Update on the Financial Well-Being of Surgical Residents in New England

BACKGROUND

Poor personal financial health has been linked to key components of health including burnout, substance abuse, and worsening personal relationships. Understanding the state of resident financial health is key to improving their overall well-being.

STUDY DESIGN

A secondary analysis of a survey of New England general surgery residents was performed to understand their financial well-being. Questions from the National Financial Capability Study were used to compare to an age-matched and regionally matched cohort.

RESULTS

Overall, 44% (250 of 570) of surveyed residents responded. Residents more frequently reported spending less than their income each year compared to the control cohort (54% vs 34%, p < 0.01). However, 17% (39 of 234) of residents reported spending more than their income each year. A total of 65% of residents (152 of 234), found it "not at all difficult" to pay monthly bills vs 17% (76 of 445) of the control cohort (p < 0.01). However, 32% (75 of 234) of residents reported it was "somewhat" or "very" difficult to pay monthly bills. Residents more frequently reported they "certainly" or "probably" could "come up with" $2,000 in a month compared to the control cohort (85% vs 62% p < 0.01), but 16% (37 of 234) of residents reported they could not. In this survey, 21% (50 of 234) of residents reported having a personal life insurance policy, 25% (59 of 234) had disability insurance, 6% (15 of 234) had a will, and 27% (63 of 234) had >$300,000 worth of student loans.

CONCLUSIONS

Surgical residents have better financial well-being than an age-matched and regionally matched cohort, but there is still a large proportion who suffer from financial difficulties.

An Interval Look at the Transplant Surgery Pipeline: Insights from General Surgery Residents' Operative Experience Using ACGME Operative Logs from 2000 to 2021

OBJECTIVE

Given the declining number of US graduates pursuing transplant surgery as well as regulatory changes regarding transplant rotations for surgical residents, this study examined the transplant surgery operative volume of residents over the past 20 years.

DESIGN

Retrospective analysis of the ACGME database of general surgery operative logs from academic year (AY) 1999-2000 to AY 2020-2021; data was categorized into time periods relative to regulatory changes: Period 1 (1999-2010) and Period 2 (2011-2021).

SETTING/PARTICIPANTS

All ACGME-accredited general surgery residency programs in the US.

FINDINGS

On average, the proportion of transplant cases to all total major cases was about 1% and did not change during the study period (p=0.61). Each graduating resident completed an average of 10.0 ± 11.0 cases during Period 1 and 10.8 ± 12.0 cases during Period 2, representing a statistically but unlikely clinically significant increase (p=0.008). Renal transplants comprised more than 50% of each resident's operative experience in transplant surgery. The proportion of resident involvement in all renal and liver transplantations nationally did not change during the study period, ranging from 34.5-42.9% for renal and 13.8-22.4% for liver.

CONCLUSIONS

Resident volume in transplant surgery has largely remained consistent over the past 20 years, suggesting that changes in operative volume are unlikely driving declining interest in transplant surgery fellowship among US trainees.

The Association Between Virtual Interviewing and Geographical Distribution of Matched Residency Programs for General Surgery Applicants

OBJECTIVE

Due to the COVID-19 pandemic, the Coalition for Physician Accountability's work group on Medical Students in the class of 2021 made the recommendation in May of 2020 that the upcoming residency recruitment cycle be conducted virtually. This flexibility may have allowed applicants to apply and interview at programs with less regard to geography, knowing that travel costs of interviewing would not be a factor. Alternatively, applicants who interviewed virtually could choose to remain in a close proximity to their home institutions where they likely have a greater comfort level and familiarity with the community both personally and professionally. We examine the distribution of applicants matched at general surgery residency programs in 2021 to those in 2020 to see if there was a change in geographic variability.

DESIGN

Retrospective review of general surgery residents SETTING: United States general surgery residency programs PARTICIPANTS: 2153 PGY1 categorical general surgery residents who were interviewed virtually and PGY2 categorical general surgery residents who interviewed in-person, who also attended residency programs and medical schools located in the continental United States with publicly accessible residency websites containing necessary biographical information.

