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Pernar LI. Familiarity, Communication, and Entrustment in the Operating Room. JAMA Surg 2024; 159:285-286. [PMID: 38198180 DOI: 10.1001/jamasurg.2023.6923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Affiliation(s)
- Luise I Pernar
- Department of Surgery, Boston Medical Center, Boston, Massachusetts
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
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Beaulieu-Jones BR, Wilson S, Howard DS, Rasic G, Rembetski B, Brotschi EA, Pernar LI. Defining a High-Quality and Effective Morbidity and Mortality Conference: A Systematic Review. JAMA Surg 2023; 158:1336-1343. [PMID: 37851458 DOI: 10.1001/jamasurg.2023.4672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
Importance Morbidity and mortality conferences (MMCs) are thought to advance trainee education, quality improvement (QI), and faculty development. However, there is considerable variability with regard to their completion. Objective To compile and analyze the literature describing the format, design, and other attributes of MMCs that appear to best advance their stated objectives related to QI and practitioner education. Evidence Review For this systematic review, a literature search with terms combining conference and QI or morbidity and mortality was performed in January 2022, using the PubMed, Embase, and ERIC (Education Resources Information Center) databases with no date restrictions. Included studies were published in English and described surgical or nonsurgical MMCs with explicit reference to quality or system improvement, education, professional development, or patient outcomes; these studies were classified by design as survey based, intervention based, or other methodologies. For survey-based studies, positively and negatively regarded attributes of conference design, format, and completion were extracted. For intervention-based studies, details of the intervention and their impact on stated MMC objectives were abstracted. Principal study findings were summarized for the other group. Study quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI). Abstract screening, full-text review, and data extraction and analysis were completed between January 2022 and December 2022. Findings A total of 59 studies met appropriateness for study inclusion. The mean MERSQI score for the included studies was 6.7 (range, 5.0-9.5) of a maximum possible 18, which implied that the studies were of average quality. The evidence suggested that preparation and postconference follow-up regarding QI initiatives are equally as important as both (1) succinctly presenting case details, opportunities for improvement, and educational topics and (2) creating a constructive space for accountability, engagement, and multistakeholder discussion. Conclusions and Relevance These findings suggest that the published literature on MMCs provides substantial insight into the optimal format, design, and related attributes of an effective MMC. This systematic review provides a road map for surgical departments to improve MMCs in order to align their format and design with their principal objectives related to practitioner and trainee education, error prevention, and QI.
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Affiliation(s)
- Brendin R Beaulieu-Jones
- Department of Surgery, Boston Medical Center, Boston, Massachusetts
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Spencer Wilson
- Department of Surgery, Boston Medical Center, Boston, Massachusetts
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Daniel S Howard
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Gordana Rasic
- Department of Surgery, Boston Medical Center, Boston, Massachusetts
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Ben Rembetski
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Erica A Brotschi
- Department of Surgery, Boston Medical Center, Boston, Massachusetts
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Luise I Pernar
- Department of Surgery, Boston Medical Center, Boston, Massachusetts
- Section of Minimally Invasive Surgery, Boston Medical Center, Boston University, Boston, Massachusetts
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Melvin J, Beesley H, Pernar LI, Richman A, Hess DT. Intern Experience Reflects Information Gathered During the Virtual Interview Process. J Surg Educ 2023; 80:1544-1551. [PMID: 37563002 DOI: 10.1016/j.jsurg.2023.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 06/15/2023] [Accepted: 07/10/2023] [Indexed: 08/12/2023]
Abstract
OBJECTIVE The onset of the coronavirus 2019 (COVID-19) pandemic brought many changes to the residency application process including transitioning to a virtual interview platform, which continues today. The transition brought many concerns from general surgery applicants about their ability to obtain adequate information about a program virtually. We sought to characterize how information presented by programs during the first ever virtual interview cycle matched the experience of general surgery interns after training at a program for 1 year. DESIGN, SETTING, AND PARTICIPANTS In May of 2022, a survey was distributed to 243 program directors who were asked to forward it to their general surgery categorical interns who matched during the 2021 virtual match cycle. Demographics, resources used to determine an impression of a program, and correlations between information presented virtually and what was subsequently experienced as an intern were collected. RESULTS Forty-six program directors confirmed forwarding the survey to their categorical interns. A total of 102 general surgery interns completed the survey. Most interns (88.2%) agreed that their experience matched expectations based on information received through the virtual interview process and 98% of interns were satisfied with their experience at their training program. Interviews with faculty (40.0%), residents (68.0%) and the program web site (29.0%) were the top 3 resources used to create the most accurate impression of a program. Interns felt they were well informed during the virtual interview experience about support from fellow residents (84.3%), culture (73.0%), surgical volume (72.5%), and intern operative experience (71.6%). In addition, 65.7% of participants thought they were able to obtain a good understanding of the program's culture from the virtual process. However, 16.7% thought that their program unintentionally misrepresented aspects of the training program. CONCLUSIONS The faculty and residency interviews were the most important factors in program ranking and most participants agreed that their virtual interview experience matched their expectations during their intern year. Most interns felt they were able to obtain a good understanding of the program's culture from the virtual process. In addition, a majority of interns felt well informed during the interview on aspects ranging from surgical volume, autonomy, and work hours to support from faculty and residents. If virtual interviews are to continue, residents can be satisfied that information gathered virtually will match the reality of their training. Programs should continue to make every effort to present their program realistically.
