Goals, Structure and Financing of Surgical Residency Training: A Subcommittee Report of the Blue Ribbon Committee II.

OBJECTIVE: As part of the Blue Ribbon Committee II, review current goals, structure and financing of surgical training in Graduate Medical Education (GME) and recommend needed changes. SUMMARY BACKGROUND DATA: Surgical training has continually undergone major transitions with the 80-hour work week, earlier specialization (vascular, plastics and cardiovascular) and now entrustable professional activities (EPAs) as part of competency based medical education (CBME). Changes are needed to ensure the efficiencies of CBME are utilized, that stable graduate medical education funding is secured, and that support for surgeons who teach is made available. METHODS: Convened subcommittee discussions to determine needed focus for recommendations. RESULTS: Five recommendations are offered for changes to GME financing, incorporation of CBME, and support for educators, students and residents in training. CONCLUSIONS: Changes in surgical training related to CBME offer opportunity for change and innovation. Our subcommittee has laid out a potential path forward for improvements in GME funding, training structure, compensation of surgical educators, and support of students and residents in training.

Evaluation of Variability in Operative Efficiency in Plastic Surgery Procedures.

BACKGROUND: As the cost of healthcare rises, it is imperative to assess value delivered to patients and impact on the economic viability of institutions. We aimed to characterize plastic surgery operative time management and identified areas for efficiency improvement. METHODS: Procedures from a US academic plastic surgery division from September 2017 to August 2018 were reviewed. Times were categorized into preparation (patient in room to incision), procedure (incision to closure), exit (closure to patient exiting room), and turnover (patient out of room to next patient in room). Median and interquartile ranges were calculated. Procedures were classified by relative value units (RVUs) for comparison of procedure complexities and resources. Components were plotted against RVUs; r2 values were calculated. RESULTS: We analyzed 522 cases; 69 were excluded for missing data, primary surgeon not a plastic surgeon, emergent cases, or burn procedures; a total of 453 cases were analyzed. Median and interquartile range (in minutes) for preparation was (34, 18 minutes; 23% of total), procedure (53, 75 minutes; 36% of total), exit (30, 27 minutes; 20% of total), and turnover (30, 26 minutes; 20% of total). Normalized to RVUs, preparation demonstrated the most variability (r2 = 0.19), followed by exit (r2 = 0.38), and procedure (r2 = 0.57). Average work RVUs per month was 678.1 ± 158.7. Average work RVUs per OR hour was 7.2. CONCLUSIONS: The largest component with greatest variability was preparation for surgery in the OR. Improved efficiency by decreasing variability increases the value of healthcare delivered to patients and OR throughput.

Quality Improvement Intervention Bundle Using the PUPPIES Acronym Reduces Pressure Injury Incidence in Critically Ill Patients.

OBJECTIVE: To assess whether a quality improvement bundle focusing on prevention is effective in reducing pressure injury (PI) incidence or costs or delaying PI onset. METHODS: A combined retrospective/prospective cohort study was performed at an academic tertiary care ICU on all patients admitted with a length of stay longer than 48 hours and Braden scale score of 18 or less. Following retrospective data collection (preintervention), a multimodal quality improvement bundle focusing on PI prevention through leadership initiatives, visual tools, and staff/patient education was developed, and data were prospectively collected (postintervention). RESULTS: Statistical and cost analyses were performed comparing both cohorts. A total of 930 patients met the study inclusion criteria (preintervention, n = 599; postintervention, n = 331). A significant decrease in PI incidence was observed from preintervention (n = 37 [6%]) to postintervention (n = 7 [2%], P = .005). This led to a predicted yearly cost savings of $826,810. Further, a significant increase in time to PI occurrence was observed from preintervention (mean, 5 days) to postintervention (mean, 9 days; P = .04). Staff were compliant with the bundle implementation 80% of the time. CONCLUSIONS: Implementation of the quality improvement bundle focused on multimodal PI prevention in critically ill patients led to a significant reduction in PI incidence, increased time to PI occurrence, and was cost-effective.

Seizing opportunity: Diverse early-entry nursing students' perceptions of seeking a PhD.