RESULTS

A total of 2153 residents were included; 1124 in their PGY1 and 1029 in their PGY2. Average distance from attended medical school to matched program (634.2 vs 662.5), percentage of matched programs within 500 miles of attended medical school (57.3 vs 55.7), average price of flight, when available, from attended medical school to matched program (222.8 vs 230.4), and percentage of attended medical schools with non-stop flight to matched program (42.9 vs 42.9) did not significantly differ between PGY1 and PGY2 residents.

CONCLUSIONS

The decision to adopt virtual interviewing practices compared to previous in-person interviews did not significantly alter the geographical distribution of students' matched programs. The distance from medical school to the matched program, flight availability, and flight pricing remained comparable between residents interviewed in-person and residents interviewed virtually.

Frequency and Characteristics of Social Media Use among General Surgery Trainees

INTRODUCTION

With increased social isolation due to COVID-19, social media has been increasingly adopted for communication, education, and entertainment. We sought to understand the frequency and characteristics of social media usage among general surgery trainees.

MATERIALS AND METHODS

General surgery trainees in 15 American training programs were invited to participate in an anonymous electronic survey. The survey included questions about demographics, frequency of social media usage, and perceptions of risks and benefits of social media. Univariate analysis was performed to identify differences between high users of social media (4-7 h per week on at least one platform) and low users (0-3 h or less on all platforms).

RESULTS

One hundred fifty-seven of 591 (26.6%) trainees completed the survey. Most respondents were PGY3 or lower (75%) and high users of social media (74.5%). Among high users, the most popular platforms were Instagram (85.7%), YouTube (85.1%), and Facebook (83.6%). YouTube and Twitter were popular for surgical education (77.3% and 68.2%, respectively). The most reported benefits of social media were improving patient education and professional networking (85.0%), where high users agreed more strongly about these benefits (P = 0.002). The most reported risks were seeing other residents (42%) or attendings (17%) with unprofessional behavior. High users disagreed more strongly about risks, including observing attendings with unprofessional behavior (P = 0.028).

CONCLUSIONS

Most respondents were high users of social media, particularly Instagram, YouTube, and Facebook. High users incorporated social media into their surgical education while perceiving more benefits and fewer risks of social media.

Elevator Cabin Decontamination With ACTIVE Particle Control™ Technology

Effectively reducing contamination and aerosolized bioburden may limit the risk of disease transmission in closed settings when social distancing is not possible. Unlike uncontrolled ionization and oxidation devices ACTIVE Particle Control™ conditions particles in a highly controlled fashion which provides effective air purification without the generation of ozone or other toxic by-products. The purpose of this study was to determine the impact of ACTIVE Particle Control™ on elevator cabin particle load compared to standard ventilation. The intervention trial utilized particle mass tools to determine the difference in particle clearance between standard elevator cabin ventilation and ACTIVE Particle Control™ technology. Cabin particulate contaminants were significantly reduced using ACTIVE Particle Control™ technology in an operating elevator.

Healthcare-associated infection impact with bioaerosol treatment and COVID-19 mitigation measures

BACKGROUND

The real-world impact of breathing zone air purification and coronavirus disease 2019 (COVID-19) mitigation measures on healthcare-associated infections is not well documented. Engineering solutions to treat airborne transmission of disease may yield results in controlled test chambers or single rooms, but have not been reported on hospital-wide applications, and the impact of COVID-19 mitigation measures on healthcare-associated infection rates is unknown.

AIM

To determine the impact of hospital-wide bioaerosol treatment and COVID-19 mitigation measures on clinical outcomes.

METHODS

The impact of the step-wise addition of air disinfection technology and COVID-19 mitigation measures to standard multi-modal infection control on particle counts, viral and bacterial bioburden, and healthcare-associated infection rates was investigated in a 124-bed hospital (>100,000 patient-days over 30 months).

FINDINGS AND CONCLUSION

The addition of air disinfection technology and COVID-19 mitigation measures reduced airborne ultrafine particles, altered hospital bioburden, and reduced healthcare-associated infections from 11.9 to 6.6 (per 1000 patient-days) and from 6.6 to 1.0 (per 1000 patient-days), respectively (P<0.0001, R2=0.86). No single technology, tool or procedure will eliminate healthcare-associated infections, but the addition of a ubiquitous facility-wide engineering solution at limited expense and with no alteration to patient, visitor or staff traffic or workflow patterns reduced infections by 45%. A similar impact was documented with the addition of comprehensive, restrictive, and labour- and material-intensive COVID-19 mitigation measures. To the authors' knowledge, this is the first direct comparison between traditional infection control, an engineering solution and COVID-19 mitigation measures.

