Survey on the Perceptions of Pregnancy and Parenthood in Trainees: Advances, Obstacles, and Growth Opportunities.

INTRODUCTION: Despite national policy changes, perspective changes on pregnancy and parenting in training are often lacking. We evaluated current viewpoints regarding pregnancy, parenthood, leave needs, and perceptions of support across trainees at our institution. METHODS: A cross-sectional survey was sent to all residents and fellows at a tertiary care academic center with >700 trainees. Demographic information, opinions on maternity and paternity leave, and opinions on institutional support and career goals were collected. The survey was sent via the Graduate Medical Education Office listserv -- 66 Accreditation Council for Graduate Medical Education (ACGME) programs and 40 non-ACGME programs. RESULTS: Seven hundred and forty-seven house officers received the survey with a response rate of 21.9% (n = 164). Of respondents, 81% were residents and 99 respondents were female (representing 31% of female trainees at our institution). Thirty-seven point two percent of respondents reported being parents. Twenty-five point three percent of respondents had been pregnant while a trainee with no statistical difference by specialty type (P = 0.0817). Statistically significant difference was noted in having children based on sex with men becoming parents at twice the rate of women (56% vs 26%, P < 0.001). No difference was noted between specialties on perceived support while pregnant and peripartum. Thirty percent of parent respondents reported thinking about leaving medical training after having children given family stressors. Statistical difference in thoughts of leaving medicine overall between females (46%) and males (17.6%; P = 0.0238). CONCLUSIONS: Men and women need support as they navigate becoming parents at a naturally stressful transition period. Females consider leaving medicine at twice the rate of males after becoming parents. Our institution and other ACGME programs need greater transparency and consistent leave practices that reflect changing times.

The COST of liver disease: The Cirrhosis Outcomes Score in Trauma Study.

BACKGROUND: Cirrhosis in trauma patients is an indicator of poor prognosis, but current trauma injury grading systems do not take into account liver dysfunction as a risk factor. Our objective was to construct a simple clinical mortality prediction model in cirrhotic trauma patients: Cirrhosis Outcomes Score in Trauma (COST). METHODS: Trauma patients with pre-existing cirrhosis or liver dysfunction who were admitted to our ACS Level I trauma center between 2013 and 2021 were reviewed. Patients with significant acute liver trauma (AAST Grade ≥ 3) or those that developed acute liver dysfunction while admitted were excluded. Demographics as well as ISS, MELD, complications, and mortality were evaluated. COST was defined as the sum of age, ISS, and MELD. Univariate and multivariable analysis was used to determine independent predictors of mortality. The area under the receiver operating curve (AUROC) was calculated to assess the ability of COST to predict mortality. RESULTS: A total of 318 patients were analyzed of which the majority were males 214 (67.3%) who suffered blunt trauma 305 (95.9%). Mortality at 30-days, 60-days, and 90-days was 20.4%, 23.6%, and 25.5%, respectively. COST was associated with inpatient, 30-day, and 90-day mortality on regression analyses and the AUROC for COST predicting mortality at these respective time points was 0.810, 0.801, and 0.813. CONCLUSION: Current trauma injury grading systems do not take into account liver dysfunction as a risk factor. COST is highly predictive of mortality in cirrhotic trauma patients. The simplicity of the score makes it useful in guiding clinical care and in optimizing goals of care discussions. Future studies to validate this prediction model are required prior to clinical use.

Noggin regulates foregut progenitor cell programming, and misexpression leads to esophageal atresia.

Esophageal atresia (EA/TEF) is a common congenital abnormality present in 1 of 4000 births. Here we show that atretic esophagi lack Noggin (NOG) expression, resulting in immature esophagus that contains respiratory glands. Moreover, when using mouse esophageal organoid units (EOUs) or tracheal organoid units (TOUs) as a model of foregut development and differentiation in vitro, NOG determines whether foregut progenitors differentiate toward esophageal or tracheal epithelium. These results indicate that NOG is a critical regulator of cell fate decisions between esophageal and pulmonary morphogenesis, and its lack of expression results in EA/TEF.

Trop2 is upregulated in the transition to dysplasia in the metaplastic gastric mucosa.