BACKGROUND: The aging and retirement of the current nursing professoriate and the increasing numbers of nurses pursuing practice doctorates has precipitated decreasing numbers of nurses, specifically diverse nurses pursuing a research doctorate, thus limiting the development of nursing science. PURPOSE: To describe factors influencing decisions about entering a PhD program from the perspectives of early-entry PhD nursing students. METHOD: A qualitative descriptive design using semistructured interviews to explore the perceptions of making the decision to pursue a PhD in nursing of the students who participated in two early-entry mentoring programs. FINDINGS: A model, entitled "Seizing Opportunity" was developed from the findings about the process of students deciding to pursue a PhD. DISCUSSION: Motivators and detractors that can help nursing educators understand how to successfully recruit diverse PhD students were uncovered. Providing knowledge and mentoring for early entry students can increase the numbers of diverse students pursuing a PhD in nursing.

Matrix metalloproteinase signals following neurotrauma are right on cue.

Neurotrauma, a term referencing both traumatic brain and spinal cord injuries, is unique to neurodegeneration in that onset is clearly defined. From the perspective of matrix metalloproteinases (MMPs), there is opportunity to define their temporal participation in injury and recovery beginning at the level of the synapse. Here we examine the diverse roles of MMPs in the context of targeted insults (optic nerve lesion and hippocampal and olfactory bulb deafferentation), and clinically relevant focal models of traumatic brain and spinal cord injuries. Time-specific MMP postinjury signaling is critical to synaptic recovery after focal axonal injuries; members of the MMP family exhibit a signature temporal profile corresponding to axonal degeneration and regrowth, where they direct postinjury reorganization and synaptic stabilization. In both traumatic brain and spinal cord injuries, MMPs mediate early secondary pathogenesis including disruption of the blood-brain barrier, creating an environment that may be hostile to recovery. They are also critical players in wound healing including angiogenesis and the formation of an inhibitory glial scar. Experimental strategies to reduce their activity in the acute phase result in long-term neurological recovery after neurotrauma and have led to the first clinical trial in spinal cord injured pet dogs.

Issues in assessing the health risks of n-butanol.

A literature review and health effects evaluation were conducted for n-butanol, a chemical that occurs naturally in some foods, which is an intermediate in the production of butyl esters and can be used as a gasoline additive or blend. Studies evaluating n-butyl acetate were included in the review as n-butyl acetate is rapidly converted to n-butanol following multiple routes of exposure. The primary n-butanol health effects identified were developmental and nervous system endpoints. In conducting the literature review and evaluating study findings, the following observations were made: (1) developmental findings were consistently identified; (2) neurodevelopmental findings were inconsistent; (3) evidence for nervous system effects was weak; (4) comparing internal doses from oral and inhalation exposures using physiologically based pharmacokinetic models introduces uncertainties; and (5) a lack of mechanistic information for n-butanol resulted in the reliance on mechanistic data for ethanol, which may or may not be applicable to n-butanol. This paper presents findings from a literature review on the health effects of n-butanol and proposes research to help reduce uncertainty that exists due to database limitations.

Multiple enzymes can make hydrogen sulfide from cysteine in Treponema denticola.

Treponema denticola is a spirochete that is involved in causing periodontal diseases. This bacterium can produce H2S from thiol compounds found in the gingival crevicular fluid. Determining how H2S is made by oral bacteria is important since this molecule is present at high levels in periodontally-diseased pockets and the biological effects of H2S can explain some of the pathologies seen in periodontitis. Thus, it is of interest to identify the enzyme, or enzymes, involved in the synthesis of H2S by T. denticola. We, and others, have previously identified and characterized a T. denticola cystalysin, called HlyA, which hydrolyzes cysteine into H2S (and pyruvate and ammonia). However, there have been no studies to show that HlyA is, or is not, the only pathway that T. denticola can use to make H2S. To address this question, allelic replacement mutagenesis was used to make a deletion mutant (ΔhlyA) in the gene encoding HlyA. The mutant produces the same amount of H2S from cysteine as do wild type spirochetes, indicating that T. denticola has at least one other enzyme that can generate H2S from cysteine. To identify candidates for this other enzyme, a BLASTp search of T. denticola strain 33520 was done. There was one gene that encoded an HlyA homolog so we named it HlyB. Recombinant His-tagged HlyB was expressed in E. coli and partially purified. This enzyme was able to make H2S from cysteine in vitro. To test the role of HlyB in vivo, an HlyB deletion mutant (ΔhlyB) was constructed in T. denticola. This mutant still made normal levels of H2S from cysteine, but a strain mutated in both hly genes (ΔhlyA ΔhlyB) synthesizes significantly less H2S from cysteine. We conclude that the HlyA and HlyB enzymes perform redundant functions in vivo and are the major contributors to H2S production in T. denticola. However, at least one other enzyme can still convert cysteine to H2S in the ΔhlyA ΔhlyB mutant. An in silico analysis that identifies candidate genes for this other enzyme is presented.