Use of a Laparoscopic Witzel Gastrostomy Without Gastropexy in Bariatric and General Surgery

Background

Gastrostomy placement is the preferred means of long-term enteral feeding for patients who cannot eat by mouth. During laparoscopic gastrostomy, it is standard to perform gastropexy, apposing visceral and parietal peritoneum. In some settings, due to altered anatomy from prior surgery, direct apposition of the stomach to the abdominal wall is not possible. This study reports a series of cases where laparoscopic gastrostomy was performed via a Witzel approach without gastropexy.

Methods

A retrospective chart review was performed of all patients at a tertiary academic medical center who underwent Witzel gastrostomy without gastropexy over a 3-year period. In each case, an 18-French tube was placed into the fundus of the stomach and secured with a purse-string suture. A 5-cm serosalized Witzel tunnel was created around the tube using running silk suture. No gastropexy was performed.

Results

Six patients underwent 7 Witzel gastrostomy procedures. In three cases, patients had undergone prior major upper abdominal surgery where adhesive disease prevented gastropexy. In the other four cases, the patients had undergone prior gastric bypass with antecolic antegastric position of the roux limb. No patient suffered leak of gastric contents into the peritoneum, and there were no postoperative complications or mortality related to the gastrostomy.

Conclusion

In cases where enteral access is necessary, and where the stomach cannot reach the anterior abdominal wall for gastropexy due to prior surgeries, a Witzel gastrostomy without gastropexy is a safe option which resulted in no morbidity or mortality in our series.

Nelfinavir and lenalidomide/dexamethasone in patients with lenalidomide-refractory multiple myeloma. A phase I/II Trial (SAKK 39/10)

The antiretroviral agent nelfinavir has antimyeloma activity and can overcome resistance to bortezomib. Our phase I/II trial investigated whether adding nelfinavir to lenalidomide-dexamethasone can overcome lenalidomide resistance in lenalidomide-refractory multiple myeloma (MM). Twenty-nine patients were included (high-risk cytogenetic aberrations 31%; ≥2 prior therapy lines 93%; lenalidomide-bortezomib double-refractory 34%). Twenty-four patients (83%) had prior bortezomib and 10 (34%) were lenalidomide-bortezomib double-refractory. They received four cycles of nelfinavir 2500 mg/day with standard-dose lenalidomide (25 mg days 1-21) and dexamethasone (40/20 mg days 1, 8, 15, 22). Minor response or better was achieved in 16 patients (55%; 95% CI 36-74%), including 40% of those who were lenalidomide-bortezomib double-refractory, and partial response or better in nine patients (31%; 95% CI 15-51%). Median progression-free survival was 3.4 (95% CI 2.0-4.9) months and median overall survival 21.6 (13.0-50.1) months. Lenalidomide-related pneumonitis, pneumonia, and neutropenic fever occurred, but there were no unexpected adverse events. Peripheral blood mononuclear cells showed a 45% (95% CI 40-51%) reduction in total proteasome activity from baseline and significant induction of unfolded protein response and autophagy. Thus, nelfinavir-lenalidomide-dexamethasone is an active oral combination in lenalidomide-refractory MM.

Vacuum-assisted early transanal closure of leaking low colorectal anastomoses: the CLEAN study

Introduction

Non-healing of anastomotic leakage can be observed in up to 50% after total mesorectal excision for rectal cancer. This study investigates the efficacy of early transanal closure of anastomotic leakage after pre-treatment with the Endosponge^® therapy.

Methods

In this prospective, multicentre, feasibility study, transanal suturing of the anastomotic defect was performed after vacuum-assisted cleaning of the presacral cavity. Primary outcome was the proportion of patients with a healed anastomosis at 6 months after transanal closure. Secondary, healing at last follow-up, continuity, direct medical costs, functionality and quality of life were analysed.