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Affiliation(s)
- Jeffrey Melvin
- Avedisian School of Medicine, Boston University Chobanian, Boston, Massachusetts; Department of Surgery, Boston Medical Center, Boston, Massachusetts
| | - Hassan Beesley
- Avedisian School of Medicine, Boston University Chobanian, Boston, Massachusetts
| | - Luise I Pernar
- Avedisian School of Medicine, Boston University Chobanian, Boston, Massachusetts; Department of Surgery, Boston Medical Center, Boston, Massachusetts
| | - Aaron Richman
- Avedisian School of Medicine, Boston University Chobanian, Boston, Massachusetts; Department of Surgery, Boston Medical Center, Boston, Massachusetts
| | - Donald T Hess
- Avedisian School of Medicine, Boston University Chobanian, Boston, Massachusetts; Department of Surgery, Boston Medical Center, Boston, Massachusetts.
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Chugh PV, Pernar LI, Hess DT. Our Efforts to Create a Welcoming Surgical Residency for LGBTQ Trainees. J Surg Educ 2023; 80:1614-1617. [PMID: 37455192 DOI: 10.1016/j.jsurg.2023.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/14/2023] [Accepted: 06/17/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE To provide a more welcoming environment for LGBTQ residents. DESIGN This paper is based upon the authors experience creating a training program welcoming to LGBTQ residents. SETTING University General Surgery Training Program. PARTICIPANTS Surgical Residents and Surgical Faculty. RESULTS Over a 9 year period, our residency has made intentional efforts to welcome LGBTQ applicants and support LGBTQ residents. We now have a residency in which over 25% of our residents identify as LGBTQ. CONCLUSIONS We see opportunities for other residencies to signal to applicants and trainees that they are welcome and celebrated for who they are.
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Affiliation(s)
- Priyanka V Chugh
- Boston University Chobanian & Avedesian School of Medicine, Department of Surgery, Boston, Massachusetts; Boston Medical Center, Department of Surgery, Boston, Massachusetts
| | - Luise I Pernar
- Boston University Chobanian & Avedesian School of Medicine, Department of Surgery, Boston, Massachusetts; Boston Medical Center, Department of Surgery, Boston, Massachusetts
| | - Donald T Hess
- Boston University Chobanian & Avedesian School of Medicine, Department of Surgery, Boston, Massachusetts; Boston Medical Center, Department of Surgery, Boston, Massachusetts.
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Pernar LI, Aly S, Hess DT. We Should Be Asking New Questions in Research on Weight Loss Surgery for Racial Minority Patients. JAMA Surg 2022; 157:907. [PMID: 36044206 DOI: 10.1001/jamasurg.2022.3727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Luise I Pernar
- Division of Weight Loss Surgery, Department of Surgery, Boston Medical Center, Boston, Massachusetts
| | - Sherif Aly
- Division of Weight Loss Surgery, Department of Surgery, Boston Medical Center, Boston, Massachusetts
| | - Donald T Hess
- Division of Weight Loss Surgery, Department of Surgery, Boston Medical Center, Boston, Massachusetts
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Pernar LI, Hess DT. Creating a Welcoming Surgery Residency Training Program for LGBTQ Trainees. Am Surg 2022; 88:2796-2801. [PMID: 35538707 DOI: 10.1177/00031348221101582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
General Surgery residencies have been perceived as unwelcoming to lesbian, gay, bisexual, transgender, and queer (LGBTQ) applicants. Historically, applicants have been reluctant to reveal their LGBTQ status when interviewing for residency positions and LGBTQ surgery residents are more likely to consider leaving their residency. Despite the increased acceptance in society and calls for diversity by governing bodies, there is a perception that the field of surgery is lagging behind. In this article, we summarize the recent literature concerning LGBTQ status in surgery residencies and the impact it has on students and trainees. We then review the recent calls to action to remedy the identified shortcomings. We then share what has been done by our surgery residency, which has been successful in recruiting LGBTQ-identifying residents and summarize recommendation for moving forward.