Glutathione catabolism by Treponema denticola impacts its pathogenic potential.

Treponema denticola is a spirochete that is etiologic for periodontal diseases. This bacterium is one of two periodontal pathogens that have been shown to have a complete three step enzymatic pathway (GTSP) that catabolizes glutathione to H2S. This pathway may contribute to the tissue pathology seen in periodontitis since diseased periodontal pockets have lower glutathione levels than healthy sites with a concomitant increase in H2S concentration. In order to be able to demonstrate that glutathione catabolism by the GTSP is critical for the pathogenic potential of T. denticola, allelic replacement mutagenesis was used to make a deletion mutant (Δggt) in the gene encoding the first enzyme in the GTSP. The mutant cannot produce H2S from glutathione since it lacks gamma-glutamyltransferase (GGT) activity. The hemolytic and hemoxidation activities of wild type T. denticola plus glutathione are reduced to background levels with the Δggt mutant and the mutant has lost the ability to grow aerobically when incubated with glutathione. The Δggt bacteria with glutathione cause less cell death in human gingival fibroblasts (hGFs) in vitro than do wild type T. denticola and the levels of hGF death correlate with the amounts of H2S produced. Importantly, the mutant spirochetes plus glutathione make significantly smaller lesions than wild type bacteria plus glutathione in a mouse back lesion model that assesses soft tissue destruction, a major symptom of periodontal diseases. Our results are the first to prove that T. denticola thiol-compound catabolism by its gamma-glutamyltransferase can play a significant role in the in the types of host tissue damage seen in periodontitis.

Social Media's Influence on Breast Augmentation.

BACKGROUND: The purpose of this study is to evaluate if and what social media use influences our patients' decisions to undergo breast augmentation. OBJECTIVES: A single-institution study was designed to evaluate women who underwent elective breast augmentation from 2017 to 2018. METHODS: Patients were contacted via validated, prompted telephone survey. Data regarding their demographic information and social media utilization pertaining to breast augmentation were collected after obtaining verbal consent. RESULTS: Inclusion criteria were met by 180 patients, of which 69% participated in the survey. Ninety-seven percent of the participants reported utilizing social media in general; the most common platforms were Facebook, Instagram, and the physician's website. Millennials (97%) and Generation X (92%) utilized social media the most and none of the baby boomers. Sixty-four percent of participants reported utilizing some form of social media to research breast augmentation, with the most common resource being Instagram. When analyzing the impact of the social media resources utilized by the participants, Instagram was reported as the most impactful at 54%. Only 18% of participants were utilizing a physician's social media account to research breast augmentation. Among the 50% of patients who utilized social media to compare their surgeon's work with another physician's, the majority (83%) were utilizing the physician's website. CONCLUSIONS: Social media influences patients' education and decisions to undergo breast augmentation, with Instagram being the most impactful. This study evaluated the patient population to stay up to date on their social media utilization and resources of education prior to breast augmentation.

Implications of Demographics and Socioeconomic Factors in Breast Cancer Reconstruction.

BACKGROUND: Not all women undergo breast reconstruction despite its vital role in the recovery process. Previous studies have reported that women who are ethnically diverse and of lower socioeconomic status are less likely to undergo breast reconstruction, but the reasons remain unclear. The purpose of this study is to evaluate the demographic characteristics of our patient population and their primary reason for not undergoing breast reconstruction. METHODS: An institutional review board-approved, single-institution study was designed to evaluate all female breast cancer patients of all stages who underwent mastectomy but did not undergo breast reconstruction from 2008 to 2014. Patients were contacted via telephone and asked to participate in a validated, prompted survey. Data regarding their demographic information and primary reason for not undergoing breast reconstruction were collected. RESULTS: Inclusion criteria were met by 181 patients, of which 61% participated in the survey. Overall, the most common reason for not undergoing breast reconstruction (26%) was unwillingness to undergo further procedures. However, the most common reason for patients that identified as Hispanic, Spanish-speaking, high school graduates, or having an annual income less than US $25,000 (P < 0.05) was insufficient information received. CONCLUSIONS: This study demonstrates that ethnicity and socioeconomic factors play a key role in determining why patients forego breast reconstruction. Ethnicity, language, education, income, and employment status are associated with patients not receiving appropriate education regarding their reconstructive options. Breast surgeons with a diverse patient population should ensure that these patients are adequately educated regarding their options, and if perhaps, more of these patients would decide to partake in the reconstruction process.