Results

Between July 2013 and July 2015, 30 rectal cancer patients with a leaking low colorectal anastomosis were included, of whom 22 underwent neoadjuvant radiotherapy. Median follow-up was 14 (7–29) months. At 6 months, the anastomosis had healed in 16 (53%) patients. At last follow-up, anastomotic integrity was found in 21 (70%) and continuity was restored in 20 (67%) patients. Non-healing at 12 months was observed in 10/29 (34%) patients overall, and in 3/14 (21%) when therapy started within three weeks following the index operation. Major LARS was reported in 12/15 (80%) patients. The direct medical costs were €8933 (95% CI 7268–10,707) per patient.

Conclusion

Vacuum-assisted early transanal closure of a leaking anastomosis after total mesorectal excision with 73% preoperative radiotherapy showed that acceptable anastomotic healing rates and stoma reversal rates can be achieved. Early diagnosis and start of treatment seems crucial.

Randomized clinical trial of biodegradeable intraluminal sheath to prevent anastomotic leak after stapled colorectal anastomosis

Background

Anastomotic leakage is a potential major complication after colorectal surgery. The C-seal was developed to help reduce the clinical leakage rate. It is an intraluminal sheath that is stapled proximal to a colorectal anastomosis, covering it intraluminally and thus preventing intestinal leakage in case of anastomotic dehiscence. The C-seal trial was initiated to evaluate the efficacy of the C-seal in reducing anastomotic leakage in stapled colorectal anastomoses.

Methods

This RCT was performed in 41 hospitals in the Netherlands, Germany, France, Hungary and Spain. Patients undergoing elective surgery with a stapled colorectal anastomosis less than 15 cm from the anal verge were eligible. Included patients were randomized to the C-seal and control groups, stratified for centre, anastomotic height and intention to create a defunctioning stoma. Primary outcome was anastomotic leakage requiring invasive treatment.

Results

Between December 2011 and December 2013, 402 patients were included in the trial, 202 in the C-seal group and 200 in the control group. Anastomotic leakage was diagnosed in 31 patients (7·7 per cent), with a 10·4 per cent leak rate in the C-seal group and 5·0 per cent in the control group (P = 0·060). Male sex showed a trend towards a higher leak rate (P = 0·055). Construction of a defunctioning stoma led to a lower leakage rate, although this was not significant (P = 0·095).

Conclusion

C-seal application in stapled colorectal anastomoses does not reduce anastomotic leakage. Registration number: NTR3080 (http://www.trialregister.nl/trialreg/index.asp).

Racial differences in weight loss, hemoglobin A1C, and blood lipid profiles after Roux-en-Y gastric bypass surgery

BACKGROUND

It is known that African American (AA) patients with obesity achieve less weight loss after Roux-en-Y gastric bypass surgery (RYGB) than their Caucasian (CA) counterparts. However, it is unclear how these differences in weight loss are reflected in clinical outcomes.

OBJECTIVES

To determine the effects of RYGB on hemoglobin A_1c (A_1c) and blood lipids in relationship to the variability in weight loss outcomes in a racially mixed patient population.

SETTING

University medical center.

METHODS

Retrospective analysis of clinical data from electronic medical records of CA, AA, and Hispanic American (HA) patients undergoing RYGB.

RESULTS

We used 2-way cluster analysis and identified 4 distinct weight loss×race clusters. CA patients separated into 2 clusters (45.5% and 28.2% weight loss, respectively), whereas, AA and HA patients separated into 1 cluster each (33.2% and 34.4% weight loss, respectively). Factors that significantly affected weight loss were race, age, gender, and physical activity as well as presence of hypertension and degenerative joint disease. Although all clusters had significant improvements in blood lipids, HA had an increase in total cholesterol (Total-c) and low-density lipoprotein cholesterol (LDL-c) at 2 years after surgery. All clusters had significant decreases in A_1c in the first year. At 2 years after RYGB, A_1c levels remained stable in CA and HA; however, AA had a significant increase. These racial differences in A_1c could not be explained by the smaller weight loss in AA patients.

CONCLUSION

Race is an important factor in the clinical outcomes of RYGB, especially in regard to diabetes control; however, its effect is not completely understood.