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Affiliation(s)
- Luise I Pernar
- 1846Boston University School of Medicine, Boston, MA, USA.,Department of Surgery, Boston Medical Center, Boston, MA, USA
| | - Donald T Hess
- 1846Boston University School of Medicine, Boston, MA, USA.,Department of Surgery, Boston Medical Center, Boston, MA, USA
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Stolarski AE, Alonso A, Aly S, Feeney T, Pereira F, Carter C, Hess D, Pernar LI, Carmine B, Drake FT. The impact of English proficiency on outcomes after bariatric surgery. Surg Endosc 2022; 36:7385-7391. [DOI: 10.1007/s00464-022-09148-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 02/15/2022] [Indexed: 11/30/2022]
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Hasley RB, Aly S, Carter CO, Carmine B, Hess DT, McAneny D, Pernar LI. Application of the Caprini Risk Assessment Model to Select Patients for Extended Thromboembolism Prophylaxis After Sleeve Gastrectomy. J Gastrointest Surg 2022; 26:298-304. [PMID: 34981292 DOI: 10.1007/s11605-021-05214-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/24/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Caprini risk assessment model is a well-validated tool that identifies patients who would benefit from extended venous thromboembolism (VTE) prophylaxis beyond hospital discharge. VTE, particularly portal mesenteric vein thrombosis (PMVT), is a potentially devastating complication of laparoscopic sleeve gastrectomy (LSG); therefore, we sought to examine whether the model can be safely applied to LSG patients. We hypothesized that its use can minimize the incidence of postoperative VTE, including PMVT, without increasing the likelihood of bleeding complications. MATERIALS AND METHODS We conducted a retrospective chart review of those patients who underwent LSG at our institution from 2010 and 2018, at which time the Caprini risk assessment model was already our institutional standard. We determined the patients' Caprini scores at the time of discharge and whether patients at high risk of VTE were discharged from hospital on extended courses of VTE prophylaxis. We also recorded if bleeding complications or VTE events occurred in the first 180 days after LSG. RESULTS Six hundred thirty-eight patients underwent LSG, including 521 (81.7%) women, with an average preoperative body mass index (BMI) of 44.4 kg/m2 (SD 6.8). One hundred fifty-eight (24.8%) patients had Caprini scores that warranted extended courses of VTE prophylaxis beyond hospital discharge. Three patients (0.47%) developed a postoperative VTE, but no patient developed PMVT. No bleeding complications were observed among patients who received extended VTE prophylaxis. CONCLUSION The Caprini risk assessment model can effectively identify patients after LSG who might benefit from extended courses of VTE prophylaxis. Extended VTE prophylaxis does not seem to confer increased bleeding risk in this patient population.
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Affiliation(s)
- Rebecca B Hasley
- Department of Surgery, Section of Minimally Invasive Surgery, Boston Medical Center, Boston, MA, 02118, USA
| | - Sherif Aly
- Department of Surgery, Section of Minimally Invasive Surgery, Boston Medical Center, Boston, MA, 02118, USA
| | - Cullen O Carter
- Department of Surgery, Section of Minimally Invasive Surgery, Boston Medical Center, Boston, MA, 02118, USA.,Boston University, School of Medicine, Boston, MA, 02118, USA
| | - Brian Carmine
- Department of Surgery, Section of Minimally Invasive Surgery, Boston Medical Center, Boston, MA, 02118, USA.,Boston University, School of Medicine, Boston, MA, 02118, USA
| | - Donald T Hess
- Department of Surgery, Section of Minimally Invasive Surgery, Boston Medical Center, Boston, MA, 02118, USA.,Boston University, School of Medicine, Boston, MA, 02118, USA
| | - David McAneny
- Boston University, School of Medicine, Boston, MA, 02118, USA.,Department of Surgery, Section of Surgical Oncology, Boston Medical Center, Boston, MA, 02118, USA
| | - Luise I Pernar
- Department of Surgery, Section of Minimally Invasive Surgery, Boston Medical Center, Boston, MA, 02118, USA. .,Boston University, School of Medicine, Boston, MA, 02118, USA.