Intestinal-type gastric adenocarcinoma arises in a field of pre-existing metaplasia. While biomarkers of cancer and metaplasia have been identified, the definition of dysplastic transition as a critical point in the evolution of cancer has remained obscure. We have evaluated Trop2 as a putative marker of the transition from metaplasia to dysplasia in the stomach in multiple mouse models of metaplasia induction and progression. In addition, TROP2 expression was evaluated in human samples by immunostaining tissue microarrays for metaplasia, dysplasia, and gastric cancer. Dysplastic mouse organoids were evaluated in vitro following shRNA knockdown of Trop2 expression. In mouse models, no Trop2 was observed in the normal corpus and Trop2 was not induced in acute models of metaplasia induction with either L635 or DMP-777. In Mist1-Kras mice, Trop2 expression was not observed in metaplasia at 1 month after Kras induction, but was observed in dysplastic glands at 3-4 months after Kras induction. In human tissues, no Trop2 was observed in normal corpus mucosa or SPEM, but Trop2 expression was observed in incomplete intestinal metaplasia, with significantly less expression in complete intestinal metaplasia. Trop2 expression was observed in all dysplastic and 84% of gastric cancer lesions, although expression levels were variable. Dysplastic mouse organoids from Mist1-Kras mice expressed Trop2 strongly. Knockdown of Trop2 with shRNA markedly reduced organoid growth and budding behavior, and induced the upregulation of apical villin expression. We conclude that Trop2 is upregulated in the transition to dysplasia in the stomach and promotes dysplastic cell behaviors. © 2020 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Care Delivered by Pediatric Surgical Specialties Through Patient Portal Messaging.

BACKGROUND: Patient portals are online applications that typically allow users to interact with providers using secure messaging. Portal messaging use and content have not been studied in pediatric surgical specialties. MATERIALS AND METHODS: We obtained all message threads initiated by pediatric patients/caregivers and sent to pediatric surgical providers through the Vanderbilt University Medical Center patient portal from June 1, 2014 to December 31, 2014. We collected patient demographics and providers' surgical specialties. We determined the number of message threads and individual messages sent by patients/caregivers and providers by specialty. Message content was analyzed by semantic types using a validated consumer health taxonomy. RESULTS: Most threads were about male (176, 60.3%), white (239, 81.8%), non-Hispanic (278, 95.2%) patients with a median age of 6 y (range: 0-21 y). A total of 292 message threads containing 1679 individual messages were sent with mean 5.8 (standard deviation [SD] 5.0) messages per thread. Messages were sent more frequently regarding younger patients (P = 0.001). Physicians directly contributed to 161 (55%) message threads. Otolaryngology received the most threads (123, 42.1%) and messages (790, 47.1%). Specialties exchanging the most messages per thread were cardiac surgery (mean 7.0, SD 11.7), and dermatology (7.0, SD 6.9). Most message threads (273, 93.5%) involved delivery of medical care with 123 (42.1%) involving appointments/scheduling; 99 (33.9%) medical problems; 81 (27.7%) treatments; 68 (23.3%) testing; and 29 (9.9%) referrals. CONCLUSIONS: Pediatric surgeons deliver substantial care within portal messages exchanged with pediatric patients and caregivers. Institutions adopting portals should consider effects on provider workload and potential disparities in access to care.

Objective endoscopic findings in patients with recurrent croup: 10-year retrospective analysis.

OBJECTIVE: (1) To determine the incidence and severity of subglottic stenosis on endoscopic evaluation in a pediatric population of patients with recurrent croup. (2) To determine the incidence of abnormal findings on bronchoalveolar lavage and esophageal biopsy in a pediatric population with recurrent croup. METHODS: Case series with historical chart review of clinical data for pediatric patients (age ≤18 years) at a tertiary care children's hospital who underwent endoscopic evaluation of the upper aerodigestive tract with a diagnosis of recurrent croup over a ten-year period (2002-2012). Subglottic stenosis was graded on Myer-Cotton scale. Lipid-laden macrophages on bronchoalveolar lavage were noted as none/small/moderate/large with evidence of reflux noted as moderate or large. Esophageal biopsy specimens were evaluated for evidence of esophagitis. Data is expressed as mean±SEM. RESULTS: 1825 charts were reviewed of which 197 met inclusion criteria. Mean age at endoscopy was 53±3 months. Subglottic stenosis was noted in 41 patients (20.8%) with 95.1% being mild or Grade I. Abnormal findings on bronchoalveolar lavage were noted on 9.5% of bronchoalveolar lavage specimens. Abnormal esophageal biopsies were noted on 19.9% of specimens. Esophagitis was noted on 8.8% of biopsy specimens. CONCLUSIONS: Subglottic stenosis is a risk factor for recurrent croup. Evidence suggestive of reflux may be noted on bronchoalveolar lavage or esophageal biopsy, but these findings may not correlate with subglottic stenosis in recurrent croup patients.