A Multifaceted Intervention to Increase Surgery Resident Engagement in Reporting Adverse Events

BACKGROUND

Although most residents have been involved in an adverse or near-miss event, they are not likely to report these incidents. To improve the culture of patient safety and to increase adverse event reporting among General Surgery residents, a multifaceted intervention focused on education, feedback, and event resolution was developed and implemented.

METHODS

Adverse events involving surgery patients at Boston Medical Center were monitored for 2 months before and for 10 months after implementation of the intervention in May 2014.

RESULTS

There was a significant increase in the number of adverse events reported by residents, from 0 to 30 per 2-month period (χ(2) = 8.56, p = 0.003). The classification types of reports filed by residents differed significantly from those of incidents submitted by other reporters (p < 0.0001).

CONCLUSION

An intervention focused on addressing barriers to reporting adverse events can significantly increase the volume of incidents reported by surgery residents. Involving residents in patient safety efforts may enhance an institution's ability to identify adverse events and to improve the overall culture of care.

Improved Insulin Sensitivity 3 Months After RYGB Surgery Is Associated With Increased Subcutaneous Adipose Tissue AMPK Activity and Decreased Oxidative Stress

Morbidly obese individuals are predisposed to a wide range of disorders, including type 2 diabetes, atherosclerotic cardiovascular disease, fatty liver disease, and certain cancers. Remarkably, all of these disorders can be improved or prevented by Roux-en-Y gastric bypass (RYGB) surgery. We have reported that decreased AMPK activity, together with increased oxidative stress and inflammation in adipose tissue, is associated with insulin resistance in morbidly obese bariatric surgery patients. In the current study, we assessed how these parameters are affected by RYGB surgery. Eleven patients (average age of 46 ± 4 years) were studied immediately prior to surgery and 3 months postoperatively. We measured subcutaneous adipose tissue AMPK phosphorylation (threonine 172, an index of its activation), malonyl-CoA content, protein carbonylation (a marker of oxidative stress), plasma adiponectin, and mRNA expression of several inflammatory cytokines. After surgery, AMPK activity increased 3.5-fold and oxidative stress decreased by 50% in subcutaneous adipose tissue. In addition, malonyl-CoA levels were reduced by 80%. Furthermore, patients had improvements in their BMI and insulin sensitivity (HOMA) and had increased circulating high-molecular weight adiponectin and decreased fasting plasma insulin levels. In contrast, the expression of inflammatory markers in subcutaneous adipose tissue was unchanged postoperatively, although plasma CRP was diminished by 50%.

Integrative population pharmacokinetic and pharmacodynamic dose finding approach of the new camptothecin compound namitecan (ST1968)

AIMS

Namitecan is a new camptothecan compound undergoing early clinical development. This study was initiated to build an integrated pharmacokinetic (PK) and pharmacodynamic (PD) population model of namitecan to guide future clinical development.

METHODS

Plasma concentration-time data, neutrophils and thrombocytes were pooled from two phase 1 studies in 90 patients with advanced solid tumours, receiving namitecan as a 2 h infusion on days 1 and 8 every 3 weeks (D1,8) (n = 34), once every 3 weeks (D1) (n = 29) and on 3 consecutive days (D1-3) (n = 27). A linear three compartment PK model was coupled to a semiphysiological PD-model for neutrophils and thrombocytes. Data simulations were used to interrogate various dosing regimens and give dosing recommendations.

RESULTS

Clearance was estimated to be 0.15 l h(-1), with a long terminal half-life of 48 h. Body surface area was not associated with clearance, supporting flat-dosing of namitecan. A significant and clinically relevant association was found between namitecan area under the concentration-time curve (AUC) and the percentage drop of neutrophils (r(2) = 0.51, P < 10(-4)) or thrombocytes (r(2) = 0.49, P < 10(-4)). With a target for haematological dose-limiting toxicity of <20%, the recommended dose was defined as 12.5 mg for the D1,8 regimen, 23 mg for the once every 3 week regimen and 7 mg for the D1-3 regimen.

CONCLUSION

This is the first integrated population PK-PD analysis of the new hydrophilic topoisomerase I inhibitor namitecan, that is currently undergoing early clinical development. A distinct relationship was found between drug exposure and haematological toxicity, supporting flat-dosing once every 3 weeks as the most adequate dosing regimen.