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Pernar LI, Sachs TE, Tseng JF, Hess DT. Structuring Research Rotations to Facilitate Surgery Residents' Academic Productivity. J Surg Educ 2022; 79:31-34. [PMID: 34366284 DOI: 10.1016/j.jsurg.2021.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/06/2021] [Accepted: 07/16/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE We sought to enhance opportunities for general surgery residents to conduct research during residency without having to take dedicated time out of clinical training. To this end, we created structured research rotations to facilitate and support resident research. DESIGN Research blocks of four week's duration were introduced for categorical interns and post-graduate year (PGY) 4 residents. Interns had no clinical responsibilities during their research blocks while PGY 4 residents shadowed their mentor in the clinical setting. Research projects were developed and prepared in advance to maximize productivity during the research rotation. SETTING General surgery residency program at an urban, academic, safety-net, tertiary care hospital PARTICIPANTS: Categorical general surgery interns and PGY 4 general surgery residents RESULTS: The research rotations were first offered in the 2019 to 2020 academic year (AY). 10 interns and 11 PGY 4 residents have since completed the rotations; of the PGY 4 residents, 6 had not previously taken any time off for research activities. Research projects varied between residents and focused on basic science, clinical outcomes, quality improvement, and education. CONCLUSIONS Through establishment of dedicated research rotations, we were able to increase resident engagement in a variety of research activities. We provide a simple model for training programs seeking increased research engagement and productivity for their residents without extending training time.
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Affiliation(s)
- Luise I Pernar
- Boston University School of Medicine, Boston, Massachusetts; Department of Surgery, Boston Medical Center, Boston, Massachusetts.
| | - Teviah E Sachs
- Boston University School of Medicine, Boston, Massachusetts; Department of Surgery, Boston Medical Center, Boston, Massachusetts
| | - Jennifer F Tseng
- Boston University School of Medicine, Boston, Massachusetts; Department of Surgery, Boston Medical Center, Boston, Massachusetts
| | - Donald T Hess
- Boston University School of Medicine, Boston, Massachusetts; Department of Surgery, Boston Medical Center, Boston, Massachusetts
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Geary AD, Sanfey H, Glynn L, Pernar LI. Teaching assistant cases in general surgery training - A literature review. Am J Surg 2021; 223:1088-1093. [PMID: 34819229 DOI: 10.1016/j.amjsurg.2021.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/10/2021] [Accepted: 11/14/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND There is a lack of understanding of the scope and purpose of teaching assistant cases, impact on patients and safety, as well as the facilitators or barriers to resident participation in these cases. METHODS Four databases (PubMed, Embase, Web of Science, and the Education Resources Information Center), were searched. The references of identified resources were additionally hand-searched. 10 articles were identified and considered in the literature review. RESULTS The TA case literature focuses on case numbers and safety. The discussions of papers allude to perceived benefits of TA cases. The literature review reveals that residents are more likely to be granted TA opportunities if they show themselves worthy of entrustment. CONCLUSIONS The work elucidates aspects of TA cases that have not previously been emphasized or highlighted. The literature review can serve to inform attending surgeons and trainees how to optimize the opportunities teaching assistant cases can afford.
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Affiliation(s)
- Alaina D Geary
- Boston University School of Medicine, United States; Department of Surgery, Boston Medical Center, United States
| | - Hilary Sanfey
- Department of Surgery, Southern Illinois University, United States
| | - Loretto Glynn
- Department of Surgery, NYU Long Island School of Medicine, United States
| | - Luise I Pernar
- Boston University School of Medicine, United States; Department of Surgery, Boston Medical Center, United States.
