National trends, safety, and effectiveness of minimally invasive concomitant chest wall resection for locally advanced lung cancer.

Objective: Concomitant chest wall resection for locally advanced lung cancer is traditionally performed via an open approach. The safety and effectiveness of minimally invasive approaches for chest wall resections are unknown. Methods: We used the National Cancer Database to identify patients undergoing lobectomy/bi-lobectomy with concomitant chest wall resection from 2010 to 2020. We stratified patients into those undergoing a minimally invasive resection (video-assisted thoracoscopic surgery [VATS]/robotic) or open, while accounting for conversions. We also compared VATS with robotic approaches. The main outcomes were length of stay, mortality, readmissions, and overall survival. We used multivariable, Kaplan-Meier and Cox proportional models to identify associations. Results: Of 2837 patients, 756 procedures (26.6%) were started minimally invasive, of which 23.1% were robotic. There were 237 (31.3%) conversions. Patients undergoing a minimally invasive operation were similar in terms of age (65.2 ± 9.8 years vs 66.0 ± 9.9 years), sex, race, tumor histology, and location (all P > .05) but had smaller cancers (5.4 ± 2.6 cm vs 6.2 ± 4.3 cm; P < .001) compared with those undergoing open. They also had shorter length of stay (8.6 ± 7.6 days vs 9.7 ± 9.3 days; P < .001) but similar unadjusted 90-day mortality (8.2% vs 8.0%; P = .999). Neoadjuvant therapy was associated with less minimally invasive approaches (adjusted odds ratio, 0.69; P ≤ .001). Larger cancers were associated with less minimally invasive operations and greater rates of conversions. However, the robotic approach was associated with lower conversion rates than VATS across all tumor sizes. Overall survival was equivalent. Conclusions: The use of minimally invasive approaches to concomitant chest wall resection is increasing. Although conversions to open are common, this approach is safe and is associated with shorter hospital stays. Overall survival is equivalent to the open approach.

Template for a program tailored ACS/APDS phase 1 curriculum: From needs assessment to implementation.

BACKGROUND: The Phase 1 ACS/APDS skills curriculum standardizes intern training. Despite this, institutional implementation varies and is nationally low. We aimed to use Kern's six-steps to tailor this to our program, providing a framework to improve implementation. METHODS: Problem identification and general needs assessment were performed. Targeted needs assessment (TNA) of incoming interns ('interns'), current residents, and attendings determined perceived importance of skills and intern's previous experience and confidence. Educational strategies were developed. Learner knowledge was assessed before and after modules, deficiencies identified enabled employment of active learning strategies. Modular and curricular evaluations were completed. RESULTS: TNA determined all interns had been taught knot tying and suturing, and were most confident with suturing, knot tying, and urethral catheterization. Educational strategies included simulation and lectures. Evaluations demonstrated improvement in test scores (pre-v post-) and skills confidence on curricula completion. CONCLUSION: Our framework utilizes institutional resources and expertise while focusing on determining existing knowledge, skill, and technical deficiencies of learners. This approach demonstrated improvement in knowledge and confidence, and could improve implementation rates of the Phase 1 curriculum.

Simulation training for the endoscopic management of upper gastrointestinal bleeding: a nationwide survey of rural surgeons' needs and preferences analysis.

BACKGROUND: Published needs analyses of rural surgeons have identified a need for training in the endoscopic management of non-variceal upper gastrointestinal bleeding (NVUGIB). The study aim was to survey rural surgeons regarding their requirements and preferences for a simulation model on which they could rehearse the endoscopic management of NVUGIB. METHODS: Rural surgeons were contacted via the American College of Surgery Advisory Council listserv and invited to complete an online survey. RESULTS: A total of 66 responses were received, representing all 4 US regional divisions. Seventy-seven percent of respondents perform > 100 endoscopy cases per year. A majority have no experience with simulation models (77%), citing cost, time, and access to training courses as the three most limiting factors. Thirty-three percent lacked confidence in managing UGIBs, and 73% were interested in receiving additional training. Preference analysis revealed that respondents preferred a portable simulation model (81%) that costs between $500 and $1000 (46%), and requires 1-2 weeks of training (34%). Verbal feedback from an expert was viewed as the most helpful type of feedback (61%). CONCLUSION: Rural surgeons frequently perform flexible endoscopy in their practice and are interested in further training for the endoscopic management of NVUGIB. These results will be used to develop a simulation platform for training in the endoscopic management of NVUGIB that meets rural surgeons' needs.

