVA), and verified with real-time quantitative polymerase chain reaction (QPCR) using SYBR green (ABI)., Results: Microarray analysis showed that 167 genes were upregulated and 39 were downregulated in the obese diabetic patients. Preoperatively, adiponectin was downregulated 1.5-fold in diabetic versus nondiabetic patients. This was confirmed with quantitative PCR analysis. Preoperatively, morbidly obese patients showed a 3.12-fold downregulation of adiponectin expression versus the control group (p = 0.05). Interestingly, postoperative adiponectin levels were upregulated 2.79-fold (p = 0.02), which is close to the level of the normal control group., Conclusions: Adiponectin is dysregulated in obese patients and significantly dysregulated in obese diabetic patients. These findings correlate with the association between low levels of adiponectin and a predisposition to insulin resistance or diabetes. The data suggest that reactivation of adiponectin expression may play a part in the resolution of type 2 diabetes after bariatric surgery. Therefore, targeting adiponectin may help to develop alternative treatments for diabetes.

Background: Currently, surgeons implant a variety of laparoscopic adjustable gastric bands. However, there is little data to guide the selection process. This study aims to determine the relationship between a patient's body mass index (BMI), height, and weight and the anatomical measurements of the gastric cardia in morbidly obese patients undergoing laparoscopic adjustable gastric band (LAGB) surgery., Methods: A total of 67 morbidly obese patients undergoing LAGB surgery were studied. Intraoperative measurements of the gastric cardia were obtained. The relative circumference and posterior diameter of the gastric cardia were measured along with the patient's height, weight, and BMI. Pearson's correlation coefficient was used to measure the relationship between the circumference and posterior diameter of the gastric cardia and the BMI, height, and weight. A p < 0.05 was considered significant., Results: No correlation exists between a patient's BMI or weight and the circumference or diameter of the gastric cardia. A correlation exists between a patient's height and the posterior diameter of the gastric cardia (p = 0.02). Of note, there is a correlation between the relative circumference and the posterior diameter of the gastric cardia for each patient (p = 0.05)., Conclusion: Our unique data show no significant correlation between a patient's BMI and weight and the measurements of the gastric cardia. There was a correlation between a patient's height and the posterior diameter of the gastric cardia. These intraoperative measurements may help surgeons objectively select the appropriate band for each respective patient undergoing LAGB surgery. This may potentially decrease postoperative dysphagia.

Background: Laparoscopy requires a reliable light source to provide adequate visualization. However, thermal energy is produced as a by-product from the optical cable. This study attempts to quantify the degree of possible thermal damage secondary to the fiber-optic light source., Methods: Using a digital thermometer, temperature measurements were recorded at the tip of optical cables from five different light sources (Karl Storz, Inc., Tuttlingen, Germany). Temperature measurements were recorded with new and old bulbs. The tip of the cable was applied to surgical drapes and the time to charring was recorded. Subsequently, the tip of the optical cable was applied to a porcine model and tissue samples were obtained after varying amounts of time (5, 15, 30, 60, and 90 s). Sections of the damaged tissue were prepared for microscopic evaluation. Parameters for thermal injury included extent of epidermal, dermal, and subcutaneous fat damage and necrosis. The lateral extent and depth of injury were measured., Results: The maximum temperature at the tip of the optical cable varied between 119.5 degrees C and 268.6 degrees C. When surgical drapes were exposed to the tip of the light source, the time to char was 3-6 s. The degree and volume of injury increased with longer exposure times, and significant injury was recorded with the optical cable 3 mm from the skin., Conclusions: This study demonstrates that the temperature at the tip of the optical light cord can induce extensive damage. The by-product of light, heat, can produce immediate superficial tissue necrosis that can extend into the subcutaneous fat even when the optical tip is not in direct contact with the skin. In addition, our study shows the variation in temperature that exists between light sources and bulb status. Overall, surgeons must realize and respect the potential complications associated with optical technology.