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Zambare WV, Hess DT, Kenzik K, Pernar LI. Outcomes in Laparoscopic Roux-en-Y Gastric Bypass and Implications for Surgical Resident Education. J Surg Educ 2021; 78:e161-e168. [PMID: 34219036 DOI: 10.1016/j.jsurg.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/12/2021] [Accepted: 06/08/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Some surgery residents feel inadequately prepared to perform advanced operations, partly due to losing operative opportunities to fellows. In turn, they are prompted to pursue fellowships. Allowing residents the opportunity to participate in advanced procedures and complex cases may alleviate this cycle, if their participation is safe. This study examined the effects of resident participation in laparoscopic Roux-en-Y gastric bypass procedures (LRYGBs). DESIGN Our MBSAQIP database was used to identify LRYGBs performed at our institution between 2015 and 2018. Operative notes were reviewed to determine training level of the assistant. Patient comorbidities and outcomes (duration of surgery, length of stay, post-operative complications, readmissions, and reoperations) were stratified by assistant level of training for comparison. SETTING Urban tertiary care hospital. PARTICIPANTS Trainees and attending surgeons acting as assistants during LRYGBs. RESULTS Among 987 total cases, the assistants for the procedures were chief residents (n = 549, 56%), fourth-year residents (n = 258, 26%), attending surgeons (n = 143, 14%), and third-year residents (n = 37, 4%). Attending surgeons assisted more often when patients had a BMI ≥ 45 (38% attendings vs. 25% residents, p = 0.007), ≥ 2 comorbidities (54% vs. 40%, p = 0.007), or had a history of prior bariatric surgery (22% vs. 3%, p < 0.0001).Post-operative complication rate was low (4%) and did not differ significantly between all training levels (p = 0.86). Average length of stay, readmission rates, and reoperation rates were not significantly different across training levels (p = 0.75, p = 0.072, and p = 0.91 respectively). CONCLUSION Complication rates, hospital length of stay, readmission rates, and reoperation rates were equivalent for patients regardless of the level of training of the assistant for LRYGBs. Involving residents in complex bariatric procedures such as LRYGB is a safe model of education that does not compromise patient safety or hospital outcomes. Involvement in advanced cases allows general surgery residents to more confidently move toward independent practice.
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Affiliation(s)
| | - Donald T Hess
- Boston University School of Medicine, Boston, MA; Department of Surgery, Boston Medical Center, Boston, Massachusetts
| | - Kelly Kenzik
- Department of Surgery, Boston Medical Center, Boston, Massachusetts; Institute for Cancer Outcomes and Survivorship; University of Alabama at Birmingham, Birmingham, Alabama
| | - Luise I Pernar
- Boston University School of Medicine, Boston, MA; Department of Surgery, Boston Medical Center, Boston, Massachusetts.
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Geary AD, Hess DT, Pernar LI. Efficacy of a resident-as-teacher program (RATP) for general surgery residents: An evaluation of 3 Years of implementation. Am J Surg 2021; 222:1093-1098. [PMID: 34615604 DOI: 10.1016/j.amjsurg.2021.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/07/2021] [Accepted: 09/27/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Teaching is a responsibility of general surgery residents and formal teaching instruction is mandated. This study examines the efficacy of a formal RATP incorporated into our general surgery residency curriculum. METHODS The RATP was developed locally and delivered longitudinally over the course of the academic year, starting in 2017. Self-assessment surveys were distributed to residents before and after completion of the program each academic year. Medical students were surveyed regarding their impression of teaching on the surgical clerkship. RESULTS RATP data was collected annually. All sessions were highly rated. Residents reported improved teaching self-efficacy after participation. Medical student agreement with the statement 'Residents provided effective teaching during the [surgery] clerkship' increased from 68.6% prior to RATP implementation to 79.7% in the following years (p < 0.05). CONCLUSIONS Incorporation of a locally developed RATP improved residents' self-perceptions and medical student perception of residents as teachers. RATPs should be adopted widely.
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Affiliation(s)
- Alaina D Geary
- Department of Surgery, Boston Medical Center, Boston, MA, USA
| | - Donald T Hess
- Department of Surgery, Boston Medical Center, Boston, MA, USA
| | - Luise I Pernar
- Department of Surgery, Boston Medical Center, Boston, MA, USA.