Treatment of idiopathic intracranial hypertension with gastric bypass surgery

Idiopathic intracranial hypertension (IIH) is defined by elevated intracranial pressure and associated headaches, changes in vision and pulsatile tinnitus, among other symptoms. It occurs most frequently in young, obese women. Gastric bypass surgery has been used to treat morbid obesity and its comorbidities, and IIH has recently been considered among these indications. We present a case report of a 29-year-old female with a maximum BMI of 50.3 and a 5-year history of severe headaches and moderate papilledema due to IIH. She also developed migraine headaches. After a waxing and waning course and various medical treatments, the patient underwent laparoscopic Roux-en-Y gastric bypass surgery with anterior repair of hiatal hernia. Dramatic improvement in IIH headaches occurred by 4 months postprocedure and was maintained at 1 year, when she reached her weight plateau with a BMI of 35. Presurgery migraines persisted. This adds to the small number of case reports and retrospective analyses of the successful treatment of IIH with gastric bypass surgery, and brings this data from the surgical literature into the neurological domain. It offers insight into an early time course for symptom resolution, and explores the impact of weight-loss surgery on migraine headaches. This treatment modality should be further investigated prospectively to analyze the rate of headache improvement with weight loss, the amount of weight loss needed for clinical improvement, and the possible correlation with improvement in papilledema.

Heterozygosity for an inactivating mutation in low-density lipoprotein-related receptor 6 (Lrp6) increases osteoarthritis severity in mice after ligament and meniscus injury

OBJECTIVE

Wnt/β-catenin signaling plays an integral and complex role in cartilage development and maintenance. β-catenin signaling has been linked to osteoarthritis (OA), but the role of Lrp6-mediated Wnt/β-catenin signaling during OA remains unexplored. Mutations in the Wnt/β-catenin co-receptors LRP5 and LRP6 (low-density lipoprotein-related receptors 5 and 6) result in skeletal abnormalities, which tend to be more severe in Lrp6 mutant mice. We examined OA development, chondrocyte and osteoblast behavior, and β-catenin signaling after ligament and meniscus damage in mice with global heterozygous deletion of Lrp6.

DESIGN

Ligament and meniscus damage was surgically induced in Lrp6(+/-) and wild-type (WT) mice, and evidence of joint disease was assessed by Microcomputed tomography (micro-CT) and histology. Wnt/β-catenin signaling, proliferation, apoptosis, chondrogenesis, osteogenesis, and catabolic enzyme activity were measured.

RESULTS

Relative to WT mice, Lrp6(+/-) mice had lower nuclear β-catenin signaling within articular cartilage. After surgery, osteophytes and reduced articular cartilage were apparent in WT mice, but more severe in Lrp6(+/-) animals. Impairments to trabecular bone geometry occurred for WT and Lrp6(+/-) mice after surgery. Relative to WT mice, Lrp6(+/-) mice had reduced trabecular BMD and thickness, and Cyclin D1 and Lrp6 gene expression after surgery. There was an increase in apoptotic cells and serum matrix metalloproteinase-9 (MMP9) for Lrp6(+/-) mice after surgery, but no differences in cell proliferation occurred.

CONCLUSIONS

Heterozygous loss-of-function mutation in Lrp6 leads to less β-catenin signaling within articular cartilage and to increased degenerative joint disease after ligament and meniscus injury. Modulation of Lrp6 function could attenuate joint disease after damage to ligaments and the meniscus.

Multiscale Simulations of Brittle Fracture and the Quantum-Mechanical Nature of Bonding in Silicon

We simulate the microscopic details of brittle fracture in silicon by dynamically coupling empirical-potential molecular dynamics of a strained sample to a quantum-mechanical description of interatomic bonding at the crack tip. Our simulations show brittle fracture at loads comparable to experiment, in contrast with empirical potential simulations that show only ductile crack propagation at much higher loading. While the ductility of the empirical potentials can be attributed to their short range, it is unclear whether the increased range of the tight-binding description is sufficient to explain its brittle behavior. Using the multiscale method we show that at a temperature of 1100 K, but not at 900 K, a dislocation is sometimes nucleated when the crack tip impinges on a vacancy. While this result is too limited in length and time scales to directly correspond to experimental observations, it is suggestive of the experimentally observed brittle to ductile transition.