Quality improvement education in surgical specialty training: A comparison of Vascular Surgery resident and Urology Resident experiences and attitudes.

BACKGROUND: Academic institutions have increasingly focused on educating physicians and surgeons in concepts of value-based care, including quality improvement (QI). The extent to which QI curricular competencies are addressed in specialty surgical residency training is unclear. METHODS: A survey instrument was developed by content experts and sent to Vascular Surgery and Urology residents electronically. Descriptive statistics and bivariate associations were calculated using StataMP 13.1. RESULTS: Vascular Surgery and Urology residents reported exposure to similar types of QI curriculum. Fewer than half of residents reported achieving targets for graduation (Vascular 31%, Urology 42%) related to QI, and few residents in either group felt very well-prepared to lead a QI initiative (Vascular 13%, Urology 8%). CONCLUSION: QI education in surgical specialty training amongst Vascular Surgery and Urology residencies is similar and insufficient. Surgical specialties may benefit from collaborative efforts to improve the quality of QI education.

Safety of Surgical Telehealth in the Outpatient and Inpatient Setting.

New telehealth platforms and interventions have proliferated over the past decade and will be further spurred by the COVID-19 pandemic. Emerging literature examines the efficacy and safety of these interventions. Early pilot studies and trials demonstrate equivalent outcomes of telehealth interventions that seek to replace routine postoperative care in low-risk patients who have undergone low-risk surgeries. Studies are underway to evaluate interventions in higher-risk populations undergoing more complex procedures. Tele-ICU platforms demonstrate promise to provide specialized, high-acuity care to underserved areas and may also be used to augment compliance with evidence-based protocols.

A National Survey of Integrated Vascular Surgery Residents' Experiences With and Attitudes About Quality Improvement During Residency.

BACKGROUND: Integrated vascular surgery residency, or "0+5," programs provide education in the Accreditation Council for Graduate Medical Education (ACGME) competencies of Systems-Based Practice (SBP) and Practice-Based Learning and Improvement (PBLI), which include milestones related to quality improvement (QI). It is unclear what QI curricula are in place in 0+5 programs nationally or how 0+5 residents perceive the importance of QI. OBJECTIVE: The purpose of this study is to assess current 0+5 residents' knowledge, experiences with, and attitudes about QI. DESIGN: A survey was developed using the ACGME Common Program Requirements and Milestones pertaining to QI. All 0+5 residents from 2017 to 2018 academic year were emailed an electronic link to the survey. Descriptive statistics and cross-tabulations were calculated using Stata/MP version 13.1. SETTING: All 0+5 vascular surgery residency programs in the United State (n = 52). PARTICIPANTS: The survey was completed by 35% (n = 90/257) of 0+5 residents, representing 75% of 0+5 programs in the United States (n = 39/52). RESULTS: Forty-one percent of respondents felt that applying QI methods is very important and 33% felt that QI education is very important for their future work, however, just 13% felt very prepared to lead a QI initiative. Residents' perceptions of preparedness to lead QI projects and the importance they attached to QI education were significantly influenced by their participation in a QI project (p = 0.003 and p = 0.038 respectively). Finally, just 8% (n = 6) of residents responded correctly to all 13 knowledge-based questions and these residents felt better prepared to lead a QI initiative compared to those who answered incorrectly (p = 0.002). CONCLUSIONS: Most 0+5 residents report participation in a QI project during residency, however, few feel prepared to lead a QI initiative in practice. Furthermore, only half of PGY5 0+5 residents report achieving specific ACGME targets for graduation pertaining to QI. Current QI curricula in 0+5 programs may be inadequate in teaching fundamental QI concepts and achieving ACGME competency targets for graduation.