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Affiliation(s)
- Luise I Pernar
- Boston University School of Medicine, USA; Department of Surgery, Boston Medical Center, USA.
| | - Alaina Geary
- Boston University School of Medicine, USA; Department of Surgery, Boston Medical Center, USA
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Gokce N, Karki S, Dobyns A, Zizza E, Sroczynski E, Palmisano JN, Mazzotta C, Hamburg NM, Pernar LI, Carmine B, Carter CO, LaValley M, Hess DT, Apovian CM, Farb MG. Association of Bariatric Surgery With Vascular Outcomes. JAMA Netw Open 2021; 4:e2115267. [PMID: 34251443 PMCID: PMC8276087 DOI: 10.1001/jamanetworkopen.2021.15267] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
IMPORTANCE Bariatric surgical weight loss is associated with reduced cardiovascular mortality; however, the mechanisms underlying this association are incompletely understood. OBJECTIVES To identify variables associated with vascular remodeling after bariatric surgery and to examine how sex, race, and metabolic status are associated with microvascular and macrovascular outcomes. DESIGN, SETTING, AND PARTICIPANTS This population-based longitudinal cohort included 307 individuals who underwent bariatric surgery. Participants were enrolled in the bariatric weight loss program at Boston Medical Center, a large, multi-ethnic urban hospital, with presurgical and postsurgical assessments. Data were collected from December 11, 2001 to August 27, 2019. Data were analyzed in September 2019. EXPOSURE Bariatric surgery. MAIN OUTCOMES AND MEASURES Flow-mediated dilation (FMD) and reactive hyperemia (RH) (as measures of macrovascular and microvascular function, respectively) and clinical variables were measured preoperatively at baseline and at least once postoperatively within 12 months of the bariatric intervention. RESULTS A total of 307 participants with obesity (mean [SD] age, 42 [12] years; 246 [80%] women; 199 [65%] White; mean [SD] body mass index, 46 [8]) were enrolled in this study. Bariatric surgery was associated with significant weight loss and improved macrovascular and microvascular function across subgroups of sex, race, and traditional metabolic syndrome (mean [SD] pre- vs postsurgery weight: 126 [25] kg vs 104 [25] kg; P < .001; mean [SD] pre- vs postsurgery FMD: 9.1% [5.3] vs 10.2% [5.1]; P < .001; mean [SD] pre- vs postsurgery RH: 764% [400] vs 923% [412]; P < .001). Factors associated with change in vascular phenotype correlated most strongly with adiposity markers and several metabolic variables depending on vascular territory (eg, association of weight change with change in RH: estimate, -3.2; 95% CI, -4.7 to -1.8; association of hemoglobin A1c with change in FMD: estimate, -0.5; 95% CI, -0.95 to -0.05). While changes in macrovascular function among individuals with metabolically healthy obesity were not observed, the addition of biomarker assessment using high-sensitivity C-reactive protein plasma levels greater than 2 mg/dL identified participants with seemingly metabolically healthy obesity who had low-grade inflammation and achieved microvascular benefit from weight loss surgery. CONCLUSIONS AND RELEVANCE The findings of this study suggest that bariatric intervention is associated with weight loss and favorable remodeling of the vasculature among a wide range of individuals with cardiovascular risk. Moreover, differences in arterial responses to weight loss surgery by metabolic status were identified, underscoring heterogeneity in physiological responses to adiposity change and potential activation of distinct pathological pathways in clinical subgroups. As such, individuals with metabolically healthy obesity represent a mixed population that may benefit from more refined phenotypic classification.
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Affiliation(s)
- Noyan Gokce
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, Massachusetts
| | - Shakun Karki
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, Massachusetts
| | - Alyssa Dobyns
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, Massachusetts
| | - Elaina Zizza
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, Massachusetts
| | - Emily Sroczynski
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, Massachusetts
| | - Joseph N. Palmisano
- Department of Public Health, Boston University School of Medicine, Boston, Massachusetts
| | - Celestina Mazzotta
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, Massachusetts
| | - Naomi M. Hamburg
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, Massachusetts
| | - Luise I. Pernar
- Department of General Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Brian Carmine
- Department of General Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Cullen O. Carter
- Department of General Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Michael LaValley
- Department of Public Health, Boston University School of Medicine, Boston, Massachusetts
| | - Donald T. Hess
- Department of General Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Caroline M. Apovian
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
| | - Melissa G. Farb
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, Massachusetts