Interleukin-1, tumor necrosis factor-alpha, and transforming growth factor-beta 1 and integrative meniscal repair: influences on meniscal cell proliferation and migration.

INTRODUCTION: Interleukin-1 (IL-1) and tumor necrosis factor-α (TNF-α) are up-regulated in injured and osteoarthritic knee joints. IL-1 and TNF-α inhibit integrative meniscal repair; however, the mechanisms by which this inhibition occurs are not fully understood. Transforming growth factor-ß1 (TGF-ß1) increases meniscal cell proliferation and accumulation, and enhances integrative meniscal repair. An improved understanding of the mechanisms modulating meniscal cell proliferation and migration will help to improve approaches for enhancing intrinsic or tissue-engineered repair of the meniscus. The goal of this study was to examine the hypothesis that IL-1 and TNF-α suppress, while TGF-ß1 enhances, cellular proliferation and migration in cell and tissue models of meniscal repair. METHODS: A micro-wound assay was used to assess meniscal cell migration and proliferation in response to the following treatments for 0, 24, or 48 hours: 0 to 10 ng/mL IL-1, TNF-α, or TGF-ß1, in the presence or absence of 10% serum. Proliferated and total cells were fluorescently labeled and imaged using confocal laser scanning microscopy and the number of proliferated, migrated, and total cells was determined in the micro-wound and edges of each image. Meniscal cell proliferation was also assessed throughout meniscal repair model explants treated with 0 or 10 ng/mL IL-1, TNF-α, or TGF-ß1 for 14 days. At the end of the culture period, biomechanical testing and histological analyses were also performed. Statistical differences were assessed using an ANOVA and Newman-Keuls post hoc test. RESULTS: IL-1 and TNF-α decreased cell proliferation in both cell and tissue models of meniscal repair. In the presence of serum, TGF-ß1 increased outer zone cell proliferation in the micro-wound and in the cross section of meniscal repair model explants. Both IL-1 and TNF-α decreased the integrative shear strength of repair and extracellular matrix deposition in the meniscal repair model system, while TGF-ß1 had no effect on either measure. CONCLUSIONS: Meniscal cell proliferation in vivo may be diminished following joint injury due to the up-regulation of inflammatory cytokines, thereby limiting native cellular repair of meniscal lesions. Therefore, therapies that can promote meniscal cell proliferation have promise to enhance meniscal repair and improve tissue engineering strategies.

Health state preferences associated with weight status in children and adolescents.

BACKGROUND: Childhood obesity is a substantial public health problem. The extent to which health state preferences (utilities) are related to a child's weight status has not been reported. The aims of this study were (1) to use a generic health state classification system to measure health related quality of life and calculate health utilities in a convenience sample of children and adolescents and (2) to determine the extent to which these measures are associated with weight status and body mass index (BMI). METHODS: We enrolled 76 children 5-18 years of age from a primary care clinic and an obesity clinic in Boston MA. We administered the Health Utilities Index (HUI) and used the HUI Mark 3 single- and multi-attribute utility functions to calculate health utilities. We determined BMI percentile and weight status based on CDC references. We examined single-attribute and overall utilities in relation to weight status and BMI. RESULTS: Mean (range) age was 10.8 (5-18) years. Mean (SD) BMI percentile was 76 (26); 55% of children were overweight or obese. The mean (SD) overall utility was 0.79 (0.17) in the entire sample. For healthy-weight children, the mean overall utility was higher than for overweight or obese children (0.81 vs. 0.78), but the difference was not statistically significant (difference 0.04, 95% CI -0.04, 0.11). CONCLUSIONS: Our results provide a quantitative estimate of the health utility associated with overweight and obesity in children, and will be helpful to researchers performing cost effectiveness analyses of interventions to prevent and/or treat childhood obesity.