Clinical exome sequencing identifies a novel TUBB4A mutation in a child with static hypomyelinating leukodystrophy.

BACKGROUND: Leukodystrophies are a large group of inherited diseases of central nervous system myelin. There are few treatments, and most patients do not receive a final genetic diagnosis. PATIENT: We report a novel presentation of a female child with hypotonia, global developmental delay, and rotatory nystagmus. Brain MRI demonstrated profound hypomyelination and minimal or no atrophy in the brain stem or cerebellum. RESULTS: Extensive testing failed to yield a diagnosis until clinical whole-exome sequencing revealed a novel pathogenic mutation in the ß-tubulin gene TUBB4A. TUBB4A is a cause of hereditary dystonia type 4 and has recently been reported to cause hypomyelination with atrophy of the basal ganglia and cerebellum. CONCLUSIONS: This report expands the phenotypic spectrum of TUBB4A-associated neurological diseases to include static hypomyelinating leukodystrophy and supports the clinical relevance of next-generation sequencing diagnosis approaches.

Topographic Maps within Brodmann's Area 5 of macaque monkeys.

Brodmann's area 5 has traditionally included the rostral bank of the intraparietal sulcus (IPS) as well as posterior portions of the postcentral gyrus and medial wall. However, different portions of this large architectonic zone may serve different functions related to reaching and grasping behaviors. The current study used multiunit recording techniques in anesthetized macaque monkeys to survey a large extent of the rostral bank of the IPS so that hundreds of recording sites could be used to determine the functional subdivisions and topographic organization of cortical areas in this region. We identified a lateral area on the rostral IPS that we term area 5L. Area 5L contains neurons with receptive fields on mostly the shoulder, forelimb, and digits, with no apparent representation of other body parts. Thus, there is a large magnification of the forelimb. Receptive fields for neurons in this region often contain multiple joints of the forelimb or multiple digits, which results in imprecise topography or fractures in map organization. Our results provide the first overall topographic map of area 5L obtained in individual macaque monkeys and suggest that this region is distinct from more medial portions of the IPS.

Schistosomiasis-induced experimental pulmonary hypertension: role of interleukin-13 signaling.

The mechanisms underlying schistosomiasis-induced pulmonary hypertension (PH), one of the most common causes of PH worldwide, remain unclear. We sought to determine whether Schistosoma mansoni causes experimental PH associated with pulmonary vascular remodeling in an interleukin (IL)-13-dependent manner. IL-13Ralpha1 is the canonical IL-13 signaling receptor, whereas IL-13Ralpha2 is a competitive nonsignaling decoy receptor. Wild-type, IL-13Ralpha1(-/-), and IL-13Ralpha2(-/-) C57BL/6J mice were percutaneously infected with S. mansoni cercariae, followed by i.v. injection of eggs. We assessed PH with right ventricular catheterization, histological evaluation of pulmonary vascular remodeling, and detection of IL-13 and transforming growth factor-beta signaling. Infected mice developed pulmonary peri-egg granulomas and arterial remodeling involving predominantly the vascular media. In addition, gain-of-function IL-13Ralpha2(-/-) mice had exacerbated vascular remodeling and PH. Mice with loss of IL-13Ralpha1 function did not develop PH and had reduced pulmonary vascular remodeling. Moreover, the expression of resistin-like molecule-alpha, a target of IL-13 signaling, was increased in infected wild-type and IL-13Ralpha2(-/-) but not IL-13Ralpha1(-/-) mice. Phosphorylated Smad2/3, a target of transforming growth factor-beta signaling, was increased in both infected mice and humans with the disease. Our data indicate that experimental schistosomiasis causes PH and potentially relies on up-regulated IL-13 signaling.