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Jolissaint JS, Dieffenbach BV, Tsai TC, Pernar LI, Shoji BT, Ashley SW, Tavakkoli A. Surgical site occurrences, not body mass index, increase the long-term risk of ventral hernia recurrence. Surgery 2020; 167:765-771. [PMID: 32063341 DOI: 10.1016/j.surg.2020.01.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 12/30/2019] [Accepted: 01/02/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND Recurrence rates after ventral hernia repair vary widely and evidence about risk factors for recurrence are conflicting. There is little evidence for risk factors for long-term recurrence. METHODS Patients who underwent ventral hernia repair at our institution and were captured in the American College of Surgeons-National Surgical Quality Improvement Program database between 2002 and 2015 were included. We reviewed all demographic, procedural, and hernia-specific data. RESULTS Six hundred and thirty patients were included for analysis with a median follow-up of 4.9 years (inter-quartile range, 2-7.3 years). By univariate analysis, index hernia repairs were more likely to recur if defect size was ≥4 cm (P = .019), no mesh was used (P = .026), or if the repair was for a recurrent hernia (P = .001). Five-year cumulative incidence of recurrence and reoperation was 24.3% and 16.0%, respectively. Patients with a perioperative surgical site occurrence, which included superficial, deep-incisional, and organ space surgical site infections as well as wound disruption, had a 5-year cumulative incidence of recurrence of 54.9% compared with 22.6% for those without surgical site occurrence. By multivariable analysis, non-primary hernia repair (hazard ratio 1.7, 95% confidence interval 1.2-2.4, P = .005) and any postoperative surgical site occurrence (hazard ratio 1.9, 95% confidence interval 1.1-3.6, P = .02) were the only risk factors predictive of recurrence. Patient body mass index had no independent effect on recurrence. CONCLUSION 1 in 4 patients undergoing an open ventral hernia repair will have a recurrence after 5 years, and this risk is doubled among patients who experience any perioperative surgical site occurrence. After controlling for patient comorbidities, including body mass index, hernia size, and mesh position, the most significant risk factor for recurrence after ventral hernia repair was a non-primary hernia and surgical site occurrence.
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Affiliation(s)
- Joshua S Jolissaint
- Department of Surgery, Brigham and Women's Hospital, Boston, MA; Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
| | | | - Thomas C Tsai
- Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | | | - Brent T Shoji
- Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Stanley W Ashley
- Department of Surgery, Brigham and Women's Hospital, Boston, MA; Laboratory for Metabolic and Surgical Research, Brigham and Women's Hospital, Boston, MA
| | - Ali Tavakkoli
- Department of Surgery, Brigham and Women's Hospital, Boston, MA; Laboratory for Metabolic and Surgical Research, Brigham and Women's Hospital, Boston, MA
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16
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Karki S, Farb MG, Sharma VM, Jash S, Zizza EJ, Hess DT, Carmine B, Carter CO, Pernar LI, Apovian CM, Puri V, Gokce N. Fat-Specific Protein 27 Regulation of Vascular Function in Human Obesity. J Am Heart Assoc 2019; 8:e011431. [PMID: 31433737 PMCID: PMC6585348 DOI: 10.1161/jaha.118.011431] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 04/15/2019] [Indexed: 12/11/2022]
Abstract
Background Pathophysiological mechanisms that connect obesity to cardiovascular disease are incompletely understood. FSP27 (Fat-specific protein 27) is a lipid droplet-associated protein that regulates lipolysis and insulin sensitivity in adipocytes. We unexpectedly discovered extensive FSP27 expression in human endothelial cells that is downregulated in association with visceral obesity. We sought to examine the functional role of FSP27 in the control of vascular phenotype. Methods and Results We biopsied paired subcutaneous and visceral fat depots from 61 obese individuals (body mass index 44±8 kg/m2, age 48±4 years) during planned bariatric surgery. We characterized depot-specific FSP27 expression in relation to adipose tissue microvascular insulin resistance, endothelial function and angiogenesis, and examined differential effects of FSP27 modification on vascular function. We observed markedly reduced vasodilator and angiogenic capacity of microvessels isolated from the visceral compared with subcutaneous adipose depots. Recombinant FSP27 and/or adenoviral FSP27 overexpression in human tissue increased endothelial nitric oxide synthase phosphorylation and nitric oxide production, and rescued vasomotor and angiogenic dysfunction (P<0.05), while siRNA-mediated FSP27 knockdown had opposite effects. Mechanistically, we observed that FSP27 interacts with vascular endothelial growth factor-A and exerts robust regulatory control over its expression. Lastly, in a subset of subjects followed longitudinally for 12±3 months after their bariatric surgery, 30% weight loss improved metabolic parameters and increased angiogenic capacity that correlated positively with increased FSP27 expression (r=0.79, P<0.05). Conclusions Our data strongly support a key role and functional significance of FSP27 as a critical endogenous modulator of human microvascular function that has not been previously described. FSP27 may serve as a previously unrecognized regulator of arteriolar vasomotor capacity and angiogenesis which are pivotal in the pathogenesis of cardiometabolic diseases linked to obesity.