Background: The causes of obesity are multifactorial but may include dysregulation of a family of related genes, such as the peroxisome proliferator activated receptor gamma (PPARgamma). When activated, the PPARgamma pathway promotes lipid metabolism. This study used microarray technology to evaluate differential gene expression profiles in obese patients undergoing bariatric surgery., Methods: The study enrolled six morbidly obese patients with a body mass index (BMI) exceeding 35 and four nonobese individuals. Blood samples were stabilized in PaxGene tubes (PreAnalytiX), and total RNA was extracted. Next, 100 ng of total RNA was amplified and labeled using the Ovation RNA Amplification System V2 with the Ovation whole-blood reagent (NuGen) before it was hybridized to an Affymetrix (Santa Clara, CA) focus array containing more than 8,500 verified genes. The data were analyzed using an analysis of variance (ANOVA) (p < 0.05) in the GeneSpring program, and potential pathways were identified with the Ingenuity program. Real-time quantitative reverse transcriptase-polymerase chain reaction was used to validate the array data., Results: A total of 97 upregulated genes and 125 downregulated genes were identified. More than a 1.5-fold change was identified between the morbidly obese patients and the control subjects for a cluster of dysregulated genes involving pathways regulating cell metabolism and lipid formation. Specifically, the PPARgamma pathway showed a plethora of dysregulated genes including tumor necrosis factor-alpha (TNFalpha). In morbidly obese patients, TNFalpha expression was increased (upregulated) 1.6-fold. These findings were confirmed using quantitative polymerase chain reaction with a 2.8-fold change., Conclusions: Microarrays are a powerful tool for identifying biomarkers indicating morbid obesity by analyzing differential gene expression profiles. This study confirms the association of PPARgamma with morbid obesity. Also, these findings in blood support previous work documented in tissue (omentum, liver, and stomach). Based on these findings in blood, the authors plan to explore postoperative changes in gene expression by analyzing blood samples after bariatric surgery. Ultimately, these findings may promote the development of therapeutic agents targeted to specific dysfunctional genes.

Introduction: The cause of diabetes in morbidly obese patients is multifactorial, including genetic, social, and dietary components. Transcription factor 7-like 2 (TCF7L2) is a gene that is related to the development of diabetes. This pilot study examines TCF7L2 expression in liver samples obtained from morbidly obese patients undergoing bariatric surgery. TCF7L2 expression is compared between diabetic and nondiabetic patients., Methods: Liver samples were obtained from 20 morbidly obese patients undergoing bariatric surgery. Samples were flash frozen in liquid nitrogen. Total RNA was extracted from tissue samples using the TRIzol reagent (Invitrogen Inc, Carlsbad, CA). Using the iScript cDNA synthesis kit (Bio-Rad Laboratories, Hercules,CA), cDNA was synthesized. Quantitative polymerase chain reaction (qPCR) was done using SYBR Green qPCR Reagents (Stratagene, Cedar Creek TX) and the 7300 Real-Time PCR system (Applied Biosystems, Foster City CA). Preoperative demographic and gene expression data were correlated using univariate analysis and logistic regression models. Only associations with a p-value less than 0.05 were considered significant., Results: For the entire group, there was no correlation between body mass index (BMI) and TCF7L2 expression. In morbidly obese nondiabetic patients, there was a positive correlation between TCF7L2 expression and BMI (R(2)=0.21). In morbidly obese diabetic patients, there was an inverse correlation between TCF7L2 expression and BMI (R(2)=0.58). There was no significant relationship between TCF7L2 expression and age or glycosylated hemoglobin (HbA1c)., Conclusions: The cause of diabetes is multifactorial but the data from our pilot study documents the relationship of TCF7L2 with type 2 diabetes in morbidly obese patients.

We have assembled arrays of approximately 2,400 BAC clones for measurement of DNA copy number across the human genome. The arrays provide precise measurement (s.d. of log2 ratios=0.05-0.10) in cell lines and clinical material, so that we can reliably detect and quantify high-level amplifications and single-copy alterations in diploid, polyploid and heterogeneous backgrounds.