Assessing Informal and Formal Diabetes Knowledge in African American Older Adults With Uncontrolled Diabetes.

Some researchers attribute the excess rates of diabetes complications among African American older adults compared to other racial/ethnic subgroups to low diabetes knowledge. Diabetes knowledge measures have a biomedical orientation, including knowledge of glycemic control and using diet and exercise to control blood sugar. Measures do not assess informal knowledge that patients obtain outside of the clinical environment. The distinction between formal and informal knowledge is meaningful for cultural groups such as African American individuals who have historically transferred knowledge about maintaining their health "through the grapevine." A qualitative approach was used to understand participants' informal diabetes knowledge. Three major themes identified addressed the threat that participants perceived when diagnosed, the social construction of diabetes knowledge through their lived and observed experiences, and the limited role that clinicians played in participants' diabetes knowledge acquisition. Findings reveal ways nurses can individualize the diabetes education they provide to African American older adults based on their experiential understanding. [Journal of Gerontological Nursing, 45(2), 35-41.].

Liposomal Bupivacaine May Benefit Select Reduction Mammaplasty Patients.

BACKGROUND: Postoperative pain control can be challenging in reduction mammaplasty patients. This study compares perioperative liposomal bupivacaine (Exparel; Pacira Pharmaceuticals, Inc, San Diego, Calif) with standard local anesthetics to determine if liposomal bupivacaine decreases opioid and antiemetic use, impacting length of stay and complication rates, thus improving patient outcomes. METHODS: A retrospective review of 170 reduction mammaplasty patients was performed. Patients were divided into groups based on local anesthetic used (bupivacaine only and liposomal bupivacaine) and into subgroups based on obesity classification. Length of hospital stay; pain scores immediately postoperatively, at discharge, and at follow-up; and postoperative analgesics and antiemetics were compared. Further analysis was performed after weight stratification within pre- and postmenopausal categories. RESULTS: Liposomal bupivacaine resulted in less pain than bupivacaine immediately postoperatively and at discharge in obesity class I (P = 0.021 and P = 0.018). In obesity class II, antiemetic use was lower in the liposomal bupivacaine group (P = 0.012). Length of stay was persistently lower with liposomal bupivacaine for premenopausal women, and this difference was significant in obesity class I (P = 0.038). In premenopausal women, discharge pain scores were lower in the overweight liposomal bupivacaine group (P = 0.034) and analgesic use was lower in obesity class III (P = 0.004). CONCLUSIONS: Liposomal bupivacaine decreases postoperative pain, opioid, and antiemetic use in select patients. Liposomal bupivacaine might not be equally efficacious in pain reduction in obese or postmenopausal women given the theoretical increased absorption by adipose tissue. In addition, liposomal bupivacaine may have a dose-dependent effect, and weight-based dosing should be investigated.

Job satisfaction, work environment and successful ageing: Determinants of delaying retirement among acute care nurses.

AIM: To determine the relationships between job satisfaction, work environment and successful ageing and how these factors relate to Registered Nurses' intent to retire. BACKGROUND: Although little studied, retention of older nurses by delaying early retirement, before age 65, is an important topic for research. Qualitative and quantitative studies have indicated that job satisfaction work environment and successful ageing are key motivators in acute care Registered Nurses retention and/or delaying retirement. This study was designed to provide information to administrators and policy makers about retaining older, experienced RNs longer and more productively. DESIGN: This was a correlational, descriptive, cross-sectional study. METHODS: An online survey of acute care Registered Nurses (N = 2,789) aged 40 years or older working in Florida was conducted from September - October 2013. Participants completed items related to job satisfaction, work environment, successful ageing and individual characteristics. Hypotheses derived from the modified Ellenbecker's Job Retention Model were tested using regression analysis. RESULTS: Job satisfaction scores were high. Highest satisfaction was with scheduling issues and co-workers; lowest with advancement opportunities. Successful ageing scores were also high with 81% reporting excellent or good health. Work environment explained 55% of the variance in job satisfaction. Years to retirement were significantly associated with successful ageing (p < .001), age (p < .001) and income (p < .010). CONCLUSIONS: This study provides quantitative evidence that environment and successful ageing are important areas that have an impact on job satisfaction and delay of retirement in older nurses and further studies in these areas are warranted to expand on this knowledge.