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Affiliation(s)
- Shakun Karki
- Evans Department of Medicine and Whitaker Cardiovascular InstituteBoston University School of MedicineBostonMA
| | - Melissa G. Farb
- Evans Department of Medicine and Whitaker Cardiovascular InstituteBoston University School of MedicineBostonMA
| | - Vishva M. Sharma
- Department of Biomedical Sciences and Diabetes InstituteOhio UniversityAthensOH
| | - Sukanta Jash
- Department of Biomedical Sciences and Diabetes InstituteOhio UniversityAthensOH
| | - Elaina J. Zizza
- Evans Department of Medicine and Whitaker Cardiovascular InstituteBoston University School of MedicineBostonMA
| | - Donald T. Hess
- Department of General SurgeryBoston University School of MedicineBostonMA
| | - Brian Carmine
- Department of General SurgeryBoston University School of MedicineBostonMA
| | - Cullen O. Carter
- Department of General SurgeryBoston University School of MedicineBostonMA
| | - Luise I. Pernar
- Department of General SurgeryBoston University School of MedicineBostonMA
| | - Caroline M. Apovian
- Evans Department of Medicine and Whitaker Cardiovascular InstituteBoston University School of MedicineBostonMA
| | - Vishwajeet Puri
- Department of Biomedical Sciences and Diabetes InstituteOhio UniversityAthensOH
| | - Noyan Gokce
- Evans Department of Medicine and Whitaker Cardiovascular InstituteBoston University School of MedicineBostonMA
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Dieffenbach BV, Jolissaint JS, Tsai TC, Mets JM, Pernar LI, Ashley SW, Tavakkoli A. Risk Factors for Hernia Recurrence: Preoperative Weight or Postoperative Complications? J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Nzara R, Rao SR, Pernar LI. There Is an Important Difference in the BMI Threshold for Increased Complications after Open vs Laparoscopic Ventral Hernia Repair. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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19
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Shaw TJ, Pernar LI, Peyre SE, Helfrick JF, Vogelgesang KR, Graydon-Baker E, Chretien Y, Brown EJ, Nicholson JC, Heit JJ, Co JPT, Gandhi T. Impact of online education on intern behaviour around joint commission national patient safety goals: a randomised trial. BMJ Qual Saf 2012; 21:819-25. [PMID: 22706930 DOI: 10.1136/bmjqs-2011-000702] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE To compare the effectiveness of two types of online learning methodologies for improving the patient-safety behaviours mandated in the Joint Commission National Patient Safety Goals (NPSG). METHODS This randomised controlled trial was conducted in 2010 at Massachusetts General Hospital and Brigham and Women's Hospital (BWH) in Boston USA. Incoming interns were randomised to either receive an online Spaced Education (SE) programme consisting of cases and questions that reinforce over time, or a programme consisting of an online slide show followed by a quiz (SQ). The outcome measures included NPSG-knowledge improvement, NPSG-compliant behaviours in a simulation scenario, self-reported confidence in safety and quality, programme acceptability and programme relevance. RESULTS Both online learning programmes improved knowledge retention. On four out of seven survey items measuring satisfaction and self-reported confidence, the proportion of SE interns responding positively was significantly higher (p<0.05) than the fraction of SQ interns. SE interns demonstrated a mean 4.79 (36.6%) NPSG-compliant behaviours (out of 13 total), while SQ interns completed a mean 4.17 (32.0%) (p=0.09). Among those in surgical fields, SE interns demonstrated a mean 5.67 (43.6%) NPSG-compliant behaviours, while SQ interns completed a mean 2.33 (17.9%) (p=0.015). Focus group data indicates that SE was more contextually relevant than SQ, and significantly more engaging. CONCLUSION While both online methodologies improved knowledge surrounding the NPSG, SE was more contextually relevant to trainees and was engaging. SE impacted more significantly on both self-reported confidence and the behaviour of surgical residents in a simulated scenario.
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Affiliation(s)
- Tim J Shaw
- Workforce Education and Development Group, K01, The University of Sydney, NSW 2006, Australia.
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Pernar LI, Peyre SE, Smink DS, Block SD, Cooper ZR. Feasibility and impact of a case-based palliative care workshop for general surgery residents. J Am Coll Surg 2011. [DOI: 10.1016/j.jamcollsurg.2011.06.294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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