Family Caregivers' Experiences of Within-Hospital Handoffs for Older Adults in Acute Care.

Family caregivers' experiences during within-hospital handoffs between acute care units are not well understood. Qualitative description methodology was employed to describe family caregivers' experiences during their loved ones' handoffs. Semistructured interviews were conducted with 10 caregivers of hospitalized older adults. Three themes emerged: Lack of care coordination, Muddling through handoffs alone, and Wariness toward the care delivery system. Findings can help clinicians shape their interactions with caregivers to maximize their involvement in post-hospital care.

The association among knowledge of and confidence in home health care services, acculturation, and family caregivers' relationships to older adults of Mexican descent.

The purposes of this study were to examine the relationships among knowledge of and confidence in health care services (HHCS), acculturation, characteristics of family caregivers of Mexican descent, and differences by caregivers' relationship (spouse or adult child). A sample of Mexican-descent older adults and their caregivers was recruited (n = 74 dyads) in Arizona. Each participant completed questionnaires on knowledge, confidence, and acculturation. There were moderate but significant associations among higher Anglo Orientation with Knowledge and with Confidence. Fear of HHCS was positively associated with higher Anglo Orientation and English Language Preference; and negatively associated with Mexican Orientation and Spanish Language Preference. For Spouse caregivers, Fear of HHCS was positively correlated with higher Anglo Orientation and English Language Preference; for Offspring caregivers, Fear of HHCS was negatively correlated with Mexican Orientation and Spanish Language Preference. Results support assessing caregiver cohort and socio-cultural context to decrease HHCS use disparities by Mexican-descent caregiving families.

Cognitive dysfunction in patients with brain metastases: influences on caregiver resilience and coping.

PURPOSE: Neurologic deficits that may be manifested as cognitive impairment contribute to the challenges faced by caregivers of patients with brain metastases. To better address their needs, we examined how caregivers respond to these challenges and explore the relationship between the patient's cognitive impairment and caregiver resilience and coping. METHODS: We conducted a descriptive, cross-sectional study using self-reported data from 56 caregivers of patients with brain metastases. Study participants from a comprehensive cancer center were asked to complete a series of instruments that measured their perception of the patient's cognitive dysfunction (revised memory and behavior problems checklist, RMBC), their own personal resilience (Resilience Scale, RS), and their utilization of a broad range of coping responses (COPE inventory and Emotional-Approach Coping scale). RESULTS: Caregivers reported that memory-related problems occurred more frequently in the patients they cared for compared to depression and disruptive behavior (mean scores 3.52 vs 2.34 vs. 1.32, respectively). Coping strategies most frequently used by caregivers were acceptance (3.28), planning (3.08), and positive reinterpretation and growth (2.95). Most caregivers scored moderate to high on the RS (77%). The coping strategy acceptance correlated significantly with the memory and disruptive behavior subscales of the RMBC. CONCLUSIONS: Given the protective effect of problem-focused coping and the high rate of caregivers utilizing less effective coping strategies in instances of worsening cognitive dysfunction, healthcare professionals need to systematically assess the coping strategies of caregivers and deliver a more personalized approach to enhance effective coping among caregivers of patients with brain metastases.

PCB concentrations in women based on breastfeeding history: NHANES 2001-2004.

Data from the 2001-2004 National Health and Nutrition Examination Survey (NHANES) were used to evaluate serum concentrations of polychlorinated biphenyls (PCBs) in women of reproductive age, with or without a history of breastfeeding. Analytical data for PCBs 138, 153, and 180 were used along with responses to the NHANES Reproductive Health questions: [Have you] breastfed any of your children? " and "[What] number of children [have been] breastfed [for] at least 1 month? " PCB concentrations were found to be significantly lower among 15-44 year old women who had a history of breastfeeding compared to those who had not breastfed any of their children. Based on data for 474 women, ages 15-44 years, mean serum PCB 138, 153, and 180 concentrations were 16.4, 21.4, and 14.3ng/g lipid for women who have a history of breastfeeding, and 24.0, 30.0, and 21.4ng/g lipid for women who have not breastfed, respectively. These results were weighted using the 2001-2004 sample weights provided by NHANES to represent over 27 million U.S. women. PCB concentrations were also lower among women who had breastfed multiple children. Mean serum PCB 138, 153, and 180 concentrations were 11.8, 15.2, and 10.1ng/g lipid, respectively, for women 35-44 years who had breastfed six children and 22.7, 31.9, and 22.5ng/g lipid, respectively, for women 35-44 years who had breastfed only one child. The results tend to support the long-standing hypothesis that depuration of PCBs may occur via breastfeeding.

Relationship management strategies for daughters in conflicted relationships with their ageing mothers.

AIMS: To study relationship management strategies of daughters in conflicted relationships with their mothers and how they promoted or prevented elder abuse. BACKGROUND: Daughters have enduring, unique relationships with their mothers that often carry over into caregiving. Pre-caregiving relationship quality is related to many caregiving outcomes, although it is unclear how. DESIGN: Qualitative study. METHODS: Grounded theory design, informed by feminism, with telephone interviews conducted between January 2013-July 2013. The sample (N = 13) was recruited through an online recruitment strategy, with advertisements posted on relevant websites asking 'Are you in an abusive relationship with your ageing mother?' RESULTS/FINDINGS: Daughters used coping strategies and self-protective strategies aimed at decreasing their exposure to aggression and emotional distress when interacting with their ageing mothers. Daughters also used spiteful aggression out of the desire for revenge. CONCLUSION: Although the daughters' strategies served their personal needs, they jeopardized the mothers' needs by creating an environment where neglect could occur. Daughters also readily and intentionally used aggression against their mothers. These were strategies daughters have found useful. These strategies may be potential areas for designing interventions to promote healthy family relationships and decrease the occurrence of elder abuse and neglect.

Adult Daughters' Descriptions of Their Mother-Daughter Relationship in the Context of Chronic Conflict.

The purpose of this article is to describe, from the perspective of the adult daughter, the mother-daughter relationship in the context of chronic conflict. Grounded theory methodology was used. An online recruitment strategy was used to identify a sample of adult daughters (N = 13) who self-identified as having an abusive relationship with their aging mother. Data collection was completed through semi-structured telephone interviews. Daughters framed their relationship around their perceptions of past childhood injustices. These injustices invoked strong negative emotions. Daughters had equally strong motivations for sustaining the relationship, driven by desire to reconcile their negative experience through seeking validation and futile-hoping as well as a sense of obligation to do due diligence. Together these factors created an environment of inevitable confrontation and a relationship defined by chronic conflict. Findings from the study provide theoretical insights to the conceptualization of aggression, power relationships, and the development of elder abuse and neglect.

Improving the risk assessment of lipophilic persistent environmental chemicals in breast milk.

Lipophilic persistent environmental chemicals (LPECs) have the potential to accumulate within a woman's body lipids over the course of many years prior to pregnancy, to partition into human milk, and to transfer to infants upon breastfeeding. As a result of this accumulation and partitioning, a breastfeeding infant's intake of these LPECs may be much greater than his/her mother's average daily exposure. Because the developmental period sets the stage for lifelong health, it is important to be able to accurately assess chemical exposures in early life. In many cases, current human health risk assessment methods do not account for differences between maternal and infant exposures to LPECs or for lifestage-specific effects of exposure to these chemicals. Because of their persistence and accumulation in body lipids and partitioning into breast milk, LPECs present unique challenges for each component of the human health risk assessment process, including hazard identification, dose-response assessment, and exposure assessment. Specific biological modeling approaches are available to support both dose-response and exposure assessment for lactational exposures to LPECs. Yet, lack of data limits the application of these approaches. The goal of this review is to outline the available approaches and to identify key issues that, if addressed, could improve efforts to apply these approaches to risk assessment of lactational exposure to these